Green Lake Presentation June 201 : simplebooklet.com

Green Lake School District Effective July 1 2017 NETWORK HEALTH BENEFIT COMPARISON HMO Plan Name Routine Preventive Care In Network Out of Network Deductible In Network Out of Network 100 Not Covered Single 1 000 POS 100 Deductible then 80 Family 2 000 N A Single 1 000 2 000 Family 2 000 4 000 Coinsurance In Network Out of Network Annual Maximum Out of Pocket includes Deductible Copay and Coinsurance In Network Out of Network Office Visits In Network 100 N A Single 2 000 100 80 Family 4 000 N A Single 2 000 4 000 Family 4 000 8 000 Primary Care Specialist 10 Copay 25 Copay 50 Copay Not Covered Primary Care Specialist 10 Copay 25 Copay 50 Copay Deductible then 80 In Network Out of Network 50 Copay Not Covered 50 Copay Deductible then 80 In Network Out of Network 150 Copay 150 Copay 150 Copay 150 Copay In Network Out of Network Deductible then 100 Not Covered Deductible then 100 Deductible then 80 In Network Out of Network Deductible then 100 Not Covered Deductible then 100 Deductible then 80 0 10 25 50 50 80 20 40 60 60 0 25 60 150 0 25 60 150 MDLIVE Primary Care Physician Specialty Care Physician Out of Network Urgent Care Emergency Room Hospital Services Diagnostic Services Prescription Drugs Retail Copays Mail Order Copays

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Your Health and Wealth Bill of Rights Our mission is to empower you to make the right decisions to protect your health and wealth We accomplish this by relentlessly innovating the way employers offer benefits that protect your health and wealth Our communications will include tools to provide transparency and ideas to make better informed decisions as benefits continue to evolve To be sure we deliver on our mission and continue to support every customer we are committed to the following Health and Wealth Bill of Rights iPlanRx will We will act in a professional ethical manner and treat you with respect We will keep every bit of personal information completely private Discretion is vital and we embrace the need for it We will return your call text email or any new form of communication within 24 hours of receipt We will put all our organizational resources to work for you and your family We will establish communication expectations up front with the goal of positioning every relationship for success today and in the future We will be your central point of contact for all services provided inside iPlanRx s Health Marketplace Exchange In return we ask for you to support our goal of best in class service Help us meet our commitments to you by providing us with your information in a timely manner Communicate all challenges concerns complaints or newly developed needs immediately Never think twice about it We can help when we know challenges exist iPlanRx Service Contacts General Service Questions Tom Madden Partner p 920 221 1633 Account Manager Susie Prokop p 920 221 1680 e tom madden iplanrx com e susie prokop iplanrx com Marketplace Health Exchange Assistance Darryl Bernhardt Benefit Consultant p 920 397 7731 Ryan Quigley Benefit Consultant p 920 489 3459 e darryl bernhardt iplanrx com e ryan quigley iplanrx com Download our Smartphone App at www iplanrx com Simple Transparent Empowering Shop Rx s See Procedure Estimates Find Providers iPlanRx 375 AMS Court Ste B Green Bay WI 54313 920 569 2508

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1570 Midway Pl Menasha WI 54952 Fax 920 720 1904 Membership Application and Change Form Name of Employer Date of Full Time Employment Group Rate Code Effective Date Date of Change Coverage Reason for Application Change HMO New Subscriber Address Change Give addition change explanations here POS Add Dependent Benefit Plan Change Dependent addition reason NationCare Termination COBRA Continuation Termination reason Network Options Dependent Termination Open Enrollment Dependent termination reason Other Name Change Waiver of Insurance Other Employee Information Last Name Legal First Name Nickname MI Address Apt City State Home Phone Status check Single Married Zip Hourly Salary Work Phone Union Non union Enrollment Section attach additional sheets of paper if necessary Dep 3 Dep 2 Dep 1 Sp Self Name Last First MI Birth date mm dd yr SSN SSN SSN SSN SSN Sex Disabled M Yes F No M Yes F No M Yes F No M Yes F No M Yes F No Relationship Primary Care Practitioner Name Strongly recommended Current Patient Self Yes No Spouse Yes No o Child o Stepchild o Grandchild o Guardianship o Child o Stepchild o Grandchild o Guardianship o Child o Stepchild o Grandchild o Guardianship Yes No Yes No Yes No Network Health Plan NHP and or Network Health Insurance Corporation NHIC as applicable requires all legal paperwork for insuring dependents involving guardianship and adoption Visit networkhealth com for an online Provider Directory to choose a primary care practitioner for yourself and dependents Other Insurance Coverage Information Do you or any dependents have other group medical insurance including Medicare Yes No If Yes does this other policy include pharmacy coverage Yes No Will this insurance continue after Network Health Plan begins Yes No Yes No Individuals who have other coverage Policyholder Name of insurance company Policy Is there a divorce decree establishing insurance responsibility Name of responsible party Date of birth Please provide Network Health Plan with a copy of the portion of the decree which states this responsibility SF 007 02 01 14 Over for signature

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Confidentiality Statement In completing this application I authorize any health care provider to release any of my medical information including those records pertaining to the testing and treatment of mental health alcohol and or substance abuse and HIV infection to Network Health Plan and or Network Health Insurance Corporation s medical and claims management personnel when reasonably related to my application for coverage through NHP and or NHIC as applicable By signing this authorization as the Employee or Spouse you also authorize the release of medical information for any covered minor dependents and or any covered dependents for which you have legal guardianship I also authorize any health care provider to release any and all of my medical records to NHP and or NHIC as applicable when reasonably related to coverage for quality measurement or administrative purposes This authorization is valid while my coverage is in effect or for as long as a claim is pending whichever is longer I understand I am entitled to inspect and obtain a copy of the released records and that I may revoke these authorizations at any time except to the extent that a health care provider has already acted in reliance upon them I also understand that I am or my authorized representative is entitled to receive a copy of this complete form By signing this form I authorize NHP and or NHIC as applicable to release this information for a period not to exceed 30 months from the date this application is signed If any law or provider requires an additional authorization for the release of medical records I will be required to sign a special consent for the release of this information I understand that NHP and or NHIC as applicable will make every effort to protect my privacy at all times and that member identifiable information will not be shared with my employer unless authorized by me the member I understand that failure to authorize the release of medical information to NHP and or NHIC as applicable may cause significant delays in the processing of my claims I also understand that NHP and or NHIC retain s the right to release claim information received from health care providers to NHP and or NHIC as applicable contracted entities to accomplish its obligations under the group contract All information furnished by me on this application is true and complete to the best of my knowledge Employee signature is not required in a cancellation due to termination but must be signed by the employer Employee Signature Date Employer Signature Date Network Health Plan and or Network Health Insurance Corporation Internal Use Only Effective Date Entered By Date HMO plans underwritten by Network Health Plan POS plans underwritten by Network Health Insurance Corporation or Network Health Insurance Corporation and Network Health Plan Fax this completed signed form to 920 720 1904 SF 007 02 01 14

Green Lake Presentation June 201

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