Benefits Notification

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					                                                 Benefits Notification
As a new employee of Sanford Health, I understand I have 30 days from my date of hire to meet with a benefit counselor and
enroll online for my benefit selections.
My start date with Sanford Health is ___________ and I have until _______ to enroll in the benefits I wish to elect.
If I elect coverage, I understand that my coverage will begin the first of the month following one month of employment, which
would be ____________. However, if I elect Long Term Disability, Supplemental Life Insurance or Dependent Life Insurance,
my coverage will begin the first of the month following 90 days of employment.
If I am interested in enrolling in voluntary benefits (Long Term Care Insurance, Universal Life Insurance, Short Term Disability,
Accident Insurance or Cancer Insurance), at orientation I understand I must sign-up for a future time to meet with a benefit
counselor within one month of my hire date to enroll in my benefits.
If I do not enroll in Long Term Disability, Supplemental Life Insurance or Dependent Life Insurance within 90 days of employment,
I can sign up at anytime, but I will be subject to underwriting guidelines (health questions).
I understand if I waive coverage at this time, my next opportunity to enroll will be during the annual Open Enrollment for a
January 1st effective date, unless I experience a Qualified Life Event during the plan year. If I experience a Qualified Life Event,
I have 30 days from the date of the event to notify Human Resources to make the changes to my benefits.
Qualified Life Events are changes in your life that affect your need and/or your dependent’s need for benefits or the benefits
available to you from another source. Listed below are examples of Qualified Life Events as defined by IRS regulation. Benefit
changes must be consistent with one of the following Qualified Life Events and proper documentation must be provided.
1.    The birth or adoption of a child, or your child’s placement for adoption
2.    Your marriage, legal separation, divorce, or annulment
3.    The termination or beginning of your spouse’s or your dependent’s employment
4.    Your, your spouse’s or your dependent’s job status changes from full-time to part-time or from part-time to full-time
5.    A significant change in your or your spouse’s health coverage
6.    Eligibility for your dependent begins or ends due to age, change in student status, or a similar circumstance
7.    A change in residence or work site for you, your spouse, or your dependent
8.    The death of your spouse or eligible dependent
9.    Commencement or return from an unpaid Leave of Absence
As a new employee, I understand I will automatically be a participant in the 401(k) Retirement Savings Plan. The effective
date will be the first of the month following one month of employment. I will be receiving in the mail from Wells Fargo, the plan
administrator, a 401(k) enrollment kit sent to the address I provided when I was hired. I will then have 30 days from my date
of hire to call the Benefits Helpline number at Wells Fargo (the helpline phone number and your PIN will be enclosed in your
enrollment kit) to allocate a percentage deferral from my paycheck. I understand at anytime I may call the Benefits Helpline to
stop my contributions, increase or decrease my contribution rate, or change my investment options. Depending on when I call in,
the change may not take effect until the following pay period. If I do NOT respond by calling the Benefits Helpline number within
30 days of my date of hire, I will default through payroll deduction at 3% of my eligible pay. The funds will then be deposited into
the Fidelity Freedom target date fund that is appropriate for me based on a retirement age of 65. Additionally, my contribution
rate will automatically be increased by 1% each year until I reach a 6% contribution rate in my fourth year of employment.
If you have any questions, please contact Benefits at (605) 333-7030. The Human Resources’ business hours are between
7:30 a.m. – 5 p.m., Monday – Friday or you may log onto www.sanfordhealth.org to review your benefits.
My signature indicates I have read the above information and received my benefits packet.
I have also received a signed copy of this form.
                                                                                                       Is this employee a rehire?
Name (Please Print)                                                     Date:
                                                                                                       __ Yes
Signature                                                                                              __ No
Humans Resources Representative


BENEFITS NOTIFICATION




100-11200-0007 rev. 9/08
                                                 Benefits Notification
As a new employee of Sanford Health, I understand I have 30 days from my date of hire to meet with a benefit counselor and
enroll online for my benefit selections.
My start date with Sanford Health is ___________ and I have until _______ to enroll in the benefits I wish to elect.
If I elect coverage, I understand that my coverage will begin the first of the month following one month of employment, which
would be ____________. However, if I elect Long Term Disability, Supplemental Life Insurance or Dependent Life Insurance,
my coverage will begin the first of the month following 90 days of employment.
If I am interested in enrolling in voluntary benefits (Long Term Care Insurance, Universal Life Insurance, Short Term Disability,
Accident Insurance or Cancer Insurance), at orientation I understand I must sign-up for a future time to meet with a benefit
counselor within one month of my hire date to enroll in my benefits.
If I do not enroll in Long Term Disability, Supplemental Life Insurance or Dependent Life Insurance within 90 days of employment,
I can sign up at anytime, but I will be subject to underwriting guidelines (health questions).
I understand if I waive coverage at this time, my next opportunity to enroll will be during the annual Open Enrollment for a
January 1st effective date, unless I experience a Qualified Life Event during the plan year. If I experience a Qualified Life Event,
I have 30 days from the date of the event to notify Human Resources to make the changes to my benefits.
Qualified Life Events are changes in your life that affect your need and/or your dependent’s need for benefits or the benefits
available to you from another source. Listed below are examples of Qualified Life Events as defined by IRS regulation. Benefit
changes must be consistent with one of the following Qualified Life Events and proper documentation must be provided.
1.    The birth or adoption of a child, or your child’s placement for adoption
2.    Your marriage, legal separation, divorce, or annulment
3.    The termination or beginning of your spouse’s or your dependent’s employment
4.    Your, your spouse’s or your dependent’s job status changes from full-time to part-time or from part-time to full-time
5.    A significant change in your or your spouse’s health coverage
6.    Eligibility for your dependent begins or ends due to age, change in student status, or a similar circumstance
7.    A change in residence or work site for you, your spouse, or your dependent
8.    The death of your spouse or eligible dependent
9.    Commencement or return from an unpaid Leave of Absence
As a new employee, I understand I will automatically be a participant in the 401(k) Retirement Savings Plan. The effective
date will be the first of the month following one month of employment. I will be receiving in the mail from Wells Fargo, the plan
administrator, a 401(k) enrollment kit sent to the address I provided when I was hired. I will then have 30 days from my date
of hire to call the Benefits Helpline number at Wells Fargo (the helpline phone number and your PIN will be enclosed in your
enrollment kit) to allocate a percentage deferral from my paycheck. I understand at anytime I may call the Benefits Helpline to
stop my contributions, increase or decrease my contribution rate, or change my investment options. Depending on when I call in,
the change may not take effect until the following pay period. If I do NOT respond by calling the Benefits Helpline number within
30 days of my date of hire, I will default through payroll deduction at 3% of my eligible pay. The funds will then be deposited into
the Fidelity Freedom target date fund that is appropriate for me based on a retirement age of 65. Additionally, my contribution
rate will automatically be increased by 1% each year until I reach a 6% contribution rate in my fourth year of employment.
If you have any questions, please contact Benefits at (605) 333-7030. The Human Resources’ business hours are between
7:30 a.m. – 5 p.m., Monday – Friday or you may log onto www.sanfordhealth.org to review your benefits.
My signature indicates I have read the above information and received my benefits packet.
I have also received a signed copy of this form.
                                                                                                       Is this employee a rehire?
Name (Please Print)                                                     Date:
                                                                                                       __ Yes
Signature                                                                                              __ No
Humans Resources Representative


BENEFITS NOTIFICATION




100-11200-0007 rev. 9/08
Table of ConTenTs
IMPoRTanT InfoRMaTIon aboUT enRollInG
        Am I “BenefIt elIgIBle”? .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3
  How do I enroll onlIne?  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3
QUalIfYInG lIfe eVenTs  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4


MY benefITs
        SUmmArY PlAn deSCrIPtIon (SPd)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4
        emPloYee ASSIStAnCe ProgrAm (eAP)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4
        worKSIte wellneSS ProgrAm  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5
        HeAltH InSUrAnCe  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5
        PreSCrIPtIon CoverAge  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10
        vISIon CoverAge  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
        dentAl InSUrAnCe  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 12
        fleXIBle SPendIng ACCoUntS  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14
        long term dISABIlItY  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14
             PlAn HIgHlIgHtS  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15
        BASe lIfe InSUrAnCe  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15
        SUPPlementAl term lIfe InSUrAnCe  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15
        ACCIdentAl deAtH And dISmemBerment  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15
        dePendent term lIfe InSUrAnCe  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15
        UnderwrItIng ProvISIonS  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16
             PlAn HIgHlIgHtS  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16
        BenefICIArY deSIgnAtIon  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16
       401(k) retIrement SAvIngS PlAn  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16


oTheR benefITs
       UnIverSAl lIfe InSUrAnCe .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
       SHort term dISABIlItY  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
       CAnCer InSUrAnCe  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
       ACCIdent InSUrAnCe  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
       long term CAre InSUrAnCe  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
       Pre-PAId legAl ServICeS  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
       IdentItY tHeft SHIeld PlAn  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18



                                                                                                                                                                                                                                   Employee 100-11200-0104 9/08


                                                                                                                                 1
Table of ConTenTs (cont.)

oTheR benefITs (cont.)
        College ACCeSS 529 College SAvIngS PlAn  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19
        403(b) retIrement SAvIngS PlAn  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19

IMPoRTanT ConTaCTs .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20

foRMs To be CoMPleTed
        fleX SPendIng formS
        401(K) retIrement SAvIngS PlAn BenefICIArY
            deSIgnAtIon form


sanfoRd healTh PReMIUMs 2009




                                                                                                                            2
                                Sanford Health’s plan year is from January 1 - December 31
 Important
 Information                             am I “benefit eligible?”
                                          If you are scheduled to work at least 24 hours per pay period (which is a two-week period
 About                                      of time), then you are eligible for benefits . to be eligible for long term disability you

 Enrolling                                   need to be scheduled to work at least 40 hours per pay period .


 Employees who are newly hired,
 or newly benefit eligible will have          how do I enroll online?
                                              Please follow these steps to enroll in benefits online:
 30 days from their date of hire
                                             Step 1: log on to www .sanfordhealth .org or sanfordconnect .
 or status change date to enroll
 or change benefit elections.               Step 2: Click on the “employees” link at the bottom of the page and then click on
                                                    “Benefits for You .”
 Please keep this benefit
                                        Step 3: to login, click on the red “Benefits for You” and click on “Click here to start your
 information as a reference
                                                enrollment now .”
 throughout the year.
                                  Step 4: Sign in using your employee number and company code (24) as your employee Id and
                                          enter your password . Your password is your six digit date of birth (mmddyy).
                          • You will immediately be asked to assign a new password for security reasons.
                   • If you forget your password, please contact your local Human Resources Department.
next, you will be able to view the following:                                                                                 Things
• My Profile: personal and dependent information                                                                      you will need
• My Benefits: view and enroll in benefits for the 2009 plan year . If you are interested                      before you enroll…
  in Flexible Spending Accounts for the 2009 plan year, you must re-enroll in this                      • An understanding of the
  benefit during the open enrollment period.                                                            benefits offered at Sanford
• My Forms: benefit summary sheets and various benefit forms for you to view                          Health — please contact
  and print . After you have reviewed and made appropriate benefit changes and                    your local Human Resources
  elections for 2009, remember to log out of the Benefits for You site .                        Department if you have any benefit
                                                                                               related questions.
                                                                                         • Spouse and dependent’s social security

The Effective Date for Benefits                                                              numbers. (if enrolling them in benefits)
                                                                                         • Flexible spending account amounts.
Benefits will become effective the first of the month following one month of
                                                                                          • Bank’s routing and account number
employment with the exception of Base life Insurance, Supplemental life Insurance,
                                                                                               for flexible spending account
dependent life Insurance, and long term disability which will become effective the
                                                                                                 enrollment.
first of the month following 90 days of employment . for open enrollment all benefits
                                                                                              • Beneficiary information for life
will be effective January 1 of the following year . long term Care insurance will become
                                                                                                      insurance.
effective the date the policy is issued .
                                                                                                     • Employee number which
                                                                                                            can be found on your
                                                                                                                 paycheck stub.




                                                                   3
Qualifying Life Events
When can I make benefit changes throughout the plan year?

              there are certain benefits offered to you which are deducted from your paycheck on a Pre-tAX basis under Section 125
                   of the Internal revenue Service Code .

    If changing
                          The following are PRE-TAX benefit offerings:
    from part-time
                           • Health Insurance                                  • Dental Insurance
    to full-time
                            • Flexible Spending Accounts                       • Vision Coverage
    you may only
                            • Accident Insurance                               • Cancer Insurance
    enroll in a benefit
    that you were
                             Because these deductions are on a Pre-tAX basis, the IrS has guidelines on when you can make changes
    not previously
                           (i .e ., enroll or cancel) to your benefit elections during the plan year . Under these IrS guidelines, you can
    eligible for.
                          only make changes to your benefits if you experience a qualifying life event during the plan year .


                   If you experience a qualifying life event, you have 30 days from the event date to notify your local Human
           resources department . examples of qualifying life events include:
•     Birth, adoption, or child’s placement for adoption
•    Marriage, divorce, or legal separation
•     Termination or beginning of your spouse’s/dependent’s employment
•     Your, your spouse’s, or your dependent’s job status changes from full-time to part-time or vice versa
•     Significant change in your or your spouse’s health coverage
•     Eligibility for your dependent begins or ends due to age, change in student status, or similar circumstance
•     Change in residence or place of work causing change in health plan availability for an employee, spouse, or dependent
•     Death of spouse or eligible dependent
•     Commencement or return from a leave of absence


All benefit changes must be consistent with one of the qualifying life events listed above and are subject to Human Resources
review and approval . You must contact your local Human resources department within 30 days of experiencing one of these
qualifying life events in order to be eligible to change or modify your benefit elections .



Summary Plan Description (SPD)
the terms and provisions of a benefit plan can be found in the Summary Plan description (SPd) . the most current summary plan
descriptions can be found on sanfordconnect under “employee Benefits” and “Summary Plan descriptions” or on the Benefits for
You website under “my forms & resources .”

Printed versions of the summary plan descriptions are available by contacting the Human resources department .



Employee Assistance Program (EAP)
Sanford’s Employee Assistance Program (EAP) provides help to employees and their family members to confront and overcome
life’s challenges. The EAP is a free and confidential professional support service that’s available 24 hours a day, 365 days a year.
Services provided through the eAP include counseling and related services to help employees and family members:
•     Resolve marital and relationship troubles           •   Relieve depression, stress, and anxiety
• Solve parenting and child concerns                      •   Recover from drug and alcohol abuse

                                                                       4
•   Cope with anger, grief, and loss                     •    Get healthy and stay active
•   Overcome legal and financial problems                •    Eliminate employee conflicts
•   Create a plan for educational success

to use the eAP service, simply call midwest eAP Solutions at 1-800-383-1908 to talk with a certified counselor or schedule a face-to-
face visit . this benefit allows up to three face-to-face sessions per issue . employees can also access these eAP services in addition to
a variety of self-help resources through their website at www .midwesteap .com .
User name: Sanford             Password: member



Worksite Wellness Program
Sanford Health’s Worksite Wellness Program focuses on the following disease states: diabetes, hypertension and high cholesterol
and includes:
•   Case management: ensures employees with complex medical issues receive the highest quality of care at the right place, right
    price and right value
•   Disease management: education on targeted disease states
•   Pharmacy management: review of medication utilization and assistance with drug options
the program provides the following services to affected employees:
•   Referral of care to ensure blood pressure checks, labs and follow ups are completed
•   One on one education to include telephone, onsite and mailings                                                       Things
•   Appropriate follow up, coordination and referrals                                                            to consider
An additional focus will be developed on wellness management to include interactive health and               before enrolling in
wellness programs .                                                                                      health insurance…
                                                                                                       • Are you covered by
                                                                                                        any other health
                                                                                                      insurance plan?
My Benefits                                                                                         • How many people in your
                                                                                                      family will be covered by
Health Insurance                                                                                        health insurance?
Sanford Health offers health insurance through Sanford Health Plan . You may choose from two           • How much out-of-
options of health coverage that best meet you and your family’s needs – Sanford Health 750 or              pocket expense are
Sanford Health 2000 .                                                                                         you comfortable
                                                                                                                   with?
                                   Total Monthly Costs for Health Insurance including both
                              Sanford Health’s Cost and the Employee’s Cost (SH750 comparison):




                 SINGLE                EMPLOYEE plus SPOUSE               EMPLOYEE plus CHILD(rEN)                   FAMILY
               Total = $402                Total = $1,006                       Total = $965                      Total = $1,207
                          ■ Employee                                                        ■ Employee
                                                         ■ Employee                                                           ■ Employee
                 $
                  112       Portion
                                                  358
                                                  $        Portion                    322
                                                                                      $       Portion                $
                                                                                                                      376       Portion
     $
         290              ■ Employer    $
                                            648                             $
                                                                                643         ■ Employer      831
                                                                                                            $
                                                         ■ Employer                                                           ■ Employer
                            Portion                                                           Portion
                                                           Portion                                                              Portion




                                                                      5
Schedule of Benefits
The Schedule of Benefits is a brief summary of benefits under this Plan for your convenience and is not a complete list. If you
would like additional information, please review the entire Summary Plan Description (SPD) located on sanfordconnect or the
Benefits For You site.

All health benefits shown on this Schedule of Benefits are subject to the individual lifetime and annual maximums, copays,
deductibles, coinsurance, and are subject to all provisions of this Plan including Medical Necessity and other benefit
determinations based on an evaluation of medical facts and Covered Services.




                                                                                            Sanford Health $750
Benefits and Coverage1                                                                    In network                     out of network

Annual Deductible                                            Individual                   $750                            $1,500
                                                             Family                       $1,500                          $5,000

Annual Out of Pocket Maximum Limits                          Individual                   $2,250                          $10,0003
                                                             Family                       $4,500                          $10,0003

Coinsurance                                                                               80% before out of               60%
  Any required deductible must be satisfied before                                        pocket max is met
  the coinsurance will apply.                                                             100% after out of               100%
                                                                                          pocket max is met


Individual Lifetime Maximum                                                               $2,000,000                      $2,000,000

Medical Office Visits
 Covers office visit services, does not include lab, x-ray and other ancillary charges.
 Sanford Clinic Providers                                                                 $20 Copay                       60%
 Other Sanford Health Plan Participating Providers                                        $30 Copay                       60%

Preventive Health Services (see Preventive Health Guidelines)
  Well Baby and Well Child Care (through 6 years old)                                     No Copay                        60%
  Routine Periodic Preventive Health Exams
    Sanford Clinic Providers                                                              $20 Copay                       60%
    Other Sanford Health Plan Participating Providers                                     $30 Copay                       60%
  Immunizations                                                                           No Copay

Allergy Testing and Treatment
  Sanford Clinic Providers                                                                $20 Copay                       60%
  Other Sanford Health Plan Participating Providers                                       $30 Copay                       60%

Emergency Services                                                                        $150 Copay                      $150 Copay
  Copay subject to prudent lay person definition as found in the SPD.
  Copay waived if directly admitted to a facility.

Laboratory, X-ray and other Ancillary Services                                            80%                             No Coverage
  Includes inpatient and outpatient hospital                                              80%                             60%
  Medical clinic laboratory charges

Acute Inpatient Hospital Services2                                                        80%                             No Coverage
  Includes semi-private room, general nursing care, other
  services and supplies as ordered by your physician.
  Includes hospice cottage/facility services.
                                                                                                (Schedule of Benefits continued on page 8)


                                                                            6
                     NOTE: Certain Covered Services require certification before
For a
                      benefits will be considered for In Network Coverage or
complete list of
                      payment. Refer to the Certification of Services Section
providers, go to
                      of the SPD for a description of these services and prior
www.sanford-
                      authorization procedures.
health.org.




   Sanford Health $2,000
  In network                      out of network

  $2,000                          $3,000
  $4,000                          $8,000

  $3,000                          $10,0003
  $6,000                          $10,0003

  80% before out of               60%
  pocket max is met
  100% after out of               100%
  pocket max is met


  $2,000,000                      $2,000,000



  80%                             60%



  80%                             60%

  80%                             60%
  80%                             60%



  80%                             60%


  $150 Copay                      $150 Copay



  80%                             No Coverage
  80%                             60%


  80%                             No Coverage



        (Schedule of Benefits continued on page 9)


                                                                 7
                                                                                                 Sanford Health $750
Benefits and Coverage1 (cont.)                                                               In network                  out of network
Maternity, Pregnancy and Newborn Care (Call to enroll in the Healthy Pregnancy Program)
 Routine prenatal care and one postpartum visit                                              100%                         60%
 Hospital Services                                                                           80%                          No Coverage

Inpatient Physician Services and Consultations2                                              80%                          60%

Outpatient Hospital Services                                                                 80%                          No Coverage

outpatient surgery2                                                                          80%                          No Coverage

home health Care2
  Home care provided through home health agency in lieu of hospital or                       80%                          60%
  skilled nursing facility. Home care limited to 40 visits per calendar year
  and does not include meals, custodial care or housekeeping.

Skilled Nursing Facility Service2
  Skilled nursing care must be provided through a state licensed nursing facility.           80%                          60%
  Limited to 30 days in any consecutive 12-month period.

Ambulance and Other Transportation Services
 Covers medically necessary transportation in an emergency                                   80%                          80%
 and plan approved hospital transfers.

Mental Health Services
 Inpatient2                                                                                  80%                          No Coverage
 Outpatient
    Sanford Clinic Providers                                                                 $20 Copay                    60%
    Other Sanford Health Plan Participating Providers                                        $30 Copay                    60%

alcohol/Chemical/Gambling Treatment
  Inpatient2 - Limited to 30 days in any consecutive 6-month period -                        80%                          No Coverage
    Lifetime Maximum of 90 days.
  Outpatient - Limited to 30 days/visits in any consecutive 6-month period.                  80%                          60%

Durable Medical Equipment (DME) and Prosthetic Devices2
  DME in lieu of continued hospital stay or to avoid hospitalization;                        80%                          No Coverage
  including artificial limbs and eyes.

outpatient Rehabilitative Therapy
  Includes physical, speech, occupational therapy and cardiac                                80%                          No Coverage
  rehabilitation for up to 30 visits per therapy per calendar year.

Transplant Services at Designated Transplant Facilities2
  For non-experimental human organ transplants.                                              80%                          No Coverage

Chiropractic Services
  Limited to 20 visits per calendar year.                                                    $20 Copay                    No Coverage
  Covers office visit services and manual manipulations only. All other covered ser-
  vices subject to deductible and coinsurance.




1
    In Network coverage levels are a percent of discounted charges that the Sanford Health Plan has negotiated with Participating Providers.
    Out of Network coverage levels are a percent of reasonable cost.
2
    These services require certification by the Sanford Health Plan for In Network coverage levels to apply.
3
    Does not apply to transplant services.




                                                                           8
Sanford Health $2,000
In network   out of network

100%         60%
80%          No Coverage

80%          60%

80%          No Coverage

80%          No Coverage


80%          60%




80%          60%



80%          80%



80%          No Coverage

80%          60%



80%          No Coverage

80%          60%


80%          No Coverage



80%          No Coverage



80%          No Coverage


80%          No Coverage




                              9
Prescription Drug Schedule of Benefits*
$15/30/45 with Oral Contraceptives


    Payments for which you are responsible                             Participating Retail        Mail Service      Non-participating
    (per 30 day supply, or less, if less is prescribed at one time)         Pharmacy                Pharmacy           Pharmacy**
    Generic Drugs                                                               $15                no Coverage         no Coverage

    Formulary Brand-Name Drugs***                                               $30                no Coverage         no Coverage

    Nonformulary Brand-Name Drugs                                               $45                no Coverage         no Coverage

    Insulin Vials (limitations may apply)                             $15 per 1 month supply       no Coverage         no Coverage

    Insulin Pens, Cartridges and Innolets                             $30 per 1 month supply       no Coverage         no Coverage

    Diabetic Supplies                                                 $15 per 1 month supply       no Coverage         no Coverage
     • Insulin syringes with needles                                  for each individual item
     • Lancets, and Devices
     • Blood/Urine testing strips and tablets
     • Glucose tablets/Glucogan

    All Self-Administered Injectable Medications                           no Coverage           Coverage through      no Coverage
    All self-administered injectable medications                                                  Curascript only:
    must be obtained from the Curascript                                                          1-888-773-7376
    Injectable Drug Program. Please call
    Curascript at 1-888-773-7376 to enroll .




Prior Authorization: Some prescription drugs require prior authorization before they may be obtained . examples are:
Beytta, exubra, lamisil & Sporanox, forteo, testosterone Products, Symlin, vytorin, Zyvox, Proton Pump Inhibitors (Prevacid
or generic omeprazole) after 90 day supply . If your prescription drug requires prior authorization, ask your pharmacist or
doctor to call Health Services at 1-800-805-7938 . Contact Health Services or refer to your Pharmacy Program Brochure for
complete information .


For questions, call Health Services at (605) 328-6807 or 1-800-805-7938.
for a complete pharmacy listing, medication information, drug options or summary of drug utilization by you or your family go to
the express Scripts link at www .sanfordhealthplan .org .

*      Please refer to your Summary of Pharmacy Benefits for additional information .

** If you choose to go to a non-participating pharmacy or fail to present your prescription Id card to your pharmacy, you
   must pay 100% of the cost of the medication to the pharmacy, except in an emergency .

*** If you request that you receive the brand-name drug when there is an equivalent generic alternative available, you will
    be required to pay the price difference between the brand and the generic in addition to your copay .




                                                                              10
For a
complete
list of Sanford
                                      Vision Coverage
                                        Sanford Health offers vision coverage through two vision plans – Sanford Health
Health Vision
                                        vision Plan administered by Sanford Health Plan and dakota eye Care . You have
providers, go to
                                        the opportunity to choose the plan that best meets you and your family’s needs.
sanfordconnect.




Services                                             Sanford Health Vision Plan                    Dakota Eye Care
                                                          (Member Pays)                           (Member Discount)
Routine eye exam                                   $10                                     20% Discount (adjusted cost is
(One exam per member/year. Contact lens fitting/                                           usually $36-$44)
evaluation is usual and customary charge.)
                                                                                                                                                   Things
Laser & Implant Vision                             $500 discount with vance                $500 discount with vance
                                                                                                                                            to consider
Correction                                         thompson vision                         thompson vision
                                                   $200 Post-operative discount with       20% Post-operative discount with a          before enrolling in
                                                   a Sanford Health vision Plan Provider   dakota eye Care Provider                 vision coverage...
Frames                                             member pays 75% of retail               20% discount                          • How many people in
Lenses (Plastic)                                                                                                                    your family would
 Single vision lenses                              $49                                     20% discount                            utilize vision coverage?
 Bifocals                                          $94                                     20% discount                         • Do you or any
 trifocals                                         $118                                    20% discount                              dependents plan to
 Standard Progressive (no line) 75% of retail                                              20% discount                                have laser vision
Lenses (Polycarbonate)                                                                                                                    surgery within the
 Single vision lenses                              $82                                     20% discount                                       plan year?
 Bifocals                                          $117                                    20% discount
 trifocals                                         $129                                    20% discount
 Standard Progressive (no line) 75% of retail                                              20% discount                                             For a
Contact Lenses                                                                                                                                 complete
 Conventional                                      80%                                     20% discount                                   list of Dakota
                                                                                                                                        Eye Care
 disposable                                        90%                                     not eligible for any discount,
                                                                                           member pays full                            providers, go
Options (Add on to base lens price)                                                                                                    online at www.
 Scratch-resistant Coating                         $17                                     20% discount                                 dakotaeyecare.
 Polished edges                                    $17                                     20% discount                                    com.
 drill mount                                       $27                                     20% discount
 Solid/Gradient Tint                               $19                                     20% discount
 Anti-reflective Coating                           $80                                     20% discount
 *Other options not mentioned above, member pays 80% of retail




                                                                                                 11
Dental Insurance
Sanford Health offers dental insurance through delta dental of South dakota . You may choose from two options of dental
coverage that best meets you and your family’s needs – Option A and Option B.


                    Services
                         Diagnostic and Preventive Services
  Things to
                             • Routine examinations - Two per calendar year
 consider before
                               • Dental prophylaxis (cleaning) - Two per calendar year
 enrolling in
                                  • Bitewing x-rays - Twice per calendar year for children up to age 19, and once per calendar year
 dental insurance…
                                     for adults age 19 and over
  • How many people in your
                                      • full mouth x-rays - once in any five-year interval, unless special need is shown
 family would take advantage
                                       • topical fluoride applications - twice per calendar year up to age 19
 of dental insurance?
                                        • Space maintainers, fixed (band type)
  • Do you or a family member
                                        • dental sealants - for unrestored first and second permanent molars of children up to age 19
 expect to have any major dental
 work done within the plan year?
                                      Basic Services
  • Do you or a family
                                     • Emergency treatment for relief of pain
 member expect to have
                                   • Extractions and other oral surgery
 orthodontic services
                                 • Amalgam, preformed crowns, synthetic porcelain, plastic and composite restorations (fillings)
   within the plan
                              • Brush biopsy
    year?

                     Endodontics and Periodontics
                • Pulpal and root canal filling
        • Treatment of diseases of the tissues supporting the teeth


Major Services
  • Gold restorations when teeth cannot be restored with another filling material
  • Crowns when teeth cannot be restored with a filling material
  • Prosthetics - provides bridges, partial dentures, complete dentures and implants


Orthodontics
  • Treatment necessary for the proper alignment of teeth


        Sanford Health recognizes the importance of managing periodontal diseases in pregnant women and/or diabetic
           patients . delta dental provides for periodontal maintenance at a frequency up to 4 times per year .


IMPORTANT      Because patients who are susceptible to periodontal diseases generally require more frequent periodontal
   NEWS        maintenance than those who are not susceptible, Sanford Health may cover up to four periodontal maintenance
               visits per year .


            employees should contact delta dental for eligibility for these additional services .




                                                                 12
       option A                           option B
(Group Number 3033)                (Group Number 2033)
% Paid By Delta                    % Paid By Delta
 100%                              80%




 80%                               80%




 80%                               50%




 50%                               50%




 80%                               no orthodontic coverage



 Deductible: none                  Deductible: $25 per person per calendar
 Maximum: $1,500 per person        year not to exceed three deductibles per
 per calendar year                 family ($75 maximum deductible) . this
 Lifetime Orthodontic              deductible does not apply to diagnostic or
 Maximum: $1,500 per person;       Preventive Services .
 first year benefit max $1,000     Maximum: $1,000 per person per
 per person; second year benefit   calendar year
 max $500 per person .




                                                        13
Flexible Spending Accounts
Sanford Health offers flexible spending accounts administered by Sanford Health Plan . You may choose to deduct pre-tax dollars for
                 a medical expense spending account and/or dependent care spending account.

                            Here’s how flexible spending accounts work:
 Things to                        1 . estimate how much you expect to spend during the 2009 Plan Year for eligible out-of-pocket medical
 consider before                      expenses (such as medical, dental, vision, pharmacy, or over-the-counter medications) or dependent
 enrolling in flexible                  care expenses (incurred to allow you and your spouse to work) . for your 2009 Plan Year, you will be
 spending accounts…                       able to submit an eligible expense with a date of service between January 1, 2009 and
 • How much do you or                      march 15, 2010 and be reimbursed with your 2009 Plan Year funds . All eligible
    your family spend each                  medical claims will need to be submitted by April 30, 2010 . dependent                  Important:
    plan year for out-of-pocket             care claims can be submitted for your 2009 Plan Year for dates                   • For purposes
    medical expenses (i.e.,                 of service January 1, 2009 to december 31, 2009 . All eligible              of a dependent care
    prescription copays, office             dependent care claims will need to be submitted by
                                                                                                                     spending account, eligible
    visit copays, over the counter          march 31, 2010 .
                                                                                                                 children include children who
    medications, etc.)?                    2 . Based on your estimation, decide how much you want
                                                                                                                are younger than age 13.
 • How much do you                        to deposit, within IRS and the employer’s guidelines, to
                                                                                                              • For purposes of a medical
    spend each year on                  each account for the upcoming Plan Year . the maximum
                                                                                                             expense spending account,
    dependent daycare                 amount you can set aside each year for each account is $5,000 .
                                                                                                             eligible children include children
                                   dependent care flexible spending account is reduced to $2,500 if
    expenses?                                                                                                 who are younger than age 19
                               separate tax returns are filed .
                                                                                                                at the end of the flex plan year
                        3 . the amount you allocate to each account is automatically deducted from
                                                                                                                 or children who are younger
                       your paycheck in equal amounts each pay period before taxes are calculated .
 Important:                                                                                                         than age 24 (for full-time
                           4 . As you incur eligible expenses, submit a claim form along with the
 The subscriber                                                                                                         students) at the end of
                             required documentation for the expenses to Sanford Health Plan .
 of the medical                                                                                                              the flex plan year.
                              5 . If your medical insurance claims are paid by Sanford Health Plan and you
 plan must also be
                               do not have other insurance, you have the option of choosing autoprocessing . If
 the subscriber of the
                               this option is chosen, all out-of-pocket expenses for deductible, coinsurance, office visit
 flex plan in order for        copays, and pharmacy copays will automatically be processed through your medical expense
 autoprocessing to            spending account and paid to you without filling out a manual claim form .
 work efficiently.          6. You will be reimbursed from your account(s) by direct deposit/ACH for eligible expenses submitted.
                         Although you are still responsible for paying the out-of-pocket expense to the provider at the time of service, you
                    are saving money because you are being reimbursed with pre-tax dollars .



Long Term Disability
employees who work at least 40 hours per pay period are eligible for long term disability . this coverage is designed
to protect you and your family from the economic loss that a long term illness or injury may cause. The Long Term
disability benefit pays you a benefit of 60% of your normal monthly earnings up to a maximum of $6,000 per
month if you are unable to work . maximum benefit duration is up to SSnrA (Social Security retirement age) .
this plan offers a worldwide emergency travel assistance services, dependent care benefit and a return to work assistance program .
this benefit plan is designed to coordinate with other sources of benefits during your disability . Your benefit amount will be offset by:
Primary Social Security Awards, Workers Compensation, Pension Benefits, and/or State Mandated Disability Benefits.




                                                                       14
Plan Highlights
Worldwide emergency travel assistance services: delivers global travel assistance including medical and legal                                                                                             Things
emergency support for employees and their families who travel for business or pleasure more than 100                                                                                              to consider
miles from home .                                                                                                                                                                             before enrolling
                                                                                                                                                                                          in long term
Rehabilitation and Return to Work Assistance Program: Available for employees who are medically able to                                                                                disability…
participate . may include, but is not limited to, coordination with employer to return to work, adaptive                                                                              • How would you
equipment, job placement services, resume preparation, and education and retraining expenses for a                                                                                    provide for your
new occupation .                                                                                                                                                                       family’s fixed expenses
                                                                                                                                                                                         if you were unable
Dependent care benefit: Pays an additional $350 per dependent per month, to an overall family maximum                                                                                        to work due to
of $1,000, to disabled employees who are receiving LTD payments while participating in the Rehab/Return                                                                                          an illness or
to work Assistance program .                                                                                                                                                                            injury?

3 Month Lump-Sum Accelerated Survivor Benefit: Pays a lump sum amount equal to 3 months of your gross disability
payment if you have been diagnosed with a terminal illness or condition, your life expectancy has been reduced to less than 12
months and you are receiving monthly payments .



                                    Base Life Insurance
  Things                 Sanford Health provides a base level of term life insurance to part-time and full-time employees at no cost to
  to consider              you . the Base life Insurance coverage amount is equal to one times your annual salary up to a maximum
  before enrolling           of $100,000 .
  in supplemental
  life insurance...
  • Is the amount of my                                  Supplemental Life Insurance
     base life insurance       the amount of term Supplemental life Insurance you may choose are in increments of one, two, three,
     adequate to provide       or four times your annual salary up to a maximum of $250,000 (combined with Base life Insurance) .
     for my beneficiary
     in the event of
     my death?                                  AD&D Insurance
                                                           (Accidental Death and Dismemberment)
                              In addition to the amount of Base life (and Supplemental life, if elected), Ad&d benefits are provided at no
                         cost to the employee if an accident results in death or dismemberment within 180 days of that accident . In
                  the case of accidental death, the amount of your benefit is doubled .

                                                                                                                                                                                                       Things to
                                                                                                                                                                                                consider before
Dependent Life Insurance                                                                                                                                                                   enrolling in
You are able to elect term dependent life Insurance coverage on your spouse and children in the
                                                                                                                                                                                        dependent life
amounts listed below:
                                                                                                                                                                                       insurance...
                                                                                                                                                                                     • Is the amount of my
Spouse Coverage  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1/2 your annual salary up
                                                                                                                                                                                        salary adequate to
                                                                                                                                                       to a maximum of $75,000
                                                                                                                                                                                         provide for expenses
Infant Coverage  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $1,000 (birth to 14 days)
                                                                                                                                                                                           in the event of
                                                                                                                                                      $2,000 (14 days to 6 months)
                                                                                                                                                                                              my spouse or
Children Coverage  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1/2 your annual salary up
                                                                                                                                                                                                  children’s
  (6 months to age 19; or 25 if full time student)                                                                                                     to a maximum of $10,000
                                                                                                                                                                                                        death?
                                                                                                                                                       per child

                                                                                                                                 15
Underwriting Provisions
If you choose to elect long term disability, Supplemental life or dependent life after your first 90 days of employment, after your
first 90 days in a benefit eligible status, or during open enrollment, you will need to complete an eligibility questionnaire that is
subject to approval. The eligibility questionnaire includes medical questions, health history and may include a physical or other lab
tests to prove your insurability .



Plan Highlights
Waiver of Premium: Provides for waiver of premium while receiving long term disability benefits .


Survivor Support: Provides free professional counseling to beneficiaries of deceased or terminally ill employees in areas of estate
planning, benefit elections, CoBrA, income tax planning, educational needs and other concerns .


Repatriation benefit: An additional benefit of up to $5,000 for preparation and transportation of the deceased insured if death
occurs at least 100 miles from principal residence .


Education Benefit for AD&D Insurance: Pays up to $24,000 (6% to $6,000 per year) for the financial support of surviving, unmarried
children under age 25 of an insured employee who dies as a result of accidental bodily injury, within 365 days of the accident and
who are enrolled in an accredited post-secondary institution .




Beneficiary Designation (Important Information)
even if you are not electing Supplemental or dependent life Insurance, you will need to designate a beneficiary for your base level
of life insurance . If you fail to designate a beneficiary, the benefit will be paid in the following order: your spouse, your children,
your mother or father, your sisters or brothers, your estate .



401(k) Retirement Savings Plan
       Sanford Health offers all employees the opportunity to contribute dollars towards their retirement by offering the Sanford
               Health 401(k) retirement Savings Plan . the 401(k) is administered by wells fargo . You are automatically enrolled at a
 You
                    3% contribution rate deposited into the fidelity freedom target date fund that is appropriate for you based on a
 will need
                      retirement age of 65 . Your contributions will start on the first paycheck following one month of employment .
 to complete
                         Additionally, your contribution rate will be automatically increased by 1% each year until you reach a 6%
 the Beneficiary
                          contribution rate in your fourth year of employment .
 Designation Form
 found in the back         Sanford Health matches dollars that you are contributing into your 401(k) account each pay period . If
 of this booklet or        you contribute a minimum of 3% each pay period, Sanford Health will contribute an additional 1% each
 online at www.            pay period . once you have been employed at Sanford Health for 12 months and have 1,000 hours of
 wellsfargo.com/          service in the plan year between January 1 – December 31, you are eligible for Sanford Health’s 2% lump
 retirement-            sum contribution which is deposited into eligible employee’s accounts on an annual basis. Refer to the Plan
 plan                 document for further details .

                  You have the right to opt out or change your contribution rate or investment elections at any time by contacting the
           Wells Fargo Helpline at 1-888-319-9451 or by logging on to the Wells Fargo website at www.wellsfargo.com/retirementplan. If
you have qualified pension funds from another employer and are interested in a direct rollover into the Sanford Health 401(k) retirement
Savings Plan, please contact the wells fargo Helpline or website .



                                                                   16
Other Benefits
If you are interested in any of the voluntary benefits listed next (universal life insurance, short term disability, cancer insurance,
accident insurance and long term care insurance) please contact Howalt-mcdowell Insurance at (605) 339-3874 .



Universal Life Insurance
life Insurance will always be the foundation of a good family financial planning program . Universal life insurance can help employees
replace income for dependents, pay final expenses, create an inheritance for beneficiaries, make significant charitable contributions
and create a source of financial protection . Policies are available for employees, spouses and dependents . Universal life
policies are highly flexible in regard to premiums and face value . Premiums can be increased, decreased or deferred,
                                                                                                                                      For a
and cash values can be withdrawn .
                                                                                                                               complete
Additional benefits included in Universal life:                                                                             brochure of
• Accelerated Death Benefit                                                                                               information, go
• Waiver of Premium                                                                                                      to sanfordconnect
• Accelerated Death Benefit for Long Term Care                                                                            under employee
• Automatic Face Amount Increase                                                                                            benefits.
• Child’s Level Term Insurance




Short-Term Disability
Short-term disability provides you with a percentage of your salary after a specified waiting period if you are unable to work due to a
non-work related illness or injury.


the key elements of the policy include:
Monthly Benefits: While you are totally disabled you’ll receive a fixed monthly income benefit that will not exceed 60% of your
monthly salary. Periods of disability of less than one month will be paid at 1/30th the monthly benefit for each day of total disability.


Elimination period: After you have been totally disabled for 14 consecutive days, your benefits begin .


Benefit Period: Your physician and the insurance company will determine how long benefits are payable, up to the maximum
of 3 months .



Cancer/Intensive Care Insurance
Cancer Insurance helps protect you and your family against the additional costs associated with cancer . there are both direct costs (such
as hospital, doctors, surgery, drugs, medicine) and indirect costs (such as loss of income, transportation, child care, meals away from
home, coinsurance, deductibles and home related recovery) . Cancer Insurance pays you benefits that can be used for non-medical,
cancer-related expenses that health insurance and disability income might not cover . It pays benefits in addition to any other hospital or
major medical coverage you have and the benefit is payable directly to you.

Benefits are payable for:
• Hospitalization                      •    Physican Charges
• Surgery                              •    Radiation, Chemotherapy and Blood
• Cancer Maintenance Therapy           •    wellness and miscellaneous Benefits
• Lump Sum Diagnosis                   •    Intensive Care Benefits


                                                                     17
Accident Insurance
Accident insurance helps protect you and your family against the additional expenses associated with an accidental injury. It pays you
benefits for specific injuries, emergency room treatment, hospital confinement, and much more.

Covered injuries include:                                Benefits are payable for:
• Accidental Death & Dismemberment                       • Hospitalization
• Dislocations and Fractures                             • Doctor Charges                                                          For a
• Tendons and Ligament Injuries                          • Emergency Treatment                                              complete
• Burns                                                  • Ambulance                                                     brochure of
• Ruptured Disc/Torn Knee Cartilage                      • Transportation                                              information, go
• Major Cuts and Lacerations Requiring Stitches          • Lodging                                                    to sanfordconnect
• Eye Injuries                                           • Aftercare                                                   under employee
• Internal Injuries                                                                                                      benefits.
• Blood Transfusions



Long Term Care Insurance
long term Care Insurance pays you benefits when you receive service from a nursing home facility or through a home health care
agency as a result of inability to perform activities of daily living or as a result of severe cognitive impairment . Sanford Health
recognizes the importance of long term Care Insurance and is pleased to provide you with access to coverage that can help you
preserve your assets, financial independence and choice of care . long term care Insurance coverage is available to you, your spouse,
parents and grandparents .



Pre-Paid Legal Services
Pre-Paid legal Services is a benefit designed to assist with the costs of various personal legal services such as:
• Contract and document review
• Will preparation
• Uncontested divorce
• Mortgage document assistance
• Phone calls and letters on your behalf



Identify Theft Shield Plan
the Identity theft Shield Plan is designed to notify you when your identity is stolen so you can prevent losses . Identity theft
Shield’s benefits include:
• “8 Simple Steps You Can Take to Reduce Your Exposure to Identity Theft”
• Updated credit report information and analysis
• Continuous daily monitoring of your credit

And, in the event your identity is stolen, the Identity theft Shield plan will:
• Issue fraud alert notifications to all three credit repositories, government agencies
    and financial institutions
•   Conduct proactive searches of applicable local and national databases to look for fraudulent activity
•   Restore your name and credit for you




                                                                   18
CollegeAccess 529 College Savings Plan
A CollegeAccess 529 Plan helps individuals save for college with after tax dollars . CollegeAccess 529 is a college investment plan
sponsored by the State of South dakota and managed by PImCo funds distributors . this plan offers many advantages, including:
• Earnings grow free from federal income tax
• Use at any accredited college, university, or technical school in any state
• You control the money in the account even after the beneficiary turns “age of majority”
• Ability to change the beneficiary to any family member, or even yourself, at any time
• Choice of 26 investment options, which utilize funds from several leading fund families
• No income or age restriction
• The highest balance limit currently available - $305,000 and NO annual contribution limit (provided you do not exceed the
    maximum balance)

As a Sanford Health employee, you are eligible for special benefits through UBS under the CollegeAccess 529 plan, such as a low
participation cost for participants . You may start a 529 plan with as little as $50 per month or a $250 initial investment . If you are
interested in participating in the CollegeAccess 529 plan, please contact your local Human resources department .



403(b) Retirement Savings Plan
In addition to the 401(k), you have the opportunity to set aside retirement dollars through the Sanford Health 403(b) retirement
Savings Plan . A 403(b) is a tax deferred retirement program that allows employees of non-profit organizations to set aside
a portion of their pay on a pre-tax bases . Because these contributions are pre-tax, this allows you to not only avoid current
federal income tax, but you also avoid taxes on the earnings or growth on the investments as well . You do not pay taxes on the
contributions or earnings until you receive distributions .

You can start or stop, increase or decrease contributions to the 403(b) any time throughout the year . You may access your funds
prior to retirement through a loan and in-service distributions are available to participants age 59 1/2 or older. The 403(b) accepts
rollovers or transfers from IRA’s and previous employer retirement plans.

A metlife resources financial Services representative will sit down with you one-on-one to answer any questions you may have
and to help you get enrolled .

Your MetLife Resources Investment Advisor in Iowa and South Dakota is Scott Plathe:
Phone: 1-800-273-5535 e-mail: splathe@metlife .com


In Minnesota, contact Adam Wolff:
Phone: 1-800-273-5535 e-mail: awolff@metlife .com




                                                                    19
Important Contacts
Sanford Health Plan  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-6800 or toll-free 1-800-752-5863
      • Health Insurance                                                                                                                                                                                                                                                    sanfordhealthplan .org
      • Vision Plan
Sanford Health Plan flexible Spending Accounts .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-6810
                                                                                                                                                                                                                                                                            sanfordhealthplan .org
Howalt mcdowell  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 339-3874
      • Universal Life Insurance                                                                                                                                                                                                                                             howaltmcdowell .com
      • Cancer Insurance
      • Short Term Disability
      • Accident Insurance
      • Long Term Care Insurance
      • Prepaid Legal Services
      • Identity Theft Shield Plan


dakota eye Care  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1 (877) 970-3937
                                                                                                                                                                                                                                                                                   dakotaeyecare .com
delta dental of South dakota  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1-800-627-3961
                                                                                                                                                                                                                                                                                     deltadentalsd .com
wells fargo Helpline (401(k) plan) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .1-888-319-9451
                                                                                                                                                                                                                                                       wellsfargo.com/retirementplan
melife resources (403(b) plan)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .1-800-273-5535
  Scott Plathe, financial Services representative  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .(712) 279-7959
                                                                                                                                                                                                                                                                                   metlife .csplans .com
CollegeAccess 529 College Savings Plan (UBS)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 336-2070
Sanford wellness Center  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-1600
                                                                                                                                                                                                                                                                                sanfordwellness .com
Sanford Health Benefits Team:
  general Benefits number  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 333-7030
  Jen Anderson, Benefits Specialist .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-0507
  tanya Cain, Benefits Specialist .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-0508
  lori monsrud, Benefits Specialist  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-0509
  luann Schultz, Benefits Specialist  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-0510
  Sherry deneui, recognition Coordinator  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-0511
  Jodi olson, Benefits manager  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-0506
  Karla Haugan, System Human resources director  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-0504

Sanford Health Network Benefits Team:
  Aleen fisher, Human resources generalist  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (605) 328-5516
  Kathy Kaltved, director of Human resources  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .(605) 328-5515
  Or for Sanford Health Network benefit questions please contact your local Human Resources representative.




                                                                                                                                                              20
P.O. Box 91110
Sioux Falls, SD 57109-1110                   FLEXIBLE S PENDING
(605) 328-6810 / Fax: (605) 328-7207
www.sanfordhealthplan.com               MEDICAL EXPENSE CLAIM F ORM
EMPLOYEE INFORMATION

Name: __________________________________________________________ID Number: ________________________________

Street: __________________________________________________________Phone: (______) ____________________________

City: ____________________________________________________________State: ________________ Zip: ________________

Employer: _______________________________________________________

Please Note: All claims must be incurred during the plan year; prepayment for future dates of service is prohibited. Processing time could be delayed if
proper documentation is not provided. An itemized statement is required including date of service, type of service and total charge. Balance forwards
statements, cancelled checks and credit card receipts are not acceptable documentation. Eligible dependents for medical expense reimbursement are
considered a participant’s spouse and/or unmarried dependent children who are younger than 19 (or an eligible full-time student who is under 24) at the end
of the calendar year.

Medical Care Expenses:
Please check the appropriate box(es) corresponding with your claim(s).
  ! Charges attached are partially covered benefits under my health and/or dental insurance coverage. Enclosed is an Explanation of Benefits from
        my insurance. An Explanation of Benefits is required even if charges are applied to your deductible or out-of-pocket liability. If your
        claim has not been submitted to your medical or dental insurance, you must do so before submitting your claim for reimbursement.
  !     Charges are not a covered benefit by any insurance plan. Enclosed is an itemized statement for this incurred service.
  !     Charges attached are for reimbursement of my office visit or prescription drug co-pay due at the time of service. Enclosed is an itemized
        receipt provided by the provider of service. NOTE: Prescription drug co-pay receipts require indication of the patient name, drug name, date
        the prescription was filled and the amount paid by the patient.
  !     Charges attached are for reimbursement of an eligible over-the-counter item. Enclosed is a detailed receipt showing the over-the-counter item.
        If I am submitting a dual purpose item, I am aware that a letter of medical necessity must be on file or attached to this claim form in order to be
        considered for reimbursement.

  Date(s) of Service                       Patient’s Name                                          Provider                             Amount Requested




                                                                                                                   Grand Total:

EMPLOYEE CERTIFICATION: Employee signature required.
I, the undersigned, certify that the above expenses were incurred by me (and/or my spouse and/or eligible dependents) and have been incurred within the
period of coverage during the plan year. The above expenses have been paid by me (or them), were not reimbursed by any other plan and to the best of my
knowledge and belief, are eligible for reimbursement under my FLEX account. I have attached Explanation of Benefits statement(s) from all insurance plan(s)
and a letter of medical necessity (when necessary) of these expenses. I understand that I cannot use the expenses reimbursed through this FLEX account as
deductions or credits when filing my income tax return. If audited, I understand that it is my responsibility (not my employer’s) to provide written proof that
these expenses were actually incurred and eligible for reimbursement.
Employee Signature: _____________________________________________________________ Date: ______________________

Did you remember ?: ! Sign and date your claim form ! Provide proper documentation ! Read the account guidelines on the
back ! Retain original document for your records
             Failure to complete all appropriate sections of the claim form or submit legible itemized receipts/EOBs
                                            may delay the processing of your claims.
                                       Medical Expense Spending Account
                                          Reimbursement Guidelines

           Contact Information:           Sanford Health Plan Flexible Benefits Department
                                          PO Box 91110
                                          Sioux Falls, SD 57109-1110
                                          Phone: 605-328-6810
                                          Fax: 605-328-7207
                                          E-mail: flex@sanfordhealth.org
                                          Online Inquiry: www.sanfordhealthplan.com


           Submitting Medical Expense Claim Forms for Reimbursements: To request a medical expense
           reimbursement, the participant must complete and submit the appropriate claim form, along with
           proper documentation to Sanford Health Plan. Claim forms can be found on
           www.sanfordhealthplan.com. Please note: Some reimbursements may require a letter of medical
           necessity.
                 Pharmacy Expenses: Proper documentation includes the receipt from the pharmacy indicating
                 the prescription filled, the date, cost, etc.
                 Medical Out-of-Pocket Expenses: Proper documentation includes the Explanation of Benefits
                 (EOB) from your insurance company, or an itemized statement showing all expenses and
                 applied insurance payments.
                 Vision/Dental Expenses: Proper documentation includes itemized statements indicating the
                 services provided, dates of service, cost, etc. If insurance is provided for any of the services, an
                 EOB must be submitted as the participant cannot be reimbursed for any amount paid or
                 discounted by insurance.
                 Over-the-Counter Expenses: Proper documentation includes cash register receipts clearly
                 showing the item purchased.

           Autoprocessing Note: If autoprocessing has been selected, the out-of-pocket expenses incurred for
           pharmacy copays, office visit copays, deductible or coinsurance amounts will be included in the
           automatic procedure. This option is elected by the employee. The autoprocessing function is
           performed weekly, with pharmacy processing the weeks following the 3rd and the 17th of each month.
           The participant should keep in mind that the provider must submit the medical claim and Sanford
           Health Plan must adjudicate the medical claim prior to being reimbursed by the medical expense
           spending account.

           Adds/Changes/Terminations: Election amounts and enrolled spouse/dependents will stay in effect
           throughout the plan year, unless a qualified life event occurs. If a qualified life event occurs, Sanford
           Health Plan must be informed within 30 days of the qualified life event in order for eligibility
           changes/election changes to occur. All eligibility changes/election changes must be consistent with
           the qualified life event.



HP-0018 5/07
P.O. Box 91110
Sioux Falls, SD 57109-1110                        FLEXIBLE S PENDING
(605) 328-6810 / Fax: (605) 328-7207
www.sanfordhealthplan.com                     DEPENDENT CARE CLAIM F ORM
EMPLOYEE INFORMATION

Name: __________________________________________________________ID Number: ________________________________

Street: __________________________________________________________Phone: (______) ____________________________

City: ____________________________________________________________State: ________________ Zip: ________________

Employer: _________________________________________________________________________________________________

Reminder: Dependent care expenses are reimbursable if the expenses are incurred to allow the employee and the employee’s spouse to be gainfully employed
or attend school. Generally, expenses incurred while an employee is on a leave of absence are not reimbursable. Dependents must be under age 13 or
disabled in order to qualify for dependent care reimbursement.
Dependent Care Expenses:
Please note the following regulations.
! Appropriate documentation is required and includes itemized daycare receipts. Receipts must reflect dates of service and must be verified with a
      provider signature or Tax ID number. The Provider Certification box on this claim form may be completed in the place of an eligible receipt.
!     Cancelled checks, credit card receipts, and balance due statements are not acceptable forms of documentation. Processing time will be delayed if
      proper documentation is not provided.
!     All claims must be incurred during the current plan year; prepayment for future dates is prohibited.
!     Requests for reimbursement will be paid according to the total dollars available in your account.

Please check the appropriate box regarding your claim substantiation.
" I have provided eligible itemized receipts reflecting the dates of service, verified by a provider signature or Tax ID number.
" My provider has completed the Provider Certification box on this claim form, verifying the expenses listed.
                                                                 Dependent Care Expenses
      Dates of Service                      Dependent’s                        Amount of                          Provider’s                     Provider’s
    From:          To:                      Name & Age                          Services                        Name & Address                 Tax ID Number




                                                      Grand Total: ____________
PROVIDER CERTIFICATION (This section can be completed by your daycare provider if receipts are not provided.)
I certify that these Dependent Care expenses were incurred by the above named participant.

Provider Address: Street_________________________________________________ City ________________________ State__________ Zip ________

Provider’s Signature: ________________________________________________________________________________ Date: _____________________

EMPLOYEE CERTIFICATION
I, the undersigned, certify that the above expenses were incurred by my eligible dependent(s) and have been incurred within the period of coverage during the plan
year. The above expenses have been paid by me (or my spouse), were not reimbursed by any other plan and, to the best of my knowledge and belief, are eligible for
reimbursement under my FLEX account. I understand that I cannot use the expenses reimbursed through this FLEX account as deductions or credits when filing my
income tax return. If audited, I understand that it is my responsibility (not my employer’s) to provide written proof that these expenses were actually incurred and
eligible for reimbursement.

Employee Signature: _______________________________________________________________________________ Date: _____________________
                                                      Unsigned claim forms will not be considered for reimbursement.
                    Dependent Care Spending Account Reimbursement Guidelines


           Contact Information:           Sanford Health Plan Flexible Benefits Department
                                          PO Box 91110
                                          Sioux Falls SD 57109-1110
                                          Phone: 605-328-6810
                                          Fax: 605-328-7207
                                          E-mail: flex@sanfordhealth.org
                                          Online Inquiry: www.sanfordhealthplan.com


           Submitting Dependent Care Expense Claim Forms for Reimbursements: To request a dependent
           care expense reimbursement, the participant must complete and submit the appropriate claim form
           along with proper documentation to Sanford Health Plan. Claim forms can be found on
           www.sanfordhealthplan.com. Photocopies of daycare receipts are acceptable, but must be legible and
           dates of service must be listed. Future dates of services will not be paid until the service has been
           incurred. Dependent care spending account reimbursements are paid only up to the balance existing in
           the dependent care spending account at the time of the claim. Dependent care spending accounts are
           for daycare expenses incurred to allow you/your spouse to work. If you are not at work and incur
           daycare expenses, those expenses cannot be reimbursed (i.e., leave of absence, babysitting). Please
           note: A dependent must be under age 13 and able to be claimed as a dependent on your income tax
           return in order to be eligible for dependent care expenses.

           Adds/Changes/Terminations: Election amounts and enrolled spouse/dependents will stay in effect
           throughout the plan year, unless a qualified life event occurs. If a qualified life event occurs, Sanford
           Health Plan must be informed within 30 days of the qualified life event in order for eligibility
           changes/election changes to occur. All eligibility changes/election changes must be consistent with
           the qualified life event.




HP-0017 5/07
             Sanford Health Retirement Savings Plan (Plan #135195)
                                          Beneficiary Designation Form
Complete this Designation of Beneficiary form, make a copy for your records, and mail the original to Wells Fargo at the following
address: Wells Fargo Retirement Plan Solutions, Attn: Sanford Health System Plan Processing, PO Box 1217, Minneapolis, MN
55440-1217. Please note that your original form will be discarded after the form is scanned and uploaded to the website.

PARTICIPANT INFORMATION (PLEASE PRINT)

Name___________________________________________ Social Security Number_____________________________

Location_________________________________________ Employee Number_________________________________

Marital Status ___ Unmarried/Divorced ___ Married ___ Separated           Spouse Name_______________________________________

A court order gives my former spouse benefit rights in this Plan: ___ Yes ___ No If “yes”, a copy of the court order is attached.

BENEFICIARY DESIGNATION INFORMATION (PLEASE PRINT)

If I die before receiving benefits under this Plan, I designate this person (or these persons) as my beneficiary(ies). This
designation replaces all prior beneficiary designations.

Primary Beneficiary__________________________________ Relationship ____________________________________

Social Security Number_______________________________ Date of Birth ____________________________________

Address ____________________________________________________________________________________________________
               Street                                  City                                           State             Zip Code


 If the primary beneficiary designated above dies before I die, then in the event of my death I hereby designate the following
beneficiary to receive benefits payable under this Plan by reason of my death.

Secondary Beneficiary________________________________ Relationship ____________________________________

Social Security Number_______________________________ Date of Birth ____________________________________

Address ____________________________________________________________________________________________________
               Street                                  City                                           State             Zip Code


AUTHORIZATION

I hereby authorize the beneficiary designated above. If I have named my spouse, I understand that in the event of my death
prior to the commencement of the distribution of my Plan benefits, my spouse may elect any form of payment provided by
the Plan in lieu of the Qualifed Preretirement Survivor Annuity (QPSA). If I have a named beneficiary other than my spouse,
I hereby elect to waive payment of a QPSA to my spouse in the event of my death prior to the commencement of the
distribution of my Plan benefits. I have read the attached QPSA notice and understand my right to make this waiver election.
I understand I may revoke this election at any time during the election period described in the Plan.

Signature of Participant ____________________________________________________ Date________________________________

SPOUSE’S CONSENT AND WAIVER OF QPSA

By my signature below, I certify that I am the spouse of the Participant, or have rights to benefits as a former spouse under a
qualified domestic relations order and that I consent to the naming of the beneficiary or beneficiaries listed above. I further
state I understand the following:


the Plan in the event that my spouse dies before benefit payments from the Plan begin.


form and that I may receive nothing from the Plan after my spouse dies.


Signature of Spouse ________________________________________________________ Date ______________________________
Consent must be witnessed by either Plan Representative or Notary, but not both.
Signature of Plan Representative _______________________________________________ Date_____________________________

OR Notary: County_______________________________________ State _______________________________________________
SWORN TO AND SUBSCRIBED before me on this _____ day of ________________, _____.

Signature_____________________________ Date my Commission Expires ________________
100-11200-0195 2/08
                                                                                                                PR11200195
QUALIFIED PRERETIREMENT SURVIVOR ANNUITY (QPSA) NOTICE
1. WHAT IS A QUALIFIED PRERETIREMENT SURVIVOR ANNUITY?

Your spouse has an account in the Sanford Health Retirement Savings Plan (the “Plan”). You have the right to receive a
special benefit if your spouse has earned retirement benefits under the Plan and dies before he or she begins receiving those
benefits. The special death benefit is equal to the retirement benefit your spouse earns before death stated in terms of a
monthly annuity payable for the remainder of your life. The special death benefit is often called a ‘‘qualified preretirement
survivor annuity’’ or ‘‘QPSA’’ benefit. (The plan will pay this death benefit in a lump sum, rather than as a QPSA, if the value of
the death benefit is $1,000 or less.)

Under the QPSA, you will receive a lifetime level monthly payment. The Trustee will distribute the QPSA using at least 50% of
your spouse’s nonforfeitable account balance to purchase an annuity contract from an insurance company. The Trustee will
distribute the contract to you as the surviving spouse. The Trustee may not commence payment of the QPSA prior to the date
your spouse, the plan participant, would have attained the later of Normal Retirement Age under the Plan or age 62 without
your consent. However, you may elect to have the distribution of the QPSA at any time following your spouse’s death.

The actual level monthly payments made under the QPSA will depend on the annuity purchase rate used by the insurance
company, your age at the time of distribution begins, and the amount of your spouse’s vested account balance at the time the
Plan Trustee purchases the annuity contract. The QPSA will not pay any benefits to other beneficiaries after your death.

2. WHAT ARE YOUR RIGHTS IF YOU WAIVE THE QPSA BENEFIT?

Your right to the QPSA benefit provided by federal law cannot be taken away unless you agree to give up that benefit.

You can agree to give up all or part of the QPSA benefit. If you agree to give up all of the QPSA benefit, the plan will pay this
benefit to another person selected by your spouse. The person your spouse selects to receive this benefit is often called a
‘‘beneficiary’’. If you agree to give up part of the QPSA benefit, that part will be paid to the beneficiary named by your spouse,
and you will receive the rest of the QPSA benefit. For example, if you agree, your spouse can have the death benefits paid to
his or her children instead of you.

Example of Naming a Beneficiary Who is Not the Spouse
Pat and Robin Doe agree that Robin will not receive the QPSA benefit. Pat and Robin also decide that Pat’s vested
account will be split between their two children, Sue and Chris. Therefore, 1/2 of Pat’s vested account in the Plan will
be paid to Sue and 1/2 will be paid to Chris. If Pat’s vested account at the time of his death is $10,000, the Plan will
pay $5,000 to both Sue and Chris and Robin will not receive anything.

3. DO YOU HAVE TO GIVE UP YOUR RIGHT TO THE QPSA BENEFIT?

Your choice must be voluntary. It is your personal decision whether you want to give up your right to the QPSA benefit.

4. CAN YOUR SPOUSE MAKE FUTURE CHANGES IF YOU SIGN THIS AGREEMENT?

 If you sign this agreement, your spouse cannot change the beneficiary named in this agreement unless you agree to the new
beneficiary by signing a new agreement. If you agree, your spouse can change the beneficiary at any time before your spouse
begins receiving benefits or dies. You do not have to agree to let your spouse change the beneficiary. However, your spouse
can later select the QPSA benefit for you without having you sign a new agreement.

5. CAN YOU CHANGE YOUR MIND AFTER YOU SIGN THIS AGREEMENT?

You cannot change this agreement after you sign it. Your decision is final.

6. WHAT HAPPENS TO THIS AGREEMENT IF YOU BECOME SEPARATED OR DIVORCED?

You may lose your right to the QPSA benefit if your spouse and you become legally separated or divorced, even if you do not
sign this agreement. However, if you become legally separated or divorced, you might be able to get a special court order
(which is called a qualified domestic relations order or ‘‘QDRO’’) that specifically protects your rights to receive the QPSA
benefit or that gives you other benefits under this plan. If you are thinking about separating or getting a divorce, you should get
legal advice on your rights to benefits from the plan.




                                                                                                                               100-11200-0195 2/08
Sanford Health Premiums 2009

                             Health Insurance Premiums – Per Pay Period
                          Sanford Health 750                                        Sanford Health 2000
           Single                                     $56.00         Single                                       $49.50
           Employee w/Spouse FT                   $179.00            Employee w/Spouse FT                       $147.50
           Employee w/Spouse PT                   $289.00            Employee w/Spouse PT                       $235.50
           Employee w/Child(ren) FT               $161.00            Employee w/Child(ren) FT                   $132.50
           Employee w/Child(ren) PT               $258.50            Employee w/Child(ren) PT                   $214.00
           Family FT                              $188.00            Family FT                                  $156.50
           Family PT                              $301.50            Family PT                                  $248.00


                             Dental Insurance Premiums – Per Pay Period
                                  Option A                                                 Option B
           Single                                      $9.20         Single                                        $4.16
           Family FT                                  $30.96         Family FT                                    $17.90
           Family PT                                  $33.06         Family PT                                    $20.00


                    Vision Insurance Premiums - Per Year (first four paychecks)
           Sanford Vision
    Administered by Sanford Health Plan                        Dakota Eye Care
 Single                        $33.00        Single                     $12 per year
 Employee w/Child(ren)         $74.00        Employee w/Child(ren)      $17 per year for the 1st covered member,
                                                                        $6 per year for each covered member thereafter
 Family                        $94.00        Family                     $17 per year for the 1st covered member,
                                                                        $6 per year for each covered member thereafter


               Long Term Disability                                            Dependent Life Insurance
     $.61 per month/per $100 of covered monthly pay                    $.50 per month/per $1,000 of dependent coverage


          Supplemental Life Insurance                                    Legal Services - Per Pay Period
           Cost per month/per $1,000 of coverage                              Prepaid Legal Services . . . . . . . . . $7.38
                                                                              Identity Theft Shield Plan . . . . . . . . $7.98
          Age of Employee                  Rate
                                                                              Combination Plan . . . . . . . . . . . . $13.85
           Less than 30                   $0.08
               30-34                      $0.10                                 (Prepaid Legal Services and
               35-39                      $0.12                                  Identity Theft Shield Plan)
               40-44                      $0.18
               45-49                      $0.30
               50-54                      $0.49
               55-59                      $0.76
               60-64                      $1.18
               65-69                      $2.08
                70+                       $3.72
                                                                                                                  100-11200-0077 rev. 9/08 Page 1 of 3
Short Term Disability (Transamerica)
Rates for a 3-month benefit with a 14/14 day elimination period
  Monthly Benefit            Ages 18-49           Ages 50-59          Ages 60+
        500                     6.65                8.30               12.50
       1000                    13.30                16.60              25.00
       1500                    19.95                24.90              37.50
       2000                    26.60                33.20              50.00
       2500                    33.25                41.50              62.50
       3000                    39.90                49.80              75.00

                                             NOT portable


Long Term Care Insurance (Unum)
Rates are based on a 3 year benefit period
Daily Benefit Amount       Ages 18-30      Ages 40           Age 50   Age 60
         $50                 5.48           9.05             13.90    24.10
        $100                10.95          18.10             27.80    48.20
        $150                16.43          27.15             41.70    72.30

Rates are based on a 6 year benefit period
Daily Benefit Amount       Ages 18-30      Ages 40           Age 50   Age 60
         $50                 7.45          12.28             18.28    31.40
        $100                14.90          24.55             36.55    62.80
        $150                22.35          36.83             54.83    94.20

Rates are based on a Lifetime year benefit period
Daily Benefit Amount       Ages 18-30      Ages 40           Age 50   Age 60
         $50                 9.43          15.38             22.25    37.75
        $100                18.85          30.75             44.50    75.50
        $150                28.28          46.13             66.76   113.25


  parents-in-law and grandparents




Accident Insurance (Transamerica)
   Employee                              5.48
   Employee + Spouse                     7.97
   Employee + Children                   9.33
   Family                                11.82




                                                                               100-11200-0077 rev. 9/08 Page 2 of 3
Cancer Insurance (Transamerica)
Hospital-$100/day; Surgery-up to $1,000 for in-hospital & up to $1,500 for outpatient surgeries; Radiation/
Chemotherapy/Blood-up to $5,000; Wellness-$50/year; Cancer Maintenance Therapy-up to $1,000; Lump


    Per Pay Period Premium Rates
    Employee                                 5.99
    Employee + Child(ren)                    6.85
    Family                                   10.82

Hospital-$200/day; Surgery-up to $2,000 for in-hospital & up to $3,000 for outpatient surgeries; Radiation/
Chemotherapy/Blood-up to $10,000; Wellness-$100/year; Cancer Maintenance Therapy-up to $2,000;


    Per Pay Period Premium Rates
    Employee                                 11.97
    Employee + Child(ren)                    13.69
    Family                                   21.63

Hospital-$300/day; Surgery-up to $3,000 for in-hospital & up to $4,500 for outpatient surgeries ; Radiation/
Chemotherapy/Blood-up to $15,000; Wellness-$150/year;Cancer Maintenance Therapy-up to $3,000; Lump


    Per Pay Period Premium Rates
    Employee                                 17.96
    Employee + Child(ren)                    20.54
    Family                                   32.45




Universal Life Insurance (Transamerica)
                                             Death Benefits (Non-Tobacco/pay period)
    Covered Individual                   $25,000             $50,000             $100,000
    Age 25                                 N/A   +
                                                               10.84               20.92
    Age 35                                 N/A   +
                                                               16.37               31.98
    Age 45                                13.49                26.22               51.67
    Age 55                                22.68                44.60               88.43

+


                                                                  dependent children and grandchildren




This sheet is a premium summary only. If there is a discrepancy between this summary and your
Certificate of Coverage, the Certificate of Coverage will take precedence in determining your benefits.



                                                                                             100-11200-0077 rev. 9/08 Page 3 of 3
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