2015-2016
Table of Contents
Introductory Letter
...2
About Your Benefits...3-4
Important Benefit Rules & Recommendations...5
Dependent Audit Information...6-11
Benefit Enrollment System Quick Guide (WORKTERRA)...12-13
Important Contact Information...14
Health and Dental Rate Sheet...15
Core Health Plan Highlights (BCBSNC)...16-19
Basic Health Plan Highlights (BCBSNC)...20-23
Dental Plan (Delta Dental)...24-25
Vision Plan (Superior Vision)...26
Employee Assistance Plan (ComPsych)...27-28
Basic & Supplemental Term Life Insurance & AD&D Benefits (RSLI)...29-30
Short Term Disability (RSLI)...31-33
Long Term Disability (RSLI)...34-36
Flexible Spending Accounts (FSA) (Laymon Group)...37-38
Healthcare Reimbursement Arrangement (HRA) (Laymon Group)...39-40
Worksite Benefits (Transamerica)………...41-43
Critical Illness, Cancer, Accident, Hospital Indemnity, & Whole Life Insurance
Legal Plan (Hyatt/MetLaw)...44
Auto and Home Insurance (Liberty Mutual)...45
Long Term Care Insurance (New York Life)...46-47
Time Off Benefits...48-51
Retirement Benefits...52-53
COBRA Continuation Benefits (P & A Group)...54-55
About This Guide and Key Terms...56
Notice of Privacy Information Practices...57
July2015
Dear City Employee:
We’d like to welcome you to the start of another open enrollment season. It is our pleasure to provide you with this important resource regarding your benefits at the City of Durham. This guide has all of the information you will need for open enrollment and throughout the year so that you can make educated decisions that are right for you and your family. Open Enrollment is a great time to review your existing benefit plans, evaluate any anticipated needs, learn more about your benefits and make adjustments for the upcoming year.
Your benefits make up an important part of your total compensation. The City of Durham offers a comprehensive benefits package for our employees and their eligible dependents. Our benefits program provides a flexible approach to certain City benefits, allowing you to select coverage that best meetsyour needs. We have placed a major focus on enhancements to the City’s Wellness program in order to create a culture of wellness. The 2015-2016plan design continues our effort to be more involved in your health care decisions, to take advantage of preventive health care options, and to adopt a healthy lifestyle.
We encourage you to continue getting the most from your healthcare benefits by expanding your awareness, attending education sessions,reading articles and specialannouncements about health programs that may be useful to you and your family.
The City’s 2015 annual OPEN ENROLLMENT period will occur July 6, 2015 - July 30, 2015. There are several changes to the benefits offering this year, therefore everyone will be required to log into the automated open enrollment tool, Workterra, to select their benefits. Remember, annual enrollment is the only chance you have each year to adjust your benefits, except for qualifying events or when court ordered. Your benefit plan changes must be completed and submitted no later than 5:00 PM Thursday, July 30, 2015. Please enroll online at www.workterra.net for health, dental, vision, life,long term disability, short term disability, Hyatt Legal Plans and flexible spending accounts.
For voluntary benefits with Transamerica, Liberty Mutual and New York Life you will be able to meet with enrollment counselorsfor assistance. The schedule of site locations and times can be found on CODI.
We look forward to working with you! Human Resources Department
About Your Benefits
Choosing Your Benefits
Some benefits such as basic life insurance are automatic.You don’t have to choose them because the City of Durham pays the entire cost. The benefitsthat you pay for, you must actively choose. Your portion of the cost is automatically taken out of your paycheck. There are two ways that the premiums can be deducted from your paycheck:
PRE-TAX premiums are collected for Medical, Dental, Vision, Pre-Paid Legal,and Flexible Spending Accounts.
POST-TAX premiums are collected for the following optional benefit plans: Short-Term Disability, Long-Term Disability,Long-Term Care, and Supplementaland Dependent Life Insurance.
Making Changes
Employee benefit elections must be made before the start of each plan year during open enrollment or as part of thenew hire benefits enrollment process.
In 2016, the City of Durham will be changing the benefit year to coincide with the City of Durham’s fiscal year. The 2015-2016 benefit year will end on June 30, 2016. Generally, you can only change your benefits choices during the annual open enrollment period. However, you can change your applicable benefit plans during the year if you have a qualifying event. A list of qualifying events follows:
Marriage
Divorceor legalseparation Addition of Certified Dependent
Birth, adoption, or placement for adoption of an eligible child
Death of spouse or covered child
Change in spouse’s or certified partner’s work status that affects benefits eligibility (e.g., starting a new job, leaving a job, or leave of absence)
A significant change in spouse’s or certified partner’s health coverage attributable to your spouse’s or certified partner’s employment(e.g., open enrollment of spouse)
A change in your child’s eligibility for benefits
Becoming eligible for Medicare or Medicaid
Commencement of or returning from an unpaid leave for employee/spouse
If you have a qualifying event, you must notify the Benefits Team in Human Resources with the appropriate paperwork within 30 days.Depending on the type of change, you may need to provide proof of the change (e.g.,a copy of a marriage license or birth certificate). If you do not notify Human Resources within 30 days, you will have to wait until the next annual enrollment period to make benefits changes unless you have another family status change.
Any changes you make to your benefits choices must be directly related to the family status change. Financial hardship is not a change in life status that qualifies for changing or stopping contributions for your insurance coverage or Flexible Spending Account.
The IRS has strict regulations regarding changes to insurance coverage and Flexible Spending Account plans that allow payroll deductions on a pre-tax basis. Once you have elected your coverage and contribution amounts, you cannot start, change, or cancel them during the benefit period unless you have a qualifying change in your life status.
The new insurance medical and dental premium deduction will appear on your second August2015paycheck. All other deductions for the 2015-2016plan years, if you choose to participate, will begin on your first
September 2015paycheck.
When Coverage Ends
Health and dental benefits will end according to your termination date. If you terminate on or before the 15th
of the month, health and dental benefits will terminate at the end of the current month. If you terminate on or after the 16thof the month, health and dental benefits will end on the last day of the following month.
Disabilityand life insurance benefits will end on the date of termination.
Flex spending will end on the date of termination. All claims filed must have a date of service before the termination date and must be submitted within 90 days ofthe termination date.
Transamerica, Colonial, New York Life Long Term Care, Liberty Mutual, Hyatt/MetLaw Legal, the City paid Reliance Standard basic life insurance and supplemental policies are portable. If employees wish to continue coverage following termination, it is their responsibility to contact the carrier.
If you have a covered dependent, the dependent’s coverage will end on the last day of the month in which the dependent’s 26th birthday falls unless that dependent is unmarried, and mentally or physically handicapped, and incapable of self-support.
Eligibility for Healthcare Benefits
All full time and specified part-time or temporary-with-benefits employees (not all benefits may apply to temporary-with-benefits employees) are eligible for medical coverage beginning on the first day of month following date of employment. You may also enroll eligible dependents, which include your:
spouse;
certified dependent (same-sex or opposite-sex partners) *;
natural children, step children, adopted children, and children of certified dependents (up to age 26);
court ordered children (up to age 26); and
unmarried children who are mentally or physicallyhandicapped and incapable of self-support, regardless of age.
Contact HR Connect for Questions at 919-560-4214.
Important Benefit Rules & Recommendations
Each employee is responsible for insuring that benefit deductions are correct for thecoverage enrolled. Each employee should carefully review deductions for accuracy and report any errors to Human Resources immediately.
The City of Durham will refund a maximum of thirty (30) days’ deductions in the event that deductions are inaccurate.
There can be no changes, other than those defined as qualifying event changes, after Open Enrollment ends. Qualifying events are as follows:
Marriage
Divorce or legal separation
Addition of Certified Dependent
Birth, adoption, or placement for adoption of an eligible child
Death of spouse or covered child
Change in spouse’s or certified partner’s work status that affects benefits eligibility (e.g., starting a new job, leaving a job, or leave of absence)
A significant change in spouse’s or certified partner’s health coverage attributable to your spouse’s or certified partner’s employment (e.g., open enrollment of spouse)
Change in your child’s eligibility for benefits
Becoming eligible for Medicare or Medicaid
Commencement of or returning from an unpaid leave for employee/spouse
Family status changes must be made within thirty (30) days of the event constituting the change. Employees must provide appropriate documentation of the change within the thirty (30) day period.
Employee family status changes occurring outside the open enrollment period may only be made within a plan tier, i.e. from “Employee” to “Employee/Spouse.” An employee may not make a change from plan to plan, i.e. from “Core” to “Basic.”Durham – Where Great Things Happen CITY OF DURHAM
Memorandum
Date: July 2, 2015 To: City Employees
From: Germaine Brewington, Department of Audit Services Director
Re: City of Durham Benefits Verification Performance Audit
We are all aware of how important it is to have adequate healthcare coverage, and how expensive paying for healthcare can be for you and for the City of Durham. Over the years, the City has worked hard to provide you and your dependents with quality health benefits. As part of thisgoal, this year the Audit Services staff will conduct a dependent verification audit. The purpose of this audit is to ensure that each spouse and dependent enrolled for Health and Dental benefits through the City is accurately listed and eligible for coverage.
We are confident this process will ensure that eligible dependentsare covered in a fair and equitable manner. All employees whoare covering a spouse or other dependents will be required to participate. In the very near future enrollment for the plan year beginning September 2015 will open. All employees whowill beelecting to covera spouse/dependent should gather and review documents during the open enrollment period (July2015)to ensure that you have the appropriate documents to verify eligibility for yourdependents/spouse. The definition of eligibility is attached. The documents that will be used to verify eligibility are also included in the attachments.
In September, a sample of employeeswill be selected from the total pool of all employees that are covering aspouse/dependent on their health benefits. Selected employeeswill be asked to provide documentation to support eligibility. Please look at the attached timeline for more details regarding this process; and your role in the process.
Claiming someone on your benefits who does not qualify as an eligible dependent is a violation of the City’s Ethics Policy and could lead to sanctions up to and including termination and repayment of claims.
It is important for you to know that the documents examinedwill be used solely to verify that dependent eligibility has been satisfied based on the rules stated in the Benefits Summary Guide that will be forthcoming. The Audit Services Department staff will take all necessary precautions to maintain the confidentially of this information.
If you have any questions please do not hesitate to e-mail me or call me at 560-4213 x 14244.
cc: Thomas J. Bonfield, City Manager
Durham – Where Great Things Happen CITY OF DURHAM
Memorandum
Dependent Verification Summary Timeline
Date Action Item
July 2015 Initial notification letter sent to all employees.
July 2015 Open enrollment period (Allemployees that are
covering a spouse/dependent should gather and review their relevant documents to support eligibility).
September2015 Sample of employees selected. Employees will
be notified via a letter.
September/October2015 Audit field work will be conducted.
Eligible Dependents and Required Documentation for Health and Dental Insurance
Dependent Type Definition Required Verification DocumentsSpouse An individual to whom you are legally
married Government Issued Marriage Certificate one of your Federal Tax Return filed within the last 2 andpage years– OR – Government Issued Marriage Certificate andProof of Joint Ownership Issued within the last 6 Months– OR – Government Issued Marriage Certificate ONLY if Married in the Current Calendar Year
Certified Dependent An individual that has reached the age of 18, is not married to anyone else, and who lives in a long term relationship of indefinite duration with a City of Durham employee, with the exclusive mutual commitment in which they share the necessities of life and are financially interdependent. See policy HRM-110-1 for full definition.
A notarized copy of the Application and Affidavit to Designate Certified Dependent and the enrollment application forms as required by policy HRM-510-1
Natural Child
(up to age 26) Biological child Government Issued Birth Certificate that names the parents of child Step Child
(up to age 26) A child of one’s spouse Government Issued Birth Certificate that names the parents of child andGovernment Issued Marriage Certificate of Employee and Spouse andpage one of your Federal Tax Return filed within last 2 years– OR – Government Issued Birth Certificate that names the parents of childandGovernment Issued Marriage Certificate of Employee and Spouse andProof of Joint Ownership Issued withinlast 6 Months– OR – Government Issued Birth Certificate that names the parents of child and Government Issued Marriage Certificate ONLY if Married in the Current Calendar Year
Child of Certified
Dependent Biological child of Certified Dependent Government Issued Birth Certificate that names the parents of child andan Application andAffidavit to Designate certified Dependent on file with the City of Durham
Disabled Child A biological child, stepchild, or adopted child that has been medically certified as disabled
Government Issued Birth Certificate that names the parents of child andpage one of your Federal Tax Return filed within last 2 years and proof of medical disability
Adopted Child A child that has been legally adopted
through the judicial process Adoption Certificate Tax Return filed withinandlastpage one of your Federal 2 Years– OR – Official Adoption Placement Agreement andSigned Petition for Adoption
Court Ordered Child A child that the City of Durham is required to cover under the insurance as
mandated by State or Federal regulations
Documents noted above for natural child, step-child, disabled child or adopted child – OR – a copy of the court order stating that the employer is required to provide insurance to the child
Federal Tax Return – Only submit first page and black out all social security numbers and financial information Proof of Joint Ownership – Mortgage or rental agreement in both names, bank account or creditcard statement
CITY OF DURHAM
Human Resources Department
101 CITY HALL PLAZA| DURHAM, NC 27701 919.560.4214| F 919.560.4969
www.DurhamNC.gov
DEPENDENT ELIGIBLE REVIEW FREQUENTLY ASKED QUESTIONS
1. Why is the City of Durham conducting this verification review?
Your health insurance is a valuable benefit, but also a costly one. It becomes more costly to you and the city when ineligible dependents are covered. The review is to ensure that only eligible dependents are covered under your benefits. This will help us control costs and ensure regulatory compliance.
2. Why am I being required to submit verification of my family members but my coworker is not?
The initial group of employees selected to submit verification of family members is a sample of all employees with dependents covered under the City’s health plan. Based on the outcome of the initial review, the City of Durham will decide whether to expand the review to all employees with covered dependents.
3. What types of dependents are being verified?
Spouses, certified dependents and children.
4. Who does the City of Durham consider an eligible dependent?
Spouse;
Certified dependent (same-sex or opposite-sex partners);*
Children (eligible for coverage until age 26, regardless of any, or a combination of any, of the following factors: financial dependency, residency with parent, student status, employment and marital status)
o your natural children;
o your spouses or certified dependent’s natural children o your legally adopted children;
o unmarried children who are mentally or physically handicapped and incapable of self-support, regardless of age; and
o children who are the subject of a Qualified Medical Child Support Order. *required documentation must be submitted per policy HRM-510
Definitions of dependents and documentation requirements can be found on the Human
Resources CODI site under Verification Review. The document is titled Eligible Dependents and Required Documentation for Health and Dental Insurance
5. What happens if I do not respond to the verification request?
CITY OF DURHAM
Human Resources Department
101 CITY HALL PLAZA| DURHAM, NC 27701 919.560.4214| F 919.560.4969
www.DurhamNC.gov
6. If my dependents are removed from coverage, why aren’t they being offered COBRA?
Termination of a dependent who was not eligible for coverage is not considered a COBRA Qualifying Event. Therefore, the dependent is not eligible for COBRA coverage.
7. What if my child’s birth certificate says “Do not copy.”
For the purpose of the review, a scanned copy will be acceptable.
8. What if my child’s birth certificate does not show the names of the parents.
Most states offer both a short and a long form of a child’s birth certificate. The long form includes the parents’ names and is the only birth certificate that will be accepted.
9. What if my child’s birth certificate has my previous last name and not my current last name. Will the City of Durham require any additional documentation to verify our relationship?
Not at this time. The City of Durham will review the documentation submitted, and will contact you within 10 business days if additional information is needed.
10. Where can I get a copy of my child’s birth certificate or my marriage license?
The North Carolina Department of health and Human Services Division of Public Health – Vital Records Unit can assist you with this. Be sure to ask for the “long Form” which includes the parents’ names. They can be contacted at 919-733-3000 or http://vitalrecords.nc.gov. If you would like to request a birth certificate online, most states refer people to VitalCheck, a private company, is not affiliated with the State of North Carolina, and additional fees are charged as well as any applicable state fees. Phone and online orders: call 877-284-1008 (toll-free). Average processing time is 5-7 business days.
11. I cannot find the birth certificate of one of my three children. I have requested a copy, but it will not arrive before the deadline. I have documentation for the other two children. What should I do?
The City of Durham would prefer that all documents be submitted at the same time; however, we understand there may be times when that is not possible. If you are unable to obtain
documentation for one of your dependents before the deadline, you should submit the
documentation for the remaining dependents to ensure their coverage will continue. Only the dependent without documentation will be dropped from coverage.
Once you obtain the documentation, submit the forms to the Audit Services Department and the dependents’ insurance will be retroactively reinstated once the forms have been validated.
CITY OF DURHAM
Human Resources Department
101 CITY HALL PLAZA| DURHAM, NC 27701 919.560.4214| F 919.560.4969
www.DurhamNC.gov
12. My dependent documentation was issued in a foreign country and is not in English. Do I need to provide a copy of the document translated into English for it to be acceptable?
Yes. Any document provided as proof of eligibility that is in a foreign language must be completely translated into English and should be certified with a letter of accuracy from the translator. If you do not have a translation and you wish to submit a copy of the foreign document, the City will try to provide a translation. If the City is unable to translate, you will be responsible for providing an acceptable English translation.
13. I am recently married and my spouse isn’t listed on my tax return. How do I show we are married?
If you have been married for less than one year, the City of Durham will accept a marriage license as verification, and you do not need to submit a tax return.
14. I have been married for many years. Why can’t you just accept a copy of my marriage license?
The purpose of the audit is to ensure that only eligible dependents are covered by the plan. A marriage license, along with a copy of page one of your most recent tax return, ensures that you are covering a current spouse and not a former spouse. Former spouses are not eligible to participate in the health and dental plans.
15. My spouse and I file our taxes separately. What should I send?
A copy of both your and your spouse’s most recent tax return.
16. My divorce decree states that I must provide health insurance for my ex-spouse, can I cover them under the City of Durham’s health plan?
City of Durham
Enrollment System Quick Guide
Sign In Instructions
WORKTERRA Website:
Type the following address into your web browser: https://www.workterra.net
You should see the WorkTerra login page pictured below.
Enter Username:
Your Username will be your full Last Name followed by your full First Name and then the last 4 digits of your Social Security number without any spaces. For example, John Smith’s Social Security Number is 123456789. His Username is: smithjohn6789
Initial Password:
Your password will be your full Date of Birth in MMDDYYYY format.
For example, if your Date of Birth is: July 9, 1983
Then your password is: 07091983
Company Name:
Enter City of Durham
Sign In:
Click the Sign In button.
Help:
If you need assistance signing in, please contact City of Durham Human Resources Department.
Legal Agreement & Welcome Page
Read the Employee Usage Agreement and click Continue at the bottom of the page. Read the Legal Agreement and click Continue at the bottom of the page.
City of Durham
Enrollment System Quick Guide
Change Password
The first time you sign in to WORKTERRA, you will be required to create a new password.
You will see the WORKTERRA password change page pictured below.
Secret Questions:
For additional security and password recovery, you will select secret questions and enter your answers.
Select 2 Secret Questions from the dropdown lists and enter your Secret Answers.
New Password:
Read the password rules at the top of the screen. Enter your new password. Enter your password again to confirm. Passwords are case sensitive.
Click on the Save and Continue button.
Demographic Information and Benefit Elections
Step by step instructions are available in the forms library in WORKTERRA, on the City’s Human Resources intranet site, and from your Department Liaison.
The following general instructions will help you navigate WORKTERRA and successfully complete your enrollment.
Do not use your internet browser “back” and “forward” buttons. If you do, WORKTERRA’s security features will log you out and you will have to sign in again.
Demographic information marked with a red asterisk is mandatory.
To enroll in a benefit, select the names of your family members to be covered by clicking the radio button next to each family member’s name. Then click the Enroll button.
After you make your enrollment selection for each plan, you automatically advance to the next enrollment option.
Your enrollment is not finished until you click the Finish button on the bottom of the Confirmation page. It is strongly recommended that you print a copy for your records.
You may sign in to WORKTERRA to change your enrollment selections during open enrollment or to view your prior confirmed enrollments.
Important Contact Information
Benefit Questions
If you have questions about any of your benefits, please contact the company that handles the plan administration for the City. If you still have questions, or need more information about any other benefit plans, please contact your Human Resources Team for assistance. They will be happy to assist you. Below is a list of companies, the plans they administer and their contact information.
Company Phone Number Website
Blue Cross/Blue Shieldof NC 1-877-275-9787 www.bcbsnc.com
Colonial Products 1-800-325-4368 www.coloniallife.com
Delta Dental 1-800-662-8856 www.deltadentalnc.com
ICMA 457 1-800-669-7400 www.icmarc.org
(Deferred Compensation)
Laymon Group 1-800-467-2259 www.wealthcareadmin.com
(Flex Spending Accountsand HRA)
Liberty Mutual Service: 919-401-1550 x56557 www.libertymutual.com/melissakiner
Claims: 1-800-225-2467
MetLaw/Hyatt Legal 1-800-821-6400 www.legalplans.com
Nationwide 457 1-877-677-3678 www.nrsforu.com
(Deferred Compensation)
New York Life Enrollment & Service: 919-401-9988 www.newyorklife.com Claims: 1-800-224-4582
NC Retirement System 919-733-4191 www.treasurer.state.nc.us
NC Supplemental Retirement 1-866-624-0151 www.prudential.com
401 (k)
P & A Group(COBRA) 1-800-688-2611 www.padmin.com
Reliance Standard 1-800-351-7500 www.reliancestandard.com
(Life Insurance, STD, & LTD)
Superior Vision 1-800-507-3800 www.superiorvision.com
Transamerica Products Service: 1-888-763-7474 www.tebcs.com
City of Durham
2015/2016 Health and Dental Insurance Rate Sheet
Monthly Employee/City Contributions
Total
City
City
Employee
Cost
Cost
%
Cost
Wellness Rate Core Plan
Employee
$589.42
$555.94
94%
$33.48
Emp/Spouse
$1,009.40
$820.41
81%
$188.99
Emp/Child(ren)
$952.75
$789.25
83%
$163.50
Family
$1,658.30
$1,177.30
71%
$481.00
Wellness Rate Basic Plan
Employee
$538.59
$538.59
100%
$0.00
Emp/Spouse
$957.90
$820.41
86%
$137.49
Emp/Child(ren)
$885.80
$789.25
89%
$96.55
Family
$1,426.55
$1,177.30
83%
$249.25
Non Wellness Rate Core Plan
Employee
$609.42
$555.94
91%
$53.48
Emp/Spouse
$1,029.40
$820.41
80%
$208.99
Emp/Child(ren)
$972.75
$789.25
81%
$183.50
Family
$1,678.30
$1,177.30
70%
$501.00
Non Wellness Rate Basic Plan
Employee
$558.59
$538.59
96%
$20.00
Emp/Spouse
$977.90
$820.41
84%
$157.49
Emp/Child(ren)
$905.80
$789.25
87%
$116.55
Family
$1,446.55
$1,177.30
81%
$269.25
Dental Rate Plan
Total
City
City
Employee
Cost
Cost
%
Cost
Employee
$45.32
$30.37
67%
$14.95
Employee/Spouse
$78.17
$45.34
58%
$32.83
Employee/Child(ren) $78.63
$45.61
58%
$33.02
City of Durham
Core PPO Plan
Blue OptionsSM Benefit Highlights (PPO)
Physician Office Services (See “Outpatient Hospital Services” for “outpatient clinic” or “hospital-based” services.)
Office Visit
Includes Office Surgery, Consultation, X-rays, Lab and benefit period
maximum of 4 office visits for the assessment of obesity in and out of network.
In-network Out-of-network1
Primary Care Provider $20 copayment 70% after deductible
Specialist $40 copayment 70% after deductible
Preventive Care
Routine Examinations, Well-Child Care, Well-Baby Care, Immunizations, Well- Woman Care, colorectal screening, bone mass measurement, newborn hearing screening, routine eye exam and prostate specific antigen tests (PSAs).
Primary Care Provider 100% Not Available*
Specialist 100% Not Available*
Outpatient Clinic 100% Not Available*
*Colorectal screening, bone mass measurement, newborn hearing screening, prostate specific antigen tests (PSAs) and certain well woman care like gynecological exams, cervical cancer screening, ovarian cancer screening and screening mammograms are covered Out-of-network.
Therapies
Short-Term Rehabilitative Therapies (Maximums apply to Home, Office and Outpatient Settings):
Physical/Occupational: 30 visits per Benefit Period Speech Therapy: 30 visits per Benefit Period
Primary Care $20 copayment 70% after deductible
Specialist $40 copayment 70% after deductible
Urgent Care Centers and Emergency Room
Urgent Care Centers $20 copayment $20 copayment
Emergency Room Visit (Inpatient Hospital benefits apply if admitted. If held for Observation, Outpatient benefits apply. See “Inpatient and Outpatient Hospital Services”)
$300 copayment $300 copayment
Ambulatory Surgical Center 80% after deductible 70% after deductible
Inpatient and Outpatient Hospital Services
Hospital and Hospital Based Services 80% after deductible 70% after deductible
Outpatient Clinic Services 80% after deductible 70% after deductible
Professional Services 80% after deductible 70% after deductible
Hospital and Professional
Outpatient Labs and Mammograms with surgery or other services 80% after deductible 70% after deductible Outpatient Labs and Mammograms without surgery or other services 100% 70% after deductible Outpatient X-rays, ultrasounds, and other diagnostic tests, such as
EEG’s and EKG’s
CT scans, MRI’s, MRA’s and PET scans in any location, including physician’s office
Other Services
80% after deductible 70% after deductible 80% after deductible 70% after deductible
Skilled Nursing Facility (60 days per Benefit Period) 80% after deductible 70% after deductible
Home Health Care, Ambulance,
Durable Medical Equipment and Hospice Maternity
Maternity Delivery includes Prenatal and Post-delivery care
80% after deductible 70% after deductible
Hospital Services (Delivery) 80% after deductible 70% after deductible
Professional Services (Delivery) 80% after deductible 70% after deductible
Transplants
Hospital Services 80% after deductible 70% after deductible
Blue OptionsSM Benefit Highlights (PPO)
Infertility Services
Limit of 3 ovulation induction cycles without insemination
Primary Care Provider $20 copayment 70% after deductible
Specialist $40 copayment 70% after deductible
Hospital Services 80% after deductible 70% after deductible
Inpatient and Outpatient Professional Services 80% after deductible 70% after deductible
Vision (Routine Eye Exams) 100% Not Available
Out-of-network1
Lifetime Maximum, Deductibles & Coinsurance Maximums In-network
The following Deductibles and Coinsurance and Medical Office Copays apply towards the Out-of-Pocket limit.
Unlimited Unlimited
Lifetime Benefit Maximum Deductibles
Individual(per Benefit Period) $750 $1,500
$1,500 $3,000
Family(per Benefit Period)
Out-of-Pocket Limits
$2,750
Individual- Medical (per Benefit Period)
Individual - Rx (per Benefit Period)
Family -Medical (per Benefit Period)
Family - Rx (per Benefit Period)
$1,500
$5,500 $3,000
$5,500 $3,000
$11,000 $6,000
Mental Health and Substance Abuse Services
*Inpatient/Outpatient Certification is required. Call Magellan Behavioral Health at 1-800-359-2422.
Mental Health Services
Office Visits Inpatient Hospital Outpatient Hospital $40 copayment 100% 100%
70% after deductible 70% after deductible 70% after deductible
Substance Abuse Services
Office Visit Inpatient Hospital Outpatient Hospital
Prescription Drugs
Up to 31 day supply. 32-90 day supply is two copayments.
Infertility Drugs up to $5000. MAC B Pricing, Brand Penalty. Rx Copays do not apply towards the Out-of-Pocket Limit.
$40 copayment 100% 100%
70% after deductible 70% after deductible 70% after deductible
Tier 1 (Generic) $0 copayment Copayment + charge over
In-network allowed amount
Tier 2 (Preferred Brand) $30 copayment Copayment + charge over
In-network allowed amount Tier 3 (Brand)
Diabetic Supplies
Spacers and Peak Flow Meters
Medco Mail Order - 90 day supply:
Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Brand)
Diabetic Supplies
Spacers and Peak Flow Meters
$45 copayment 100% 100% $0 copayment $60 Copayment $90 copayment 100% 100%
Copayment + charge over In-network allowed amount
100% 100% Not Available Not Available Not Available Not Available Not Available
Benefit Period
ADDITIONAL INFORMATION ABOUT BLUE OPTIONS FROM BCBSNC Health and Wellness Program
The period of time, usually 12 months as stated in the group contract, during which charges for covered services provided to a member must be incurred in order to be eligible for payment by BCBSNC. A charge shall be considered incurred on the date the service or supply was provided to a member.
Allowed Amount
The charge that BCBSNC determines using a methodology that is applied to comparable providers for similar services under a similar health benefit plan.
Coinsurance Maximum
The dollar amount of coinsurance a member must pay prior to BCBSNC paying 100% for certain services. NOTE: In some plans, there is no coinsurance maximum; members are responsible for coinsurance once the deductible has been met.
Day and Visit Maximums
All day and visit maximums are on a combined In- and Out-of Network basis.
Utilization Management
To make sure you have access to high quality, cost-effective health care, we manage utilization through a variety of programs including certification, transplant management, concurrent and retrospective review and care management. If you have a concern regarding the final determination of your care, you have the right to appeal the decision. If you would like a copy of a benefit booklet providing more information about our Utilization Management programs, call the toll free number listed in your information packet.
Certification
Certification is a program designed to make sure that your care is given in a cost effective setting and efficient manner.
If you need to be hospitalized, you must obtain certification. Non-emergency and non-maternity hospital admissions must be certified prior to the hospitalization. If the admission is not certified, a penalty will be applied.
For maternity admissions, your provider is not required to obtain certification from BCBSNC for prescribing a length of stay up to 48 hours for a normal vaginal delivery, or up to 96 hours for delivery by cesarean section. You or your provider must request certification for coverage for additional days, which will be given by BCBSNC, if medically necessary. All inpatient and certain outpatient Mental Health and Substance Abuse services must be certified in advance by Magellan Behavioral Health. Office visits do not require certification.
In-network providers are responsible for obtaining certifications. The member will bear no financial penalties if the in-network provider fails to obtain the appropriate authorization. The member is responsible for obtaining certification for services rendered by an out-of-network provider. Obtaining certification for Mental Health and Substance Abuse services is the member’s responsibility.
Because we want to help you stay healthy, we offer a variety of wellness benefits and services. You can take advantage of HealthLine Blue, our 24-hour health information service, a health topics library, asthma and diabetes management and a prenatal program. You will also receive Active Blue, our health magazine and have access to online health and wellness information at www.bcbsnc.com. With our program you can get health advice anytime you need it, so you can learn how to take charge of your health.
What Is Not Covered?
The following are summaries of some of the coverage restrictions. A full explanation and listing of restrictions will be found in your benefit booklet.
Your health benefit plan does not cover services, supplies, drugs or charges that are:
Not medically necessary
For injury or illness resulting from an act of war
For personal hygiene and convenience items
For inpatient admissions that are primarily for diagnostic studies
For palliative or cosmetic foot care
For investigative or experimental purposes
For hearing aids or tinnitus maskers
For cosmetic services or cosmetic surgery
For custodial care, domiciliary care or rest cures
For treatment of obesity, except for surgical treatment of morbid obesity, or as specifically covered by your health benefit plan
For reversal of sterilization
For treatment of sexual dysfunction not related to organic disease
For conception by artificial means
For self-injectable drugs in the provider's office
A waiting period for coverage of pre-existing conditions may apply to your coverage. BCBSNC defines pre-existing conditions as those conditions for which medical advice, diagnosis, care or treatment was received or recommended within 6 months of the date that your [BCBSNC] coverage begins. You may receive credit toward the 12-month waiting period if your enrollment date is within 63 days of the termination of your previous health coverage.
The benefit highlights is a summary of Blue Options benefits. This is meant only to be a summary. Final interpretation and a complete listing of benefits and what is not covered are found in and governed by the group contract and benefit booklet. You may preview the benefit booklet by requesting a copy of the Blue Options benefit booklet from BCBSNC Customer Services.
®, SMRegistration and Service marks of the Blue Cross and Blue Shield Association.
City of Durham
Basic PPO Plan
Blue OptionsSM Benefit Highlights (PPO)
Physician Office Services (See “Outpatient Hospital Services” for “outpatient clinic” or “hospital-based” services.)
Office Visit
Includes Office Surgery, Consultation, X-rays, Lab and benefit period
maximum of 4 office visits for the assessment of obesity in and out of network.
In-network Out-of-network1
Primary Care Provider $25 copayment 70% after deductible
Specialist $50 copayment 70% after deductible
Preventive Care
Routine Examinations, Well-Child Care, Well-Baby Care, Immunizations, Well- Woman Care, colorectal screening, bone mass measurement, newborn hearing screening, routine eye exam and prostate specific antigen tests (PSAs).
Primary Care Provider 100% Not Available*
Specialist 100% Not Available*
Outpatient Clinic 100% Not Available*
*Colorectal screening, bone mass measurement, newborn hearing screening, prostate specific antigen tests (PSAs) and certain well woman care like gynecological exams, cervical cancer screening, ovarian cancer screening and screening mammograms are covered Out-of-network.
Therapies
Short-Term Rehabilitative Therapies (Maximums apply to Home, Office and Outpatient Settings):
Physical/Occupational: 30 visits per Benefit Period Speech Therapy: 30 visits per Benefit Period
Primary Care $25 copayment 70% after deductible
Specialist $50 copayment 70% after deductible
Urgent Care Centers and Emergency Room
Urgent Care Centers $25 copayment $25 copayment
Emergency Room Visit (Inpatient Hospital benefits apply if admitted. If held for Observation, Outpatient benefits apply. See “Inpatient and Outpatient Hospital Services”)
$300 copayment $300 copayment
Ambulatory Surgical Center 80% after deductible 70% after deductible
Inpatient and Outpatient Hospital Services
Hospital and Hospital Based Services 80% after deductible 70% after deductible
Outpatient Clinic Services 80% after deductible 70% after deductible
Professional Services 80% after deductible 70% after deductible
Hospital and Professional
Outpatient Labs and Mammograms with surgery or other services 80% after deductible 70% after deductible Outpatient Labs and Mammograms without surgery or other services 100% 70% after deductible Outpatient X-rays, ultrasounds, and other diagnostic tests, such as
EEG’s and EKG’s
CT scans, MRI’s, MRA’s and PET scans in any location, including physician’s office
Other Services
80% after deductible 70% after deductible 80% after deductible 70% after deductible
Skilled Nursing Facility (60 days per Benefit Period) 80% after deductible 70% after deductible
Home Health Care, Ambulance, Durable Medical Equipment and Hospice 80% after deductible 70% after deductible
Maternity
Maternity Delivery includes Prenatal and Post-delivery care
Hospital Services (Delivery) 80% after deductible 70% after deductible
Professional Services (Delivery) 80% after deductible 70% after deductible
Transplants
Hospital Services 80% after deductible 70% after deductible
Blue OptionsSM Benefit Highlights (PPO)
Infertility Services
Limit of 3 ovulation Induction cycles without insemination.
Primary Care Provider $25 copayment 70% after deductible
Specialist $50 copayment 70% after deductible
Hospital Services 80% after deductible 70% after deductible
Inpatient and Outpatient Professional Services 80% after deductible 70% after deductible
Vision (Routine Eye Exam) 100% Not Available
Out-of-network1 In-network
Unlimited Unlimited
Lifetime Maximum, Deductibles & Coinsurance Maximums
The following Deductibles and Coinsurance and Medical Office Copays apply towards the Out-of- Pocket Limit.
Lifetime Benefit MaximumDeductibles
$1,500 $3,000
$3,000 $6,000
$4,500 Individual(per Benefit Period)
Family(per Benefit Period)
Out-of –Pocket Limits
Individual- Medical (per Benefit Period) Individual - Rx(per Benefit Period) Family- Medical (per Benefit Period) Family - Rx(per Benefit Period)
$2,000 $9,000 $4,000 $9,000 $4,000 $15,000 $8,000
Mental Health and Substance Abuse Services
*Inpatient/Outpatient Certification is required. Call Magellan Behavioral Health at 1-800-359-2422.
Mental Health Services
Office Visits Inpatient Hospital Outpatient Hospital $50 copayment 100% 100%
70% after deductible 70% after deductible 70% after deductible
Substance Abuse Services
Office Visit Inpatient Hospital Outpatient Hospital
Prescription Drugs
Up to 31 day supply. 32-90 day supply is two copayments.
Infertility Drugs up to $5000. MAC B Pricing, Brand Penalty. Rx Copays do not apply to the Out-of-Pocket Limit.
$50 copayment 100% 100%
70% after deductible 70% after deductible 70% after deductible
Tier 1 (Generic) $0 copayment Copayment + charge over
In-network allowed amount
Tier 2 (Preferred Brand) $35 copayment Copayment + charge over
In-network allowed amount Tier 3 (Brand)
Diabetic Supplies
Spacers and Peak Flow Meters
Medco Mail Order - 90 day supply:
Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Brand)
Diabetic Supplies
Spacers and Peak Flow Meters
$50 copayment 100% 100% $0 copayment $70 Copayment $100 copayment 100% 100%
Copayment + charge over In-network allowed amount
100% 100% Not Available Not Available Not Available Not Available Not Available
Benefit Period
ADDITIONAL INFORMATION ABOUT BLUE OPTIONS FROM BCBSNC Health and Wellness Program
The period of time, usually 12 months as stated in the group contract, during which charges for covered services provided to a member must be incurred in order to be eligible for payment by BCBSNC. A charge shall be considered incurred on the date the service or supply was provided to a member.
Allowed Amount
The charge that BCBSNC determines using a methodology that is applied to comparable providers for similar services under a similar health benefit plan.
Coinsurance Maximum
The dollar amount of coinsurance a member must pay prior to BCBSNC paying 100% for certain services. NOTE: In some plans, there is no coinsurance maximum; members are responsible for coinsurance once the deductible has been met.
Day and Visit Maximums
All day and visit maximums are on a combined In- and Out-of Network basis.
Utilization Management
To make sure you have access to high quality, cost-effective health care, we manage utilization through a variety of programs including certification, transplant management, concurrent and retrospective review and care management. If you have a concern regarding the final determination of your care, you have the right to appeal the decision. If you would like a copy of a benefit booklet providing more information about our Utilization Management programs, call the toll free number listed in your information packet.
Certification
Certification is a program designed to make sure that your care is given in a cost effective setting and efficient manner.
If you need to be hospitalized, you must obtain certification. Non-emergency and non-maternity hospital admissions must be certified prior to the hospitalization. If the admission is not certified, a penalty will be applied.
For maternity admissions, your provider is not required to obtain certification from BCBSNC for prescribing a length of stay up to 48 hours for a normal vaginal delivery, or up to 96 hours for delivery by cesarean section. You or your provider must request certification for coverage for additional days, which will be given by BCBSNC, if medically necessary. All inpatient and certain outpatient Mental Health and Substance Abuse services must be certified in advance by Magellan Behavioral Health. Office visits do not require certification.
In-network providers are responsible for obtaining certifications. The member will bear no financial penalties if the in-network provider fails to obtain the appropriate authorization. The member is responsible for obtaining certification for services rendered by an out-of-network provider. Obtaining certification for Mental Health and Substance Abuse services is the member’s responsibility.
Because we want to help you stay healthy, we offer a variety of wellness benefits and services. You can take advantage of HealthLine Blue, our 24-hour health information service, a health topics library, asthma and diabetes management and a prenatal program. You will also receive Active Blue, our health magazine and have access to online health and wellness information at www.bcbsnc.com. With our program you can get health advice anytime you need it, so you can learn how to take charge of your health.
What Is Not Covered?
The following are summaries of some of the coverage restrictions. A full explanation and listing of restrictions will be found in your benefit booklet.
Your health benefit plan does not cover services, supplies, drugs or charges that are:
Not medically necessary
For injury or illness resulting from an act of war For personal hygiene and convenience items For inpatient admissions that are primarily for
diagnostic studies
For palliative or cosmetic foot care For investigative or experimental purposes For hearing aids or tinnitus maskers For cosmetic services or cosmetic surgery For custodial care, domiciliary care or rest cures For treatment of obesity, except for surgical
treatment of morbid obesity, or as specifically covered by your health benefit plan
For reversal of sterilization
For treatment of sexual dysfunction not related to organic disease
For conception by artificial means
For self-injectable drugs in the provider's office
A waiting period for coverage of pre-existing conditions may apply to your coverage. BCBSNC defines pre-existing conditions as those conditions for which medical advice, diagnosis, care or treatment was received or recommended within 6 months of the date that your [BCBSNC] coverage begins. You may receive credit toward the 12-month waiting period if your enrollment date is within 63 days of the termination of your previous health coverage.
The benefit highlights is a summary of Blue Options benefits. This is meant only to be a summary. Final interpretation and a complete listing of benefits and what is not covered are found in and governed by the group contract and benefit booklet. You may preview the benefit booklet by requesting a copy of the Blue Options benefit booklet from BCBSNC Customer Services.
®, SMRegistration and Service marks of the Blue Cross and Blue Shield Association.
Delta Dental PPO plus Premier Benefits at a Glance
City of Durham
We are pleased to announce City of Durham has chosen Delta Dental of North
Carolina as your new dental provider! You will be covered under two of
the nation’s largest dental networks – Delta Dental PPO
SMand Delta Dental
Premier®.
You can still see your current dentist; however, if they are not in our networks,
you may pay more. You are likely to
save more money
by visiting a dentist who
is in one of these networks.
You can check for network dentists by visiting Delta Dental’s website at www.deltadentalnc.com or by calling
Delta Dental’s Customer Service Center. Customer Service is available Monday to Friday from 8:30 a.m. until
8:00 p.m. (Eastern Time) to help you.
Covered Services:
Delta Dental
PPO Dentist
Premier Dentist
Delta Dental
Out-of-Network
Dentist*
Diagnostic & Preventative
Diagnostic and Preventative Services
– exams, cleanings,
fluoride, sealants, and X-rays,
100%
100%
100%
Emergency Palliative Treatment
– temporarily relieve pain
100%
100%
100%
Brush Biopsy
– detect oral cancer
100%
100%
100%
Basic Services
Space Maintainers
– appliances to prevent tooth movement
80%
80%
80%
Minor Restorative Services
– fillings and crown repair
80%
80%
80%
Endodontic Services
– root canals
80%
80%
80%
Oral Surgery Services
– extractions and dental surgery
80%
80%
80%
Other Basic Services
– miscellaneous services
80%
80%
80%
Major Services
Relines and Repairs
– repairs to bridges, implants, and
dentures
50%
50%
50%
Periodontic Services
– treatment for gum disease
50%
50%
50%
Major Restorative Services
– crowns
50%
50%
50%
Prosthodontic Services
– bridges, implants, and dentures
50%
50%
50%
Orthodontic Services
Orthodontic Services
– braces
(No age limit)50%
50%
50%
*When you receive services from an out of network dentist, the percentages above indicate the portion of Delta Dental’s Non-participating Dentist Fee that will be paid for those services. The amount may be less than what your dentist charges and you are responsible for the difference.
Maximum Payment
- $3,000 per person total per benefit year. Orthodontic services have a $1,500 per person
total lifetime maximum.
Deductible
- $50 deductible per person total per benefit year with a maximum deductible of $150 per family
per benefit year on all services except diagnostic and preventative, emergency palliative treatment, and brush
biopsy.
Are there any new benefits?
Brush biopsies
to detect oral cancer will be covered.
Implants
to replace missing teeth will also be a covered service.
Delta Dental will be
paying Out-of-Network providers directly
for services.
What are the benefits of network providers?
Delta Dental PPO
and
Delta Dental Premier Dentists
Submits claims for you
Only charges you for your copayment and deductible,
if any.
Out-of-pocket costs are likely lower
Out-of-Network Dentists
May require you to submit your own claims
May charge you the full cost for the service
Will receive payment directly from Delta
Dental
How can I find a network dentist? How can I find out if my dentist is in the network?
You can find network dentists by visiting our website at www.deltadentalnc.com or by calling Delta Dental’s
Customer Service department at (800) 662-8856.
Participating dentists are in one of two networks. Delta Dental PPO has the biggest discounts and Delta Dental
Premier is also discounted, but not as much as the Delta Dental PPO. If you choose a Delta Dental PPO dentist,
you will pay the least out-of-pocket and your Maximum Payment will last longer.
Will Delta Dental recruit my dentist if I ask?
You can ask us to recruit your dentist if they are not in one of our networks by calling Customer Service or by
completing the “Refer Your Dentist” form on the www.deltadentalnc.com website.
What if I am in orthodontic treatment?
Have your orthodontist submit a new treatment plan to Delta Dental. We will work with them to set up
payment for the remaining treatment based on how much you have already used.
Where do I send claims?
For services
on or
after September 1, 2015, either you or your dentists should send your claims to Delta Dental:
Delta Dental
PO Box 9085
Farmington Hills, MI 48333-9085
Have Questions?
Please call Delta Dental’s Customer Service Department at 1-800-662-8856.
NOTE: Payment examples are just to demonstrate savings.
Fees vary by location and dentist.
Delta Dental
PPO Dentist
Premier Dentist
Delta Dental
Out-Of-Network
Dentist
ADULT
CLEANING
Dentist Charges:
$80.00
$80.00
$80.00
What Delta Dental Accepts:
$54.00
$77.00
$63.00
Coverage Level:
100%
100%
100%
Amount Delta Dental Pays:
$54.00
$77.00
$63.00
AMOUNT YOU PAY:
$0.00
$0.00
$17.00
CROWN
Dentist Charges:
$950.00
$950.00
$950.00
What Delta Dental Accepts:
$675.00
$898.00
$744.00
Coverage Level:
50%
50%
50%
Amount Delta Dental Pays:
$337.50
$449.00
$372.00
Vision Plan Benefits for City of Durham
Co-Pays
Monthly Premiums
Services/Frequency
Exam $10 Emp. only $8.37 Exam 1 per plan year
Materials $10
(applies to frame and lenses)
Emp. + spouse $16.74 Frame 1 per plan year
Contact Lens Fitting $10 Emp. + child(ren) $19.00 Contact Lens Fitting 1 per plan year (standard & specialty) Emp. + family $29.35 Lenses 1 pair per plan year Contact Lenses 1 allowance per plan year
Benefits
In-Network Out-of-Network
Exam (Ophthalmologist) (Co-pay applies) Covered in full Up to $44 retail Exam (Optometrist) (Co-pay applies) Covered in full Up to $39 retail Frames (Copay Applies) $150 retail allowance Up to $60 retail Contact Lens Fitting(standard2) (Co-pay applies) Covered in full Not covered
Contact Lens Fitting(specialty2) (Co-pay applies) $50 retail allowance Not covered Lenses (standard) per pair (Co-pay applies)
Single Vision Covered in full Up to $26 retail
Bifocal Covered in full Up to $34 retail
Trifocal Covered in full Up to $50 retail
Progressive lens upgrade See description3 Up to $50 retail
Contact Lenses4 $150 retail allowance Up to $100 retail
Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1Materials co-pay applies to lenses and frames only, not contact lenses
2See your benefits materials for definitions of standard and specialty contact lens fittings
3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay
4Contact lenses are in lieu of eyeglass lenses and frames benefit
Discount Features
Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-30%) prior to service as they vary.
Discounts on Covered Materials
Frames: 20% off amount over allowance Lens options: 20% off retail
Progressives: 20% off amount over retail lined trifocal lens, including lens options
The following options have out-of-pocket maximums5 on standard
(not premium, brand, or progressive) lenses.
Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal
Scratch coat $13 $13
Ultraviolet coat $15 $15
Tints, solid or gradients $25 $25 Anti-reflective coat $50 $50
Polycarbonate $40 20% off retail
High index 1.6 $55 20% off retail Photochromics $80 20% off retail
Discounts on Non-Covered Exam and Materials
Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other
prescription materials: 20% off retail Disposable contact lenses: 10% off retail
.
Network: Superior National Refractive Surgery
Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from
15%-50%, and are the best possible discounts available to Superior Vision.
5Discounts and maximums may vary by lens type. Please check with your provider.
The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.
Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, anddefinitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.
North Carolina residents: Please contact our customer service department if you are unable to secure a timely (at least 30 days) appointment with your provider or need assistance finding a provider within a reasonable distance (30miles) of your residence. Adjustments to your benefits may be available.
SuperiorVision.com
Customer Service
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