boo ®


2024

Enrollment

Guide


KeyStaff, Inc.


boongroup.com


Welcome!

Welcome to your health plan provided by KeyStaff, Inc.!


Plan Enrollment Options

SmartMEC

You have the option to enroll in the SmartMEC plan. SmartMEC offers you and your family affordable minimum essential coverage that covers


SmartMVP Silver

If you desire a higher level of coverage, you have the option to enroll in the SmartMVP Silver plan. SmartMVP Silver is a minimum value plan that services, hospital stays and more.



Weekly Cost


SmartMEC

SmartMVP Silver

Less than $13.99/hr

$14.00 - $15.99/hr

$16.00 +

Employee Only

$10.82

$23.50

$34.93

$40.70

Employee & Spouse

$26.71

$145.45

$156.19

$161.96

Employee & Child(ren)

$35.56

$107.34

$118.08

$123.85

Employee & Family

$52.23

$200.96

$211.70

$217.47


Enrollment Instructions

dependents or update any relevant information and submit by the enrollment deadline. You can submit your form by one of the


Questions? Member Services is here to help!

Please do not hesitate to contact Boon Member Services at 866 868 4139 for any questions pertaining to your plan. Representatives are available to assist you Monday – Friday 6:00 am – 7:00 pm and Saturday – Sunday 9:00 am – 12:00 pm, Central Time.


We appreciate your participation and look forward to serving you.


Thank you!

Boon Administrative Services, Inc.

6300 Bridgepoint Parkway,

Bldg. 3, Suite 200

Austin, TX 78730

866 868 4139

boongroup.com



Plan Overview

Plan Coinsurance

100%

Individual Deductible

$0

Individual Coinsurance Limit

$0

Lifetime Maximum

Unlimited

ACA Required Preventive Care / Screening

100%


MEC Coverage Overview

Routine Physical Exam

Flu and Pneumonia Vaccines

Well Woman Exam (Annual)

Bone Density Test

Annual Mammogram

Routine Immunizations

Annual Pap Smear and Other Routine Lab

Well Baby / Well Child Care Exam

Breast Thermography


Counseling

Obesity & Healthy Eating


Contraception

FDA approved contraceptive methods

Treating Depression

Sterilization procedures

Alcohol & Drug Abuse


Smoking Cessation

Does not include abortifacient drugs

Domestic & Interpersonal Violence


Cancer Screenings

Cervical Cancer

Sexually Transmitted Diseases

Breast Cancer


Routine Lab, X-Rays, Diagnostic Testing, & Other Medical Screenings


Colorectal Cancer

Diabetes

Lung Cancer

Cholesterol

The recommendations and guidelines may be found here:


www.uspreventiveservicestaskforce.org/ or

SmartMEC Plan

Administered by Boon Administrative Services, Inc.


Minimum Essential Coverage Plan - with Dependents


This plan intends to comply with the Patient Protection and Affordable Care Act’s (PPACA) requirement to offer coverage for certain preventive services without cost-sharing. To comply with PPACA, and in accordance with the recommendations and guidelines, the Plan will provide overage for:

  1. Evidence-based items or services rated A or B in the United States Preventive Services Task Force recommendations;

  2. Recommendations of the Advisory Committee on Immunization Practices adopted by the Director of the Centers for Disease Control and Prevention;

  3. Comprehensive guidelines for infants, children, and adolescents supported by the Health Resources and Services Administration (HRSA); and

  4. Comprehensive guidelines for women supported by the Health Resources and Services Administration (HRSA).



Preventive Care Services for Adults

Charges for covered Preventive Services as listed below:


  1. ages who have ever smoked;

  2. Alcohol Misuse screening and counseling;

  3. Aspirin use for men and women of certain ages;

  4. Blood Pressure screening for all adults;

  5. Cholesterol screening for adults of certain ages or at higher risk;

  6. Colorectal Cancer screening for adults over 50, including bowel preparation medications, physician charges, facility charges, anesthe- sia charges, specialist consultation prior to preventive colonoscopy

    if recommended by attending provider and polyp biopsy associated with preventive colonoscopy;

  7. Depression screening for adults;

  8. Type 2 Diabetes screening for adults with high blood pressure and adults who are overweight;

  9. Diet counseling for adults at higher risk for chronic disease;

  10. Fall Prevention, to include physical therapy and Vitamin D supplemen- tation in community dwellings, ages 65+;

  11. Hepatitis B screening for non-pregnant adults and adolescents;

  12. Hepatitis C screening for adults at high risk;

    Preventive Care Services for Children

    Charges for covered Preventive Services as listed below:

    1. Alcohol Misuse screening and counseling for adolescents; 2.

    1. Autism screening for Children at 18 and 24 months;

    2. Behavioral assessments / Well-Child visits for Children of all ages as

    4. Cervical Dysplasia screening for sexually active females;

    5. Congenital Hypothyroidism screening for newborns;

    6. Depression screening for Children at doctor’s discretion;

    8. Dyslipidemia (Cholesterol) screening for Children at higher risk of

    10. Gonorrhea preventive medication for the eyes of all newborns;

    11. Hearing screening for all newborns;

    12. Height, Weight and Body Mass Index measurements for children as

    13. Hematocrit or Hemoglobin screening for Children;

    14. Hemoglobinopathies or sickle cell screening for newborns;

    15. HIV screening for adolescents at higher risk;

    16. Immunizations for Children from birth to age 18 - doses, recommend- ed ages, and recommended populations vary: Diphtheria, Tetanus,

      Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Rotavirus; and Varicella


  13. HIV screening for all adults at higher risk;

  14. Immunizations for adults-doses, recommended ages, and recom- mended populations vary: Hepatitis A; Hepatitis B; Herpes Zoster; Hu-

    Meningococcal; Pneumococcal; Tetanus, Diphtheria, Pertussis; and Varicella;

  15. Lung Cancer screening for adults ages 55-80 who smoke 30 packs per year

  16. Obesity screening and intensive, multicomponent behavioral interven-

  17. (PSA) test for men age 50 and over or age 40 with risk factors;

  18. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk;

  19. Syphilis screening for all adults at higher risk;

  20. Tobacco Use screening for all adults and cessation interventions for tobacco users;

  21. Well Adult Routine Physical Exams.


  1. Iron supplements for Children ages 6 to 12 months at risk for anemia;

  2. Lead screening for children at risk of exposure; 21.


22.


23.


  1. Phenylketonuria (PKU) screening for this genetic disorder in new- borns;

  2. Prenatal and related preventative care related to the pregnancy of a dependent child;

  3. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk;

  4. Skin cancer behavioral counseling for children 10-24 who have fair skin

  5. Tobacco screening, counseling and cessation interventions for chil- dren and adolescents

  6. Tuberculosis screening for children at doctor’s discretion for children at high risk; and

  7. Vision screening for all Children.

    SmartMEC Plan

    Administered by Boon Administrative Services, Inc.


    Charges for covered Preventive Services as listed below:


    1. Anemia screening on a routine basis for pregnant women;

    2. Aspirin for treatment of pre-eclampsia in pregnant women;

    3. Bacteriuria urinary tract or other infection screening for pregnant women;

    4. BRCA counseling about genetic testing for women at higher risk;

    5. Breast Cancer Mammography screenings every year for women over 40;

    6. Breast Cancer Chemoprevention counseling for women at higher risk;

    7. Breastfeeding comprehensive support and counseling from trained providers, as well as the purchase of breast pumps, for pregnant and nursing women;

    8. Cervical Cancer screening for sexually active women;

    9. Chlamydia Infection screening for younger women and other women at higher risk;

    10. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures (including facility charges, physi- cian charges and anesthesia charges), and patient education and counseling, not including abortifacient drugs;

    11. Depression screening for pregnant and postpartum women as provid-

    12. Domestic and interpersonal violence screening and counseling for all women;

    13. Folic Acid supplements for women who may become pregnant;


    14. Gestational diabetes screening for women 24 to 28 weeks pregnant,

      -

      tional diabetes;

    15. Gonorrhea screening for all women at higher risk; 16.

17.

sexually active women;

  1. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older;

  2. Osteoporosis screening for women; 1 time per year, women age 65 years and older; 1 per year for younger women if recommended by a physician.

  3. Rh Incompatibility screening for all pregnant women and followup testing for women at higher risk;

  4. Tobacco Use screening and interventions for all women, and expand- ed counseling for pregnant tobacco users;

  5. Sexually Transmitted Infections (STI) counseling for sexually active women;

  6. Syphilis screening for all pregnant women or other women at in- creased risk; and

  7. Well-woman visits to obtain recommended preventive services,


    Limitations and Exclusions

    Some health care services are not covered by the Plan. The following is an example of services that are generally not covered. See plan documents for a



    Charges for the treatment of illness or disease, or charges other than those that are:








•


endurance or physical performance


Get the Most From Your Benefits With First Health Network Providers

As a member of a health plan that offers you the First Health Network for your medical care, you have access to a national network of providers and great savings. Using providers that participate in the First Health Network is the easiest way to maximize your benefits.

The First Health Network

By going to a First Health provider, you can reduce your out-of-pocket expenses and stretch your benefit dollars. In addition:

Maximize Your Benefits

Unlike non-participating doctors and hospitals, First Health Network providers have agreed to provide services for discounted fees. Therefore, you can stretch your benefits and reduce your out-of-pocket expenses by using participating First Health Network providers.

Compare network and non-network costs

The following example shows how benefits would be calculated when an in-network provider is used, versus an out-of-network provider. This example is for illustration purposes only and is not specific to your plan of benefits.

Example - Office Visit


First Health provider

Non-network provider

Your office visit

$250.00

$250.00

Provider discount

- $150.00

$0

Total charge with discount applied

$100.00

$250.00

Plan covers

$80.00

$125.00

Your total responsibility

$20.00

$125.00


Find a Network Provider

The most convenient way to find a doctor, hospital or other health care service provider participating in the First Health Network is by searching our online provider directory at www.firsthealthlbp.com. The electronic provider directory, available 24 hours a day, 7 days a week, includes the most detailed provider information available and is constantly updated. You can also call your administrator for assistance in locating a provider, at 1-866-868-4139.


5/13 ©2013 First Health Group Corp. All rights reserved.

PRESCRIPTION DRUG COVERAGE AND MEDICARE


Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.



Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.




Your employer has determined that the prescription drug coverage offered by your employer’s plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays. Therefore, your coverage is considered .

.


You can keep your current coverage from your employer’s plan. However, because your coverage is non-creditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on

are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully—it explains your options.


When Can You Join A Medicare Drug Plan?

.


When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

Since the coverage under your employer’s plan is not creditable, depending on how long you go without creditable prescription drug

that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19%


What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

affected.


Contact the person listed below for further information.

You’ll get this notice each year. You will also get it before the next period

For More Information About This Notice Or Your Current Prescription Drug Coverage

time.


For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at , or call them at .

SmartMVP Silver Buy-Up Plan

Benefit Overview of plan features. Please see Plan Summary for detailed information about the benefits and exclusions that shall prevail over the terms of this benefit overview.


SmartMVP Silver Self-Funded Medical Benefits


Plan Coinsurance 100%


Individual / Family Deductible $0 / $0


Individual / Family Maximum Out of Pocket $3,150 / $12,700 Lifetime Maximum Unlimited

Doctor’s Office & Specialist Office Visits

Office Visit Copay Specialist Copay

Prescription Drug Benefit

Generic Prescription Copay Preferred Brand Prescription Copay

Non-Preferred Brand Prescription Copay (Specialty Drugs excluded)


Emergency Room Copay


$15

$25


$15

$25

$75


$400


Urgent Care Copay $200


Outpatient Laboratory and Professional Services Copay

(Not covered if services are provided at a hospital)


Outpatient X-rays and Diagnostic Imaging

(Not covered if services are provided at a hospital)


Outpatient Imaging (CT, PET scans, MRI) Copay

(Not covered if services are provided at a hospital)


Hospitalization (Room & Board Only)

including MHSA (Mental Health & Substance Abuse)

Plan Coinsurance

Per Admission Copay

Maximum number of covered days per plan year


Preventative Care/Screening/Immunization Services (MEC)


$50


$50


$400


60%

$500

10 days

100% Covered


Disease Management Included


Medicare Reference Reimbursement @1 0% Included






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Provide your ID card information on the phone


you didn’t pay your Patient Responsibility at the time of service,


Your Patient Advocate will


However, the end result will save you money and help drive


you didn’t pay your Patient Responsibility at the time of service,


Your Patient Advocate will


However, the end result will save you money and help drive


Condition coaching:

Ready to do something good for yourself? Now, it’s easier than ever. This personalized coaching program can help you eat better, get more active and manage a health condition. You choose how to use the program. You can go at your own pace with online digital coaching. Or you can work with a coach in live, group coaching sessions or one to one over the phone.

MyActiveHealth website:

Managing your health can be challenging. But the tools that help you don’t have to be. That’s why we’ve made it easy to track your activity, get wellness advice, find healthy recipes and more. Whatever gets you closer to achieving your health goals. You’ll find it online at MyActiveHealth.com/BoonGroup

ActiveHealth app:

Always on the go? No problem. The ActiveHealth app is ready for you wherever you are. Just search for “ActiveHealth” in your app store and download the app.

Health Actions:

Small actions matter — especially when it comes to staying at your best health. You’ll get notifications from ActiveHealth with important steps to take to help you achieve your best health. We call these Health Actions. Track them online on MyActiveHealth.com/BoonGroup

Maternity support:

Pregnancy is an exciting time in your life. You may have a lot of questions or need support. Even if you’re an experienced mom. This program includes support and resources just for you. You can even call and speak to a nurse coach if you want.

Case management:

Your health should be front and center. That’s true whether you’re managing a chronic condition or recovering from an injury. Or maybe you’re dealing with another challenge. We’ll pair you with an experienced nurse. Your nurse coach can help take care of the details of whatever you’re facing. That leaves you free to focus on getting better.



You can get started today. Call 877-749-6997

or log on MyActiveHealth.com/BoonGroup


Services are provided by ActiveHealth Management, Inc. Our programs, care team and care managers do not provide diagnostic or direct treatment services. We assist you in getting the care you need, and our program is not a substitute for the medical treatment and/or instructions provided by your health care providers.

©2020 ActiveHealth Management, Inc.


Feel better, get active and be healthier with your wellness program

Don’t miss out! Your wellness program includes:

PROGRAM OVERVIEW

GENERAL NOTICE CONTINUATION COVERAGE RIGHTS UNDER COBRA

Introduction

You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. When you become eligible for COBRA, you may also be eligible for other coverage options that may cost less than COBRA continuation coverage.


The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985(COBRA). COBRA Continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.


You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower-out-ofpocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan) even if that plan generally doesn’t accept late enrollees.


What is COBRA Continuation Coverage?

COBRA Continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.


If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens:



When is COBRA Coverage Available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to the employer, or the employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.


You Must Give Notice of Some Qualifying Events

For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must send written notice of a qualifying event to the Plan Administrator at the following address:

. The notice must identify the qualifying event and the date such event occurred and include any supporting documentation available (such as a divorce decree) and the name and address of all qualified beneficiaries whose coverage is affected by the qualifying event.


How is COBRA Continuation Coverage Provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.


COBRA continuation coverage is a temporary continuation coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

boongroup.com

There are also ways in this 18-month period of COBRA continuation coverage can be extended:


Disability extension of 18-month period of continuation coverage

If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the

18-month period of continuation coverage. In the event that you become disabled prior to the 60th day of COBRA continuation coverage, you must provide a notice of such disability within 60 days of receiving a disability determination from the Social Security Administration, and in no event later than the expiration of the 18-month period of continuation coverage to the following:


. Please include any available supporting documentation pertaining to the disability, including the Social Security Administration determination of disability.


Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. In

the event that you experience a second qualifying event while you are receiving COBRA Continuation Coverage, within 30 days of such qualifying event, please provide notice to:


. The notice must identify the qualifying event and the date such event occurred and include any supporting documentation available (such as a divorce decree) and the name and address of all qualified beneficiaries whose coverage is affected by the qualifying event.


Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at .


Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?

In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period to sign up for Medicare Part A or B, beginning on the earlier of

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.


If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.


For more information visit .


If You Have Questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at

. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.). For more information about the Marketplace, visit .


Keep Your Plan Informed of Address Changes

In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should keep a copy, for your records, of any notices you send to the Plan Administrator.


Plan Contact Information

For more information concerning your rights under COBRA, please contact:


boongroup.com

PRESCRIPTION DRUG COVERAGE AND MEDICARE



Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.



Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.


Your employer has determined that the prescription drug coverage offered by your employer’s plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.


When Can You Join A Medicare Drug Plan?

.


However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.


What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current coverage through your employer’s plan will not be affected.


When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with your employer and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.


If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Boon changes. You also may request a copy of this notice at any time.


For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:


If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at , or call them at .


  1. If you need your prescription filled right away, ask your doctor to write two prescriptions for your long-term medicines:

  2. Complete the mail service order form. You can fill out and print the form online at Caremark.com by clicking on New

    Prescriptions. An incomplete form can cause a delay in processing.

  3. Mail your order form along with your prescription(s) and payment in the envelope provided, or use your own envelope to mail the form and payment to the CVS Caremark Mail Service Pharmacy address printed on the form. You can pay using an electronic check, Bill Me Later®, or credit card (VISA®,

    MasterCard®, Discover®or American Express®). Or you can pay by check or money order. Do not send cash.


  4. Allow up to 1O days from the day you submit your order for delivery of your medicine.


If you're not in a hurry to get your medicine, then just get a 90-day prescription from your doctor to send to CVS Caremark.


Tips for saving time and money.

  1. Ask your doctor about generic medicines. Research shows that you can save an average of 30% to 80%** when you fill your prescriptions with a generic instead of a brand-name drug.


  2. If your prescription benefit program has a Preferred Drug List, print a copy of the list from

    Caremark.com and take it with you to your doctor's office. Using medicines on this list may save you and your prescription plan money.

  3. Make sure the prescription you receive from your doctor is legible. It should include the patient's full name,

Caremark.com puts the power in your hands.

the prescribing doctor's contact information and the prescription details - including the date it was written.



Register today at Caremark.com to actively manage your own health and wellness. You will need information from your benefit ID card to register.


CVS

CAREMAfx.K

www.caremark.com


*Copayment,copay or coinsurance means the amount a plan participant isrequired topay for a prescription in accordance with a Plan,whichmay be a deductible,a percentage of the prescription price,a fixedamount, orother charge,with the balance,if any,paid by the Plan.

**Theamount of your savings willbe based on yourbenefit plan. Source:GenericPharmaceutical Association's Web site: www.gphaonline.org


©2008 Caremark. All rights reserved. 106-13586 08.08 [PP] QTY



tend to arrive sooner.


Allow up to 10 days from the day you submit your order for delivery of your medicine. Regular delivery is free. Overnight or second-day delivery is available for an additional charge.


Packaged for safety.

Your medicine will be mailed to you in plain, tamper-proof packaging. An order form and a

return envelope are included with every delivery. All items in your order typically arrive in one package. If an item is not available, CVS Caremark will contact you to determine if you want the available items shipped or held until all items are ready.


Special handling.

Certain items require special handling and may be shipped by a faster method at no additional cost. In such cases, you may receive a call letting you know your order is being shipped.


coolers, and/or express delivery when necessary.


What you will pay.

Your benefit materials explain your copayment* or coinsurance for mail service. You can receive up to a 90-day supply of your medicine for a copay that may be significantly less than you would pay at a participating retail pharmacy. If you are unsure of your cost, contact your benefit provider, call the toll-free number listed on your benefit ID card or in your Welcome Kit, or check drug costs on Caremark.com.


If you will be traveling.

If you need your medicine shipped to a temporary address, you can let us know by phone, on your order form or by updating your profile on Caremark.com. If you need more medicine

while traveling than the quantity allowed by your prescriber or benefit plan (i.e., more than a 90-day supply), contact your benefit office for approval at least 30 days before you need a refill.


If your medicine looks different.

There may be times when a cost-saving generic drug is available to treat your condition. In this situation, you may receive the generic, unless your doctor tells us you must receive the brand-name medicine. A generic drug may look different, but all generic drugs are approved by the U.S. Food and Drug Administration to have the same active ingredients as the brand-name medicines


To learn more about your medicine.

Important information on common medicine uses, specific instructions and possible side effects is included with each order. If you need additional information, visit Caremark.com or call the toll-free number on your benefit ID card or in your Welcome Kit.

SPECIAL ENROLLMENT RIGHTS

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).


In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within “30 days” after the marriage, birth, adoption, or placement for adoption.



WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998


and Cancer Rights Act of 1998 (WHCRA). The Act provides for:




NEWBORN’S ACT DISCLOSURE


length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Version 2023.08.02



Notice of Premium Assistance Under Medicaid and the

Premium Assistance Under Medicaid and the



If you or your children are eligible for Medicaid or

your employer, your state may have a premium as- sistance program that can help pay for coverage, us- ing funds from their Medicaid or CHIP programs. If you

tance programs but you may be able to buy individ- ual insurance coverage through the Health Insur- ance Marketplace. For more information, visit www.healthcare.gov.


If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed be- low, contact your State Medicaid or CHIP office to find out if premium assistance is available.


If you or your dependents are NOT currently en- rolled in Medicaid or CHIP, and you think you or any

of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.in- surekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-spon- sored plan.


If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligi- ble under your employer plan, your employer must allow you to enroll in your employer plan if you

ro you must request cov-

erage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

Health & Welfare Plan Notices & Disclosures


If you live in one of the following states, you may be eligible for assistance from Medicaid in paying for your employer health plan premiums. The following list of states is current as of Jul. 31, 2023. Contact your State for more information on eligibility


ALABAMA | Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447

ALASKA | Medicaid

The AK Health Insurance Premium Payment Program

Website: http://myakhipp.com/ Phone: 1-866-251-4861

Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: https://health.alaska.gov/dpa/Pages/ default.aspx

ARKANSAS | Medicaid Website: http://myarhipp.com/

Phone: 1-855-MyARHIPP (855-692-

7447)

CALIFORNIA | Medicaid Website:

Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp

Phone: 916-445-8322

Fax: 916-440-5676

Email: hipp@dhcs.ca.gov

COLORADO | Health First Colorado

Child Health Plan Plus (CHP+) Health First Colorado Website:

https://www healthfirstcolorado.com/ Health First Colorado Member Con- tact Center: 1-800-221-3943/ State Relay 711

CHP+: https://hcpf.colo- rado.gov/child-health-plan-plus CHP+ Customer Service: 1-800-359- 1991/ State Relay 711

Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692- 6442

FLORIDA | Medicaid Website:

https://www.flmedicaidtplrecov- ery.com/flmedicaidtplrecov- ery.com/hipp/index.html

Phone: 1-877-357-3268

GEORGIA | Medicaid

GA HIPP Website: https://medi- caid.georgia.gov/health-insurance- premium-payment-program-hipp Phone: 678-564-1162, Press 1

GA CHIPRA Website: https://medicaid.georgia.gov/pro- grams/third-party-liability/childrens- health-insurance-program-reauthori- zation- act-2009-chipra

Phone: 678-564-1162, Press 2

INDIANA | Medicaid

Healthy Indiana Plan for low-income adults 19-64

Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479

All other Medicaid

Website: https://www.in.gov/medi- caid/

Phone: 1-800-457-4584

IOWA Medicaid and CHIP (Hawki) Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki

Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/mem- bers/medicaid-a-to-z/hipp

HIPP Phone: 1-888-346-9562

KANSAS | Medicaid Website: https://www.kan- care.ks.gov/

Phone: 1-800-792-4884

HIPAA Phone: 1-800-967-4660

KENTUCKY | Medicaid

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agen- cies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328

Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kid- shealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718

Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dms

LOUISIANA | Medicaid

Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp

Phone: 1-888-342-6207 (Medicaid

hotline) or 1-855-618-

5488 (LaHIPP)

MAINE | Medicaid Enrollment Website:

https://www.mymaineconnec- tion.gov/benefits/s/?language=en_US Phone: 1-800-442-6003

TTY: Maine relay 711

Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/ap- plications-forms

Phone: 1-800-977-6740

TTY: Maine relay 711

MASSACHUSETTS | Medicaid and CHIP

Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840

TTY: 711

Email: masspremassistance@accenture.com

MINNESOTA | Medicaid

Website: https://mn.gov/dhs/people- we-serve/children-and-fami- lies/health-care/health-care-pro- grams/programs-and-services/other- insurance.jsp

Phone: 1-800-657-3739



Page 2

Health & Welfare Plan Notices & Disclosures


MISSOURI | Medicaid

Website: http://www.dss.mo.gov/ mhd/participants/pages/hipp.htm Phone: 573-751-2005

MONTANA | Medicaid

Website: http://dphhs.mt.gov/Mon- tanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Email: HHSHIPPProgram@mt.gov

NEBRASKA | Medicaid

Website: http://www.ACCESSNe- braska.ne.gov

Phone: 1-855-632-7633

Lincoln: 402-473-7000

Omaha: 402-595-1178

NEVADA | Medicaid Medicaid Website: https://dhcfp.nv.gov

Medicaid Phone: 1-800-992-0900

NEW HAMPSHIRE | Medicaid Website: https://www.dhhs.nh.gov/programs- services/medicaid/health-insurance-pre- mium-program

Phone: 603-271-5218

Toll free number for the HIPP pro- gram: 1-800-852-3345, ext. 5218

NEW JERSEY | Medicaid and CHIP Medicaid Website: http://www.state.nj.us/human- services/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamily care.org/ index.html

CHIP Phone: 1-800-701-0710

NEW YORK | Medicaid Website:

https://www.health.ny.gov/health_ca re/medicaid/

Phone: 1-800-541-2831

NORTH CAROLINA | Medicaid Website: https://medi- caid.ncdhhs.gov/

Phone: 919-855-4100

NORTH DAKOTA | Medicaid Website: https://www.hhs.nd.gov/healthcare Phone: 1-844-854-4825

OKLAHOMA | Medicaid and CHIP Website: http://www.insureokla- homa.org

Phone: 1-888-365-3742

OREGON | Medicaid

Website: http://healthcare.ore- gon.gov/Pages/index.aspx Phone: 1-800-699-9075

PENNSYLVANIA | Medicaid and CHIP Website: https://www.dhs.pa.gov/Services/As- sistance/Pages/HIPP-Program.aspx Phone: 1-800-692-7462

CHIP Website: https://www.dhs.pa.gov/CHIP/Pages/ CHIP.aspx

CHIP Phone: 1-800-986-KIDS (5437)

RHODE ISLAND | Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347, or 401-462-

0311 (Direct RIte Share Line)

SOUTH CAROLINA | Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820

SOUTH DAKOTA | Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

TEXAS | Medicaid Website:

https://www.hhs.texas.gov/ser- vices/financial/health-insurance-pre- mium-payment-hipp-program Phone: 1-800-440-0493

UTAH | Medicaid and CHIP Medicaid Website: https://medi- caid.utah.gov/

CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

VERMONT | Medicaid Website: https://dvha.ver-

mont.gov/members/medicaid/hipp- program

Phone: 1-800-250-8427

VIRGINIA | Medicaid and CHIP Website: https://coverva.dmas.vir- ginia.gov/learn/premium-assis- tance/famis-select https://coverva.dmas.vir- ginia.gov/learn/premium-assis- tance/health-insurance-premium-pay- ment-hipp-programs

Medicaid/CHIP Phone: 1-800-432-

5924

WASHINGTON | Medicaid Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

WEST VIRGINIA | Medicaid and CHIP Website: https://dhhr.wv.gov.bms/ http://mywvhipp.com/

Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855- MyWVHIPP (1-855-699-8447)

WISCONSIN | Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/badg- ercareplus/p-10095.htm

Phone: 1-800-362-3002

WYOMING | Medicaid Website:

https://health.wyo.gov/healthcare- fin/medicaid/programs-and-eligibility/ Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since Jul. 31, 2023, or for more information on spe- cial enrollment rights, contact either:


U.S. Department of Labor

Employee Benefits Security Administration

www.dol.gov/agencies/ebsa

1-866-444-EBSA (3272)

U.S. Department of Health and Human Services

Centers for Medicare & Medicaid Services

www.cms.hhs.gov

1-877-267-2323, Menu Option 4, Ext. 61565


Page 3


Boon Administrative Services, Inc.

6300 Bridgepoint Parkway,

Bldg. 3, Suite 200

Austin, TX 78730

866 868 4139

boongroup.com