SBC: I hereby acknowledge receipt of the Summary of Benefits and Coverage (SBC) found in Ease. I have read the SBC and am familiar with its contents. If I have any questions concerning the information, I will contact the carrier or my Human Resource Department to have my questions answered. I understand this SBC is not a contract, and the material represents guidelines subject to change.

Offer of Coverage: I certify that I have received enrollment and plan information for health care coverage that Pharmacy Management Services of Acadiana, L.L.C. offers, representing that it meets ACA requirements for affordable, minimum essential coverage, offering minimum value to me. I have been given the opportunity to enroll in or decline that coverage.

Pre-Tax Payroll Deductions: I authorize any payroll deductions required for the elections made in this online enrollment portal. I understand that these deductions will be made on a pre-tax basis unless I elect otherwise on this form. I understand that I cannot change my elections until the next open enrollment period, but I may change coverage for the dependents I am insuring or add new dependents if there is a "qualified" change in status. I have read the plan description and understand the post-tax deduction option.

Required Benefit Notices: Below is a link to the required benefit notices. I attest that I have read and understand the Required Benefit Notices.