altius peak plus traditional plan
Transcription
altius peak plus traditional plan
Box Elder School District 2012-2013 Employee Benefits Guide GBS Benefits, Inc. Altius 10421 South Jordan Gateway, Ste. 400 South Jordan, UT 84095 HealthEquity 15 W. Scenic Pointe Drive, Ste. 400 Draper, UT 84020 Dental Select 5373 S. Green Street, 4th Floor Salt Lake City, UT 84123 Opticare of Utah 1901 West Parkway Blvd Salt Lake City, UT 84119 The Hartford 7400 College Blvd, 6th Floor Overland Park, KS 66210 EMI Health 852 E. Arrowhead Lane Murray, UT 84107 National Benefits Service 8523 S. Redwood Road West Jordan, UT 84088 URS (Utah Retirement Systems) 560 East 200 South Salt Lake City, UT 84102 GBS Benefits, Inc. 465 South 400 East, Ste 300 Salt Lake City, UT 84111 Box Elder School District Medical (800) 377-4161 www.altiushealthplans.com Health Savings Account (866) 346-5800 www.healthequity.com Dental (800) 999-9789 (801) 495-3000 www.dentalselect.com (800) 323-0950 (801) 869-2020 www.opticareofutah.com (800) 523-2233 www.thehardford.com Vision Life Long-Term Disability Flexible Spending Account Retirement Denise House Account Manager Maegan Heiner Benefit Secretary (800) 622-5851 (801) 262-7475 www.emihealth.com (800) 274-0503 (800) 478-1528 Fax www.nbsbenefits.com (801) 366-7770 – Retirement (801) 366-7720 – 401k, 457, IRA www.urs.org (800) 427-6586 x 1160 801) 364-7233 x 1160 [email protected] (435) 734-4800 x 137 [email protected] In an effort to make your benefits more understandable, this brief summary of your benefits has been prepared. The benefit booklet is provided as a summary of your employee benefits only. While the benefits listed are considered accurate, they are not a guarantee of service, or payment by the insurance company. For complete details regarding any of your employee benefits, please see plan summaries. This summary of benefits is a cursory description of your employee benefits and should be considered such. Table of Contents Enrollment Information ..........................................................................................................................................5 HRconnection Tip Sheet ..........................................................................................................................................7 Medical – Altius Health Plans ..................................................................................................................................8 Peak Plus $750/$2,250 Plan Summary ..........................................................................................................9 Peak Plus $1,000/$3,000 Plan Summary .......................................................................................................12 Limitations & Exclusions for Traditional Plans ...............................................................................................15 Peak Plus Qualified High Deductible Health Plans $1,200/$2,400 Plan Summary ........................................18 Limitations & Exclusions for High Deductible Plan ........................................................................................21 Preventive Care ..............................................................................................................................................24 Provider List ...................................................................................................................................................27 Frequently Asked Questions ..........................................................................................................................31 Health Savings Account – HealthEquity ..................................................................................................................38 A Healthy Choice for Your Savings .................................................................................................................39 Sample Expenses............................................................................................................................................42 Dental – Dental Select .............................................................................................................................................43 Co-Pay Gold Plan Summary of Benefits .........................................................................................................44 Gold PPO Network Schedule of Co-Pay/Plan Payments ................................................................................45 Co-Pay Platinum Plan Summary of Benefits ..................................................................................................49 Platinum Network Schedule of Co-Pay/Plan Payments .................................................................................50 Max Indemnity Platinum Plan Summary of Benefits .....................................................................................54 Vision – Opticare of Utah ........................................................................................................................................55 70C Opticare Plan Summary ..........................................................................................................................56 120C Opticare Plan Summary ........................................................................................................................57 Online Provider Search ..................................................................................................................................58 Life – The Hartford ...................................................................................................................................................59 Group Basic Life and Supplemental Life Benefit Highlights ...........................................................................60 Long Term Disability – EMI Health ..........................................................................................................................62 Box Elder School District LTD Plan Summary .................................................................................................63 Flexible Spending Plan (Section 125) – National Benefit Services..........................................................................64 Highlights .......................................................................................................................................................65 Sample Expenses............................................................................................................................................66 Additional Information ...........................................................................................................................................67 Health Care Reform & Changes to Your Benefits ..........................................................................................68 Medicare Part D .............................................................................................................................................69 Medicaid & CHIP Model Notice .....................................................................................................................70 Premiums.................................................................................................................................................................72 Altius Premiums .............................................................................................................................................73 Dental Select Premiums .................................................................................................................................74 Opticare Premiums ........................................................................................................................................74 Enrollment Information August 2012 The district fringe benefit package is an important part of your whole compensation. The district is pleased to offer you the opportunity to select from a variety of benefit options. Eligible employees can elect participation in any of all of the following: • Health Insurance • Dental Insurance • Vision • Section 125 Flexible Spending Benefit Plan • Basic Term Life Insurance • Supplemental Term Life Insurance • Long Term Disability • 401(k), 457, 403(b), IRA and Roth IRA This booklet is designed to help you make decisions about what coverage is best for you and your family. Enclosed you will find a brief description of the options available, a comparison of basic plan coverage and cost information about any of the plans, don’t hesitate to contact the insurance companies directly. Provider listings can be found on the website of the carrier. Company phone numbers and websites are listed on the back cover of this booklet. Once again Box Elder School District will be providing online access to all your benefit information through HRconnection. Each individual will have their own username and password. Go to www.hrconnection.com and enter your information. The username and password are case sensitive. Once logged in you will be able to make your annual benefit elections. Also, this resource will provide you with general benefit information, plan summaries, summary plan descriptions, provider directories, customer service information and much more. EVERYONE MUST LOGON TO HRCONNECTION AND EITHER ELECT OR WAIVE HEALTH, DENTAL, VISION, AND FLEXIBLE SPENDING. Please take time to carefully go through this information and make decisions about these valuable benefits. Employees, who have carefully considered and selected their benefit options, will have fewer questions or problems with their benefit throughout the year. Everything must be completed online by Friday, August 17, 2012 by NOON. Once complete, enrollment confirmation statements and any other necessary forms must be signed and returned to Maegan Heiner at the District Office. If you have any question about insurance choices, contact Maegan Heiner at the District office at (435) 7344800 or Denise Perez-House at GBS Benefits at (800) 427-6589 ext. 1160. Open Enrollment Box Elder School District open enrollment will be held from August 3 through August 17, 2012. This is a period of time when employees are able to enroll in insurance coverage or elect changes to your benefits. It is important to note that this is the only period of time that you can make changes to your insurance coverage (with the exception of changes necessary due to a change in status). 5 This booklet contains a brief description of the insurance options available; comparison of plan coverage’s, cost information and other important notes to help you evaluate your insurance choices. During this period of time, please take the opportunity to review your coverage choices, as well as any changes made to the group plans, benefits and premiums. Active Employees and Retirees Open enrollment is the only time you can make changes to your benefits, except when a status change occurs (described below). Everyone must enroll online on HRconnection, even if you do not want your benefits to change. If you do not elect your benefits during this time frame, you forfeit your right to participate in these benefits. Newly Hired or Newly Eligible If you are a newly hired or a newly eligible employee, you are required to enroll within 30 days of hire. Contact Maegan Heiner at the District Office with instruction on doing so. Change of Status A change of status includes many things. For example: • Marriage • Birth/Adoption • Legal Guardianship • Divorce • Death • Loss of Spouse’s Job Those employees experiencing a status change and wishing to change their benefits need to do so within 30 days of the effective date of change. If notice is not submitted to Maegan Heiner in a timely manner, you change request may not occur. A change of part-time hours is also considered a change of status. If you were a part-time employee who initially declined coverage at your first eligibility date but experienced a change in assignment or approved work hours, you have another opportunity to enroll in benefit coverage. Those wishing to make changes for this reason are still required to give notification to Maegan Heiner within 30 days of the effective date of change. Eligibility Licensed/Certified Employees: All contracted certified employees are eligible for benefits. Classified Employees: Classified employees must be on contract with the district and work a minimum of 5 hours per day if hired after September 15, 2005 or a minimum of 4 hours if hired before that date. Employees on an extended contract (205 days or more), who work a minimum of 5 hours per day are eligible for benefits as well. Eligible Dependents: Employee’s spouse, if not legally separated from employee Employee’s single and married children under age 26. Employee’s children with disabilities as specifically approved by the insurance carrier 6 Information Needed 1. Username/Password (temporary password) 2. If you’re adding a spouse/child you will need their SSN & Date of Birth Step 1 - Getting started 1. 2. 3. 4. 5. In your web browser type www.hrconnection.com in the address bar. Enter your Username Temporary Password = Box2012 Old Password = Box2012 New Password Requirements: minimum of 7 characters (capital letter, lowercase letter and a number) Step 2 – Verify your Personal,Dependent Information 1. Click at the top left hand corner of the screen 2. Click on the next to you and each of your dependents and verify the information, then click SAVE at the bottom of the screen. 3. Make sure the status shows pending after you have confirmed/updated your personal and dependent information 4. If you need to add a dependent, click Add Contact (This is located in the upper right corner above “Actions”.) 5. Once all of your information has been verified/updated see Step 3. Step 3 – Make Your Open Enrollment Elections 1. Click on the next to Medical 2. Select or waive the coverage 3. At the bottom of the screen click the box next to each dependent that needs to be covered. 4. Click Elect and Continue to continue to the next benefit option. Once you are done making your elections you will confirm your elections, see Step 4. Step 4 - Confirm your Elections 1. Click on Confirm Open Enrollment Elections 2. Verify your elections are correct & all your dependents are listed as they should be for each plan 3. Click Confirm 4. Pop up box will appear to Print your Confirmation Summary. 5. Click Yes 6. You will now be in a new window where you can print any forms applicable to you. If there are no forms click done. 7. Sign the Confirmation Summary and turn into your HR Department. You are now done enrolling online. 7 MEDICAL Altius Health Plans Traditional $750 Deductible Plan Traditional $1,000 Deductible Plan QHDHP $1,200 Deductible Plan 8 ALTIUS PEAK PLUS TRADITIONAL PLAN UTLPPT87 750-R15_30_60B-C80 NSB Box Elder School District September 1, 2012 Participating Providers Non-Participating Providers $750 / $2,250 $1,500 / $4,500 $2,000 / $6,000 $3,000 / $9,000 DEDUCTIBLE, OUT-OF-POCKET & LIMITS Plan Year Deductible – (Individual / Family) Does not apply to Out-ofPocket Maximum. Cumulative across benefit levels. Out-of-Pocket Maximum – Cumulative across benefit levels. Lifetime Maximum – Cumulative across benefit levels. Unlimited OUTPATIENT SERVICES YOU PAY Preventive Care Services – When provided in conjunction with a preventive diagnosis, as determined by Altius, including annual adult physical examinations, well child care, family planning, routine immunizations, minor diagnostic laboratory tests, and colonoscopies. Some services you receive during a preventive office visit may not qualify as Preventive Care Services and will be subject to applicable deductibles, copays, and/or coinsurance You Pay Nothing 30%* AD Office Visits – Primary Care 20%* AD 30%* AD Office Visits – Specialty Care 20%* AD 30%* AD After-Hours Care / Urgent Care – Care received in a physician’s 20%* AD 30%* After Participating Deductible year. 20%* AD Participating Providers Only Eye Exams – Optometrist 10%* AD 30%* AD Major Diagnostic Laboratory Tests and Radiology – 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD office or urgent care facility. Chiropractic Office Visits – Limited to 20 visits per member, per plan Including, but not limited to CT scans and MRIs. Minor Diagnostic Laboratory Tests and X-Rays – Including, but not limited to mammograms and chest X-rays. Outpatient Hospital / Facility Services – Including, but not limited to, outpatient surgery, observation, chemotherapy, radiation therapy, dialysis, cardiovascular services, infusion therapy, endoscopy, and pulmonary services. Includes physician charges. Cardiac rehabilitation and pulmonary rehabilitation limited to a combined benefit of 18 outpatient facility visits per member, per plan year. Physiotherapy Services at a Provider's Office – Physical, occupational and speech therapy provided on an outpatient basis. Limited to a combined benefit of 20 provider's office and/or outpatient facility visits of each type per member, per plan year. Physiotherapy Services at an Outpatient Facility – Physical, occupational and speech therapy provided on an outpatient basis. Limited to a combined benefit of 20 provider's office and/or outpatient facility visits of each type per member, per plan year. EMERGENCY CARE YOU PAY Emergency Room Care – When medically necessary, as determined by Altius. Includes all services provided in an Emergency Room setting. Inpatient benefit applies when admitted. Outpatient hospital benefit applies when transferred to an operating room. 20%* AD 20%* AD Urgent Care – When medically necessary, as determined by Altius. 20%* AD 30%* After Participating Deductible Ambulance / Paramedics – (including Air Ambulance) When medically 20%* AD Participating Benefit Applies necessary, as determined by Altius. Deductibles do not apply to the out-of-pocket maximum. Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com * Applies to out-of-pocket maximum (OOPM), AD = after deductible, APD = after Pharmacy Deductible PTCMPOS3302 Rev. 10-10 9 ALTIUS PEAK PLUS TRADITIONAL PLAN UTLPPT87 750-R15_30_60B-C80 NSB Participating Providers Box Elder School District September 1, 2012 INPATIENT SERVICES Non-Participating Providers YOU PAY Inpatient Hospital / Facility Services Inpatient Physiotherapy Services – Physical, occupational and speech therapy provided on an inpatient basis. Limited to 60 days per member per plan year for all therapy types combined. Physician, Surgeon, Assistant Surgeon, Anesthesiologist Organ Transplant Services – Organ and tissue transplant services, including, but not limited to, cornea, kidney, heart, lung, heart-lung, liver, pancreas, and bone marrow transplants and related services. 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD Participating Providers Only MATERNITY SERVICES YOU PAY Pre-Natal and Post-Natal Care – Professional Services – Routine pre-natal office visits, delivery (including surgeon and assistant surgeon), and post-natal care. Regular benefits apply for complications of pregnancy. Inpatient Hospital / Facility Services 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD Participating Benefit Applies Adoption Indemnity Benefit – Indemnity benefit for a child placed for adoption with the subscriber within 90 days of birth. The maximum benefit amount is $4,000, and will be reduced by any applicable deductible, copay, and/or coinsurance. INJECTABLE OR IMPLANTABLE MEDICATIONS YOU PAY Injectable or Implantable Medications – Non-Facility – Injectable or implantable medications received in a physician’s office or through a home health provider. (Preferred / Non-Preferred) Injectable or Implantable Medications – Pharmacy (Preferred / Non-Preferred) 20%* / 30%* 30%* AD / 40%* AD 20%* / 30%* Participating Providers Only PRESCRIPTION DRUGS YOU PAY If you receive a brand name drug when a preferred generic equivalent can be substituted, you will pay the difference in cost between the generic and the brand name drug, any applicable deductible, and/or the generic copay. Regular benefits apply if a preferred generic cannot be substituted. Prescription Drugs – Up to a 30-day supply. This benefit also includes the Preferred Generic: $15 following injectable medications when provided by an Altius participating Preferred Brand: $30 pharmacy: insulin, Imitrex, Symlin, Byetta, glucagon, Lovenox, and epinephrine kits Non-Preferred: $60 (such as Epi-Pen). Participating Providers Only Preferred Generic: $45 Preferred Brand: $90 Non-Preferred: $180 Participating Providers Only Prescription Drugs Mail Order – 90-day supply of maintenance medication. MENTAL HEALTH / SUBSTANCE ABUSE YOU PAY Inpatient Services 20%* AD 30%* AD Outpatient Services 20%* AD 30%* AD Deductibles do not apply to the out-of-pocket maximum. Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com * Applies to out-of-pocket maximum (OOPM), AD = after deductible, APD = after Pharmacy Deductible PTCMPOS3302 Rev. 10-10 10 ALTIUS PEAK PLUS TRADITIONAL PLAN UTLPPT87 750-R15_30_60B-C80 NSB Participating Providers Box Elder School District September 1, 2012 ALLERGY CONDITIONS Testing and Treatment Serum Injections Non-Participating Providers YOU PAY 20%* AD 20%* AD 20%* AD OTHER BENEFITS 30%* AD 30%* AD 30%* AD YOU PAY Accident Related Dental Services – Dental services required as the result of an accidental injury. Services include, but are not limited to, crowns, caps, bridges, and root canals. Limited to a combined lifetime maximum of $1,000 per member. 50% AD Participating Benefit Applies Durable Medical Equipment (DME) – Including corrective 50% AD 50% AD 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD 50% AD Participating Providers Only determined medically necessary by Altius. 20% AD 50% AD Neuropsychological Testing 50%* AD 50%* AD Skilled Nursing Facility – Limited to a combined benefit of 60 days per member, per plan year. 20%* AD 30%* AD Sterilization Procedures – Services received at a physician’s office. Sterilization Procedures – Services received at an outpatient facility. 20%* AD 20%* AD 30%* AD 30%* AD Temporomandibular Joint Dysfunction (TMJ) – Evaluation, 50% AD 50% AD appliances and prosthetic devices. Home Health Care – Limited to a combined benefit of 60 visits per member, per plan year. Hospice Care – Care for a terminally ill member through a licensed hospice agency. Implantable Contraceptives and Intra-Uterine Devices (IUDs) – Includes charges for insertion and removal. Infertility Services – Evaluation, testing, and diagnostic services. Includes services that are provided for the purpose of ruling out infertility. Limited to $750 per member, per plan year, up to a lifetime maximum of $5,000. Medical Supplies – Disposable medical supplies and accessories as testing and diagnostic services. Limited to a combined lifetime maximum of $1,000. GENERAL INFORMATION Plan Year Deductible – You must satisfy an individual or family deductible each plan year before certain benefits will be provided under this benefit plan. Deductibles do not count towards the out-of-pocket maximum. Out-of-Pocket Maximum – Deductibles do not apply. When you or your family fulfill out-of-pocket maximums during a plan year, then no further out-of-pocket expenses will be required for the remainder of that plan year. This provision does not apply to any payments for prescription drugs, dental services (even when necessitated by accidental injury), durable medical equipment, infertility services, TMJ services, charges that exceed eligible medical expenses or non-covered services. You are required to keep receipts for out-of-pocket expenses and furnish such proof to the Altius Claims Department when you reach your maximum. Securing Benefits and Payment for Services Through Altius In order for a medical service to be eligible for coverage, it must be defined as a covered benefit and properly coordinated through Altius. Prior authorization is required for certain services (excluding emergency care) in order to verify that the services to be provided are covered by your benefit plan and are medically necessary and appropriate. It is your responsibility to determine that providers and facilities have obtained prior authorization from Altius prior to receiving care. If prior authorization from Altius is not obtained, coverage may be denied. Deductibles do not apply to the out-of-pocket maximum. Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com * Applies to out-of-pocket maximum (OOPM), AD = after deductible, APD = after Pharmacy Deductible PTCMPOS3302 Rev. 10-10 11 ALTIUS PEAK PLUS TRADITIONAL PLAN UTLPPT87 1000-R15_30_60B-C80 NSB Participating Providers Non-Participating Providers Plan Year Deductible – (Individual / Family) Does not apply to Out-ofPocket Maximum. Cumulative across benefit levels. $1,000 / $3,000 $2,000 / $6,000 Out-of-Pocket Maximum – Cumulative across benefit levels. $2,000 / $6,000 $3,000 / $9,000 Box Elder School District September 1, 2012 DEDUCTIBLE, OUT-OF-POCKET & LIMITS Lifetime Maximum – Cumulative across benefit levels. Unlimited OUTPATIENT SERVICES YOU PAY Preventive Care Services – When provided in conjunction with a preventive diagnosis, as determined by Altius, including annual adult physical examinations, well child care, family planning, routine immunizations, minor diagnostic laboratory tests, and colonoscopies. Some services you receive during a preventive office visit may not qualify as Preventive Care Services and will be subject to applicable deductibles, copays, and/or coinsurance You Pay Nothing 30%* AD Office Visits – Primary Care 20%* AD 30%* AD Office Visits – Specialty Care 20%* AD 30%* AD After-Hours Care / Urgent Care – Care received in a physician’s 20%* AD 30%* After Participating Deductible year. 20%* AD Participating Providers Only Eye Exams – Optometrist 10%* AD 30%* AD Major Diagnostic Laboratory Tests and Radiology – 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD office or urgent care facility. Chiropractic Office Visits – Limited to 20 visits per member, per plan Including, but not limited to CT scans and MRIs. Minor Diagnostic Laboratory Tests and X-Rays – Including, but not limited to mammograms and chest X-rays. Outpatient Hospital / Facility Services – Including, but not limited to, outpatient surgery, observation, chemotherapy, radiation therapy, dialysis, cardiovascular services, infusion therapy, endoscopy, and pulmonary services. Includes physician charges. Cardiac rehabilitation and pulmonary rehabilitation limited to a combined benefit of 18 outpatient facility visits per member, per plan year. Physiotherapy Services at a Provider's Office – Physical, occupational and speech therapy provided on an outpatient basis. Limited to a combined benefit of 20 provider's office and/or outpatient facility visits of each type per member, per plan year. Physiotherapy Services at an Outpatient Facility – Physical, occupational and speech therapy provided on an outpatient basis. Limited to a combined benefit of 20 provider's office and/or outpatient facility visits of each type per member, per plan year. EMERGENCY CARE YOU PAY Emergency Room Care – When medically necessary, as determined by Altius. Includes all services provided in an Emergency Room setting. Inpatient benefit applies when admitted. Outpatient hospital benefit applies when transferred to an operating room. 20%* AD 20%* AD Urgent Care – When medically necessary, as determined by Altius. 20%* AD 30%* After Participating Deductible Ambulance / Paramedics – (including Air Ambulance) When medically 20%* AD Participating Benefit Applies necessary, as determined by Altius. Deductibles do not apply to the out-of-pocket maximum. Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com * Applies to out-of-pocket maximum (OOPM), AD = after deductible, APD = after Pharmacy Deductible PTCMPOS3302 Rev. 10-10 12 1 ALTIUS PEAK PLUS TRADITIONAL PLAN UTLPPT87 1000-R15_30_60B-C80 NSB Participating Providers Box Elder School District September 1, 2012 INPATIENT SERVICES Non-Participating Providers YOU PAY Inpatient Hospital / Facility Services Inpatient Physiotherapy Services – Physical, occupational and speech therapy provided on an inpatient basis. Limited to 60 days per member per plan year for all therapy types combined. Physician, Surgeon, Assistant Surgeon, Anesthesiologist Organ Transplant Services – Organ and tissue transplant services, including, but not limited to, cornea, kidney, heart, lung, heart-lung, liver, pancreas, and bone marrow transplants and related services. 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD Participating Providers Only MATERNITY SERVICES YOU PAY Pre-Natal and Post-Natal Care – Professional Services – Routine pre-natal office visits, delivery (including surgeon and assistant surgeon), and post-natal care. Regular benefits apply for complications of pregnancy. Inpatient Hospital / Facility Services 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD Participating Benefit Applies Adoption Indemnity Benefit – Indemnity benefit for a child placed for adoption with the subscriber within 90 days of birth. The maximum benefit amount is $4,000, and will be reduced by any applicable deductible, copay, and/or coinsurance. INJECTABLE OR IMPLANTABLE MEDICATIONS YOU PAY Injectable or Implantable Medications – Non-Facility – Injectable or implantable medications received in a physician’s office or through a home health provider. (Preferred / Non-Preferred) Injectable or Implantable Medications – Pharmacy (Preferred / Non-Preferred) 20%* / 30%* 30%* AD / 40%* AD 20%* / 30%* Participating Providers Only PRESCRIPTION DRUGS YOU PAY If you receive a brand name drug when a preferred generic equivalent can be substituted, you will pay the difference in cost between the generic and the brand name drug, any applicable deductible, and/or the generic copay. Regular benefits apply if a preferred generic cannot be substituted. Prescription Drugs – Up to a 30-day supply. This benefit also includes the Preferred Generic: $15 following injectable medications when provided by an Altius participating Preferred Brand: $30 pharmacy: insulin, Imitrex, Symlin, Byetta, glucagon, Lovenox, and epinephrine kits Non-Preferred: $60 (such as Epi-Pen). Participating Providers Only Preferred Generic: $45 Preferred Brand: $60 Non-Preferred: $180 Participating Providers Only Prescription Drugs Mail Order – 90-day supply of maintenance medication. MENTAL HEALTH / SUBSTANCE ABUSE YOU PAY Inpatient Services 20%* AD 30%* AD Outpatient Services 20%* AD 30%* AD Deductibles do not apply to the out-of-pocket maximum. Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com * Applies to out-of-pocket maximum (OOPM), AD = after deductible, APD = after Pharmacy Deductible PTCMPOS3302 Rev. 10-10 13 ALTIUS PEAK PLUS TRADITIONAL PLAN UTLPPT87 1000-R15_30_60B-C80 NSB Participating Providers Box Elder School District September 1, 2012 ALLERGY CONDITIONS Testing and Treatment Serum Injections Non-Participating Providers YOU PAY 20%* AD 20%* AD 20%* AD OTHER BENEFITS 30%* AD 30%* AD 30%* AD YOU PAY Accident Related Dental Services – Dental services required as the result of an accidental injury. Services include, but are not limited to, crowns, caps, bridges, and root canals. Limited to a combined lifetime maximum of $1,000 per member. 50% AD Participating Benefit Applies Durable Medical Equipment (DME) – Including corrective 50% AD 50% AD 20%* AD 30%* AD 20%* AD 30%* AD 20%* AD 30%* AD 50% AD Participating Providers Only determined medically necessary by Altius. 20% AD 50% AD Neuropsychological Testing 50%* AD 50%* AD Skilled Nursing Facility – Limited to a combined benefit of 60 days per member, per plan year. 20%* AD 30%* AD Sterilization Procedures – Services received at a physician’s office. Sterilization Procedures – Services received at an outpatient facility. 20%* AD 20%* AD 30%* AD 30%* AD Temporomandibular Joint Dysfunction (TMJ) – Evaluation, 50% AD 50% AD appliances and prosthetic devices. Home Health Care – Limited to a combined benefit of 60 visits per member, per plan year. Hospice Care – Care for a terminally ill member through a licensed hospice agency. Implantable Contraceptives and Intra-Uterine Devices (IUDs) – Includes charges for insertion and removal. Infertility Services – Evaluation, testing, and diagnostic services. Includes services that are provided for the purpose of ruling out infertility. Limited to $750 per member, per plan year, up to a lifetime maximum of $5,000. Medical Supplies – Disposable medical supplies and accessories as testing and diagnostic services. Limited to a combined lifetime maximum of $1,000. GENERAL INFORMATION Plan Year Deductible – You must satisfy an individual or family deductible each plan year before certain benefits will be provided under this benefit plan. Deductibles do not count towards the out-of-pocket maximum. Out-of-Pocket Maximum – Deductibles do not apply. When you or your family fulfill out-of-pocket maximums during a plan year, then no further out-of-pocket expenses will be required for the remainder of that plan year. This provision does not apply to any payments for prescription drugs, dental services (even when necessitated by accidental injury), durable medical equipment, infertility services, TMJ services, charges that exceed eligible medical expenses or non-covered services. You are required to keep receipts for out-of-pocket expenses and furnish such proof to the Altius Claims Department when you reach your maximum. Securing Benefits and Payment for Services Through Altius In order for a medical service to be eligible for coverage, it must be defined as a covered benefit and properly coordinated through Altius. Prior authorization is required for certain services (excluding emergency care) in order to verify that the services to be provided are covered by your benefit plan and are medically necessary and appropriate. It is your responsibility to determine that providers and facilities have obtained prior authorization from Altius prior to receiving care. If prior authorization from Altius is not obtained, coverage may be denied. Deductibles do not apply to the out-of-pocket maximum. Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com * Applies to out-of-pocket maximum (OOPM), AD = after deductible, APD = after Pharmacy Deductible, PTCMPOS3302 Rev. 10-10 14 Limitations & Exclusions When required by federal law, limitations and exclusions will not apply to injuries resulting from an act of domestic violence or a medical condition (including both physical and mental health conditions). The following benefits are limited under this benefit plan: ••• Physiotherapy services (occupational, physical and speech) are limited to medically necessary services for conditions resulting from illness or injury where therapy can be provided in a short-term rehabilitation program that is likely to significantly improve the member’s condition, as determined by Altius. ••• Altius reserves the right to include only one manufacturer’s product on the Altius formulary when the same or similar drug (that is, a drug with the same active ingredient), supply, or equipment is made by two or more different manufacturers. The product or products not listed on the Altius formulary will be excluded from coverage. ••• Altius reserves the right to include only one dosage or form of a drug on the Altius formulary when the same drug is available in different dosages or forms (for example, dissolvable tablets, capsules, etc.), from the same or different manufacturers. The product or products in other forms or dosages that are not listed on the Altius formulary will be excluded from coverage. ••• Implantable contraceptive capsules such as Norplant and Implanon are limited to one implantation and removal during the maximum implantation period of the product, as determined by the product manufacturer. ••• Neuropsychological evaluation and treatment is limited to those services that diagnose or treat an underlying medical condition and is covered only when there is clinically significant brain dysfunction. ••• Accident-related dental services are covered only when required as a result of an accidental injury to sound, natural teeth. Dental services must be received within two years following the accidental injury. ••• A determination by Altius that a service is infertility-related may be based on medical records or other documented evidence, and is not dependent on whether Altius actually receives a claim with a diagnosis of infertility. ••• Certain medications, including those that are administered by a medical professional, are covered only when they are purchased through designated specialty pharmacies. To obtain a current list of these medications, visit the Altius web site or call customer service. ••• Cochlear implants are covered only for those members who meet all of the following criteria: member has been diagnosed with bilateral profound sensorineural hearing loss; member has a functioning auditory nerve; member is less than 18 years old; member has the cognitive ability to communicate effectively with restored hearing; hearing cannot be restored adequately with conventional hearing aids; and member and family are willing and able to participate in postimplant rehabilitation. ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• The following are excluded from coverage under this benefit plan: ••• Services provided outside the United States of America and its territories, except as required for an emergency or urgent condition. ••• New procedures, services, supplies, and medications until they are reviewed for safety, efficacy and cost effectiveness and approved by Altius. ••• Experimental or investigational treatment, procedures, tests, equipment, or facilities, or any health care service which is still undergoing evaluation and review. ••• Services, drugs, and supplies that are not medically necessary, as determined by Altius. ••• Medication amounts in excess of maximum quantity and/or dosage levels indicated by the drug manufacturer and the FDA. ••• Experimental medications; medications for non-approved FDA indications or non-approved indications determined by Altius Health Plans; over-the-counter medications and products, except those specifically listed in the Altius formulary and those for which coverage is required by law; prescription medications that have an over-thecounter equivalent or alternative, unless otherwise specified in the ••• ••• ••• ••• ••• ••• ••• 15 Altius formulary; medications for athletic and mental performance; compounding fees; non-covered ingredients used in a compounded medication; medications for cosmetic indications; hair growth products and medications; homeopathic medications; hypodermic needles; impotence medications; medications for the treatment of infertility; skin patches for motion sickness; medications for the treatment of nail fungus; progesterone cream and suppositories; smoking cessation products, including any medications prescribed for smoking cessation; medications required exclusively for foreign travel; oral vitamins (except prescription prenatal vitamins); medications for shift work sleep disorder; medications or nutritional supplements for weight loss, or for weight gain for non-medical conditions. Replacement of lost, stolen, or damaged prescription drugs. Immunizations required exclusively for foreign travel. Food supplements, food substitutes, medical foods, and formulas when taken orally, except when related to inborn errors of amino acid or urea cycle metabolism. Infertility treatment. In-vitro fertilization, GIFT, ZIFT, artificial insemination, and similar services. This includes any related services such as prescription medications, embryo transport, collection, and preparation costs. Reversal of elective sterilization. Amniocentesis and ultrasonography for sex determination. Predictive genetic testing. Predictive diagnostic testing and screenings, and other preventive services performed in the absence of illness or injury, other than those procedures or tests specifically recommended by Altius, the United States Preventive Services Task Force (USPSTF), the Centers for Disease Control (CDC), and local government public health authorities. Preventive services performed more often than, or outside of the guidelines of Altius, the USPSTF, CDC, and local government health authorities, are excluded. Elective home delivery for childbirth. Procedures, services, drugs, and supplies related to elective abortions, except when the life of the woman would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest, or to prevent the birth of a child that would be born with grave defects. Surgical treatment for obesity (including morbid obesity) and/or complications therefrom, including a reversal of these surgeries. Sex change operations or related health care services. Treatment, services, devices, and supplies related to sexual dysfunction. This exclusion does not apply to implantation of a penile prosthesis or use of an external device for impotence caused by an organic disease such as diabetes mellitus or hypertension, or caused by surgery for genitourinary cancer. Surgery performed in order to prevent the possible onset of a condition or disease with which the member has not been diagnosed. Services, supplies, or treatment in connection with cosmetic or reconstructive procedures which alter appearance but do not restore or improve impaired physical function, or which are performed for psychological or emotional purposes. This exclusion does not apply to: (1) reconstructive surgery required as the result of an accidental injury, infection, or cancer. Services must be rendered (or a planned, staged series of services, as specifically documented in the member’s medical record, must be initiated) within 12 months of the cause or onset of the injury, infection, or cancer; (2) circumcision for a newborn child up to three months of age; or (3) reconstruction of the breast(s) following a medically necessary mastectomy. Treatment of hyperhidrosis (perspiration/sweating) or sialorrhea (drooling). Autopsy procedures. Health education services not closely related to the care and treatment of an illness or injury, except as specifically recommended by the USPSTF and provided within USPSTF guidelines. Services provided by an athletic trainer or a personal trainer. Telephone consultations, electronic mail communication, and communication services that do not require direct face-to-face contact between the patient and the provider. Charges for failure to keep a scheduled appointment. Interest or finance charges, except as specifically required by law. 4 PTCMPOS3302 Rev. 10-10 ••• Psychotherapy, counseling or other services in connection with marital or family problems; social, occupational, religious, or other social maladjustments; conduct disorders; chronic adjustment disorders; psychosexual disorders; chronic organic brain syndromes; personality disorders; developmental disorders; learning disabilities; or mental retardation. This exclusion does not apply to the initial assessment for diagnosis of the condition, nor to the medical management of an underlying medical illness which may be contributing to the disability. ••• Electrosleep or electronarcosis therapy, rapid detoxification programs, and milieu therapy. ••• Psychiatric treatments or services performed in the absence of a psychiatric diagnosis. ••• Treatment for mental disorders that are irreversible or for which there is little or no reasonable expectation for improvement. ••• Substance abuse maintenance therapy, such as methadone clinics and similar clinics and services. ••• Evaluation, testing, and treatment provided by public or private schools. ••• Charges in connection with a work-related injury or sickness for which coverage is provided or would be provided under any workers’ compensation, employer’s liability, or occupational disease law. When the employer is required by law to have such coverage, this exclusion applies whether or not such coverage is in effect. ••• Services, supplies, or treatment for which coverage is provided under any motor vehicle no-fault plan. When the member is required by law to have no-fault insurance, this exclusion applies to charges up to the minimum coverage required by law whether or not such coverage is in effect. ••• Expenses for which the member has no legal responsibility to pay or for which the member would not ordinarily be charged in the absence of coverage under this benefit plan. ••• Care for military service connected disability to which the member is legally entitled, and for which facilities are reasonably available to the member. ••• Care or treatment of an illness or injury caused by war or any act of war (whether declared or undeclared), hostilities, or voluntary participation in a riot or civil insurrection. ••• Care for conditions which state or local law requires to be treated in a public facility. ••• Services and treatments provided in connection with, or to comply with, involuntary admissions, police detentions, and similar arrangements. ••• Examinations and services obtained for administrative purposes, such as treatment, care, reports or appearances obtained for, or pursuant to, legal proceedings, court orders, employment, continuing or obtaining insurance coverage, governmental licensure, travel, or military services. ••• Oral surgery, including but not limited to orthognathic surgery, and any services related to the treatment of Temporomandibular Joint Syndrome (TMJ), unless determined medically necessary by Altius for treatment of obstructive sleep apnea or direct treatment of an invasive tumor or acute traumatic injury. This exclusion does not apply to diagnosis and evaluation of TMJ dysfunction. ••• Dental or orthodontic splints or dental prostheses, unless determined medically necessary by Altius for treatment of obstructive sleep apnea or necessitated by accidental injury. ••• Services related to the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth, unless herein provided or necessitated by accidental injury. ••• Acupuncture or acupressure. ••• Holistic and homeopathic treatments. ••• Alternative medicine programs such as hypnosis, massage therapy and biofeedback. ••• Recreational therapy, wilderness therapy, or residential treatment programs. ••• Injury or illness resulting from voluntary participation in an illegal activity. ••• Services for which a provider waives the member’s copay, coinsurance, and/or deductible. ••• Services provided by a member of the patient’s immediate family or household. ••• Prolotherapy (the use of injections to strengthen tendons and ligaments). ••• Services for crossmatching and/or harvesting organs when the organ recipient is not an Altius member. ••• Routine foot care. This exclusion does not apply to members with severe diabetes. ••• Treatment of weak, strained or imbalanced feet. ••• Foot orthotics, wedges or shoe inserts, unless herein provided. This exclusion does not apply to foot orthotics or shoe inserts for members with severe diabetes. ••• Corrective appliances, prostheses, artificial aids and durable medical equipment, including supplies and accessories, are excluded when determined to be primarily for convenience, comfort, non-therapeutic purposes, or in the absence of illness or injury. ••• Helmet therapy for benign positional plagiocephaly. ••• Routine periodic servicing, such as cleaning and regulating, of durable medical equipment, corrective appliances, and prostheses is not covered. Replacement is not covered unless the existing device has become inoperable through normal wear and tear and cannot be repaired, or replacement is prescribed by a physician because of a change in the member’s physical condition. ••• All shipping, handling, or postage charges, except as incidentally provided without a separate charge. ••• Any devices used to aid hearing, including, but not limited to, cochlear implants for members 18 years of age and older and hearing aids, including the fitting of such devices and related hearing examinations. ••• Routine periodic servicing, repairs, batteries and accessories for any hearing aid device. ••• Visual training and vision therapy. ••• Eyeglasses, contact lenses, and examinations for contact lenses. This exclusion does not apply to: (1) the first pair of contact lenses or eyeglasses following the initial diagnosis of aphakia or the surgical removal or surgical replacement of an organic lens; or (2) hydrophilic contact lenses used as a corneal bandage to treat conditions involving the cornea. ••• Eye surgeries performed primarily to correct refractive errors. Examples include, but are not limited to: PRK (photorefractive keratectomy), LASIK (laser-assisted in-situ keratomileusis), RL (refractive lensectomy), ICRS (intracorneal ring segments), Intacs, phakic intraocular lenses (unless related to post-cataract surgery), and astigmatism correction (Limbal Relaxing Procedure). This exclusion does not apply to cornea transplants. ••• Non-emergency follow-up care provided in an emergency room. ••• Charges for transportation, including ambulance, unless determined medically necessary by Altius. ••• Travel expenses, including hotel, motel and other non-medical room and board. ••• Private hospital rooms, unless medically necessary. ••• Hospital take-home drugs and personal, comfort, or convenience items. ••• Private duty nursing. ••• Custodial care, domiciliary care, rest cures, and independent living training. ••• Home health services requested for the convenience of the patient or family that do not require the training and technical skills of a nurse. ••• Hospice services that are not reasonable and necessary for palliation or management of a terminal illness. ••• Vocational testing and treatment. ••• Physiotherapy services (occupational, physical and speech) for psychosocial and/or developmental delays, including, but not limited to speech therapy for stuttering. ••• Physiotherapy services (occupational, physical and speech) for work hardening or for recreational purposes, including, but not limited to sports or vocal performance. ••• Services related to the treatment of sensory processing dysfunction or sensory integration disorder. This exclusion does not apply to the initial assessment for diagnosis of the condition or to the medical management of an underlying medical illness which may be contributing to the condition. 16 5 PTCMPOS3302 Rev. 10-10 ••• Expenses related to non-covered services, including pre- and postoperative evaluation, diagnostic testing, and complications resulting from non-covered services, supplies, and/or medications. When a noncovered procedure is performed as part of the same operation or process as a covered service, then only eligible charges relating to the covered service will be covered. ••• Pre-existing conditions during the pre-existing condition waiting period, when applicable. ••• Benefits and services not specified as covered in the Group Service Agreement. ALTIUS HEALTH PLANS 10421 South Jordan Gateway Suite 400 South Jordan, UT 84095 • 800-365-1334 www.AltiusHealthPlans.com 17 6 PTCMPOS3302 Rev. 10-10 ALTIUS PEAK PLUS QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN UTPPQ861200-B-R10_25_50-C80 Box Elder School District September 1, 2012 Participating Providers Non-Participating Providers $1,200* / $2,400* $2,400* / $4,800* $3,500 / $7,000 $7,000 / $14,000 DEDUCTIBLE, OUT-OF-POCKET & LIMITS Plan Year Deductible – (Single / Family) Deductible applies to Out-ofPocket Maximum. Cumulative across benefit levels. Out-of-Pocket Maximum – (Single / Family) All copays and coinsurance apply. Cumulative across benefit levels. Unlimited Lifetime Maximum OUTPATIENT SERVICES YOU PAY Designated Preventive Care Services – Certain covered office visits, minor diagnostic tests and x-rays, and outpatient hospital/facility services received through participating providers are not subject to deductible when provided in conjunction with a preventive diagnosis, as determined by Altius and in accordance with Section 223 of the Internal Revenue Code. Services include the following: Annual adult physical examinations, annual gynecological examinations, well child care, preventive childhood and adult immunizations, preventive blood screening, bone density screening, mammograms, prostate cancer screening, and colorectal cancer screening. Some services you receive during a preventive office visit may not qualify as Designated Preventive Care Services and will be subject to deductible. You Pay Nothing 40%* AD Office Visits – Primary Care 20%* AD 40%* AD Office Visits – Specialty Care 20%* AD 40%* AD After-Hours Care / Urgent Care – Care received in a physician’s 20%* AD 40%* After Participating Deductible year. 20%* AD Participating Providers Only Eye Exams – Optometrist 20%* AD 40%* AD Major Diagnostic Laboratory Tests and Radiology – 20%* AD 40%* AD 20%* AD 40%* AD 20%* AD 40%* AD 20%* AD 40%* AD 20%* AD 40%* AD Other preventive services that are covered by this benefit plan are subject to deductible. office or urgent care facility. Chiropractic Office Visits – Limited to 20 visits per member, per plan Including, but not limited to CT scans and MRIs. Minor Diagnostic Laboratory Tests and X-Rays – Including, but not limited to mammograms and chest X-rays. Outpatient Hospital / Facility Services – Including, but not limited to, outpatient surgery, observation, chemotherapy, radiation therapy, dialysis, cardiovascular services, infusion therapy, endoscopy, and pulmonary services. Includes physician charges. Cardiac rehabilitation and pulmonary rehabilitation limited to a combined benefit of 18 outpatient facility visits per member, per plan year. Physiotherapy Services at a Provider's Office – Physical, occupational and speech therapy provided on an outpatient basis. Limited to a combined benefit of 20 provider's office and/or outpatient facility visits of each type per member, per plan year. Physiotherapy Services at an Outpatient Facility – Physical, occupational and speech therapy provided on an outpatient basis. Limited to a combined benefit of 20 provider's office and/or outpatient facility visits of each type per member, per plan year. Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com * Applies to out-of-pocket maximum (OOPM), AD = after deductible PQCMPOS3500 Rev. 10-10 18 ALTIUS PEAK PLUS QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN UTPPQ861200-B-R10_25_50-C80 Participating Providers Box Elder School District September 1, 2012 EMERGENCY CARE Non-Participating Providers YOU PAY Emergency Room Care – When medically necessary, as determined by Altius. Includes all services provided in an Emergency Room setting. Inpatient benefit applies when admitted. Outpatient hospital benefit applies when transferred to an operating room. 20%* AD 20%* AD Urgent Care – When medically necessary, as determined by Altius. 20%* AD 40%* After Participating Deductible Ambulance / Paramedics – (including Air Ambulance) When medically 20%* AD Participating Benefit Applies necessary, as determined by Altius. INPATIENT SERVICES YOU PAY 20%* AD 40%* AD 20%* AD 40%* AD Physician, Surgeon, Assistant Surgeon, Anesthesiologist 20%* AD 40%* AD Organ Transplant Services – Organ and tissue transplant services, including, but not limited to, cornea, kidney, heart, lung, heart-lung, liver, pancreas, and bone marrow transplants and related services. Office visits and other services related to organ transplant may have an additional copay. 20%* AD Participating Providers Only Inpatient Hospital / Facility Services Inpatient Physiotherapy Services – Physical, occupational and speech therapy provided on an inpatient basis. Limited to 60 days per member, per plan year for all therapy types combined. MATERNITY SERVICES Pre-Natal and Post-Natal Care – Obstetrician or Certified Nurse Midwife – Routine pre-natal office visits, delivery (including surgeon and assistant surgeon), and post-natal care. Regular benefits apply for complications of pregnancy. Inpatient Hospital / Facility Services YOU PAY 20%* AD 40%* AD 20%* AD 40%* AD 20%* AD Participating Benefit Applies Adoption Indemnity Benefit – Indemnity benefit for a child placed for adoption with the subscriber within 90 days of birth. The maximum benefit amount is $4,000, and will be reduced by any applicable deductible, copay, and/or coinsurance. INJECTABLE OR IMPLANTABLE MEDICATIONS Injectable or Implantable Medications – Non-Facility – Injectable or implantable medications received in a physician’s office or through a home health provider. (Preferred / Non-Preferred) Injectable or Implantable Medications – Pharmacy (Preferred / Non-Preferred) YOU PAY 20%* AD / 30%* AD 40%* AD / 50%* AD 20%* AD / 30%* AD Participating Providers Only PRESCRIPTION DRUGS YOU PAY If you receive a brand name drug when a preferred generic equivalent can be substituted, you will pay the difference in cost between the generic and the brand name drug, any applicable deductible, and/or the generic copay. Regular benefits apply if a preferred generic cannot be substituted. Prescription Drugs – Up to a 30-day supply. This benefit also includes the following injectable medications when provided by an Altius participating pharmacy: insulin, Imitrex, Symlin, Byetta, glucagon, Lovenox, and epinephrine kits (such as Epi-Pen). (Preferred Generic / Preferred Brand / Non-Preferred) Prescription Drugs – 90 day supply of maintenance medication. (Preferred Generic / Preferred Brand / Non-Preferred) $10* / $25* / $50* All copays are after medical deductible Participating Providers Only $30* / $75* / $150* All copays are after medical deductible Participating Providers Only MENTAL HEALTH / SUBSTANCE ABUSE YOU PAY Inpatient Services 20%* AD 40%* AD Outpatient Services 20%* AD 40%* AD Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com * Applies to out-of-pocket maximum (OOPM), AD = after deductible PQCMPOS3500 Rev. 10-10 19 ALTIUS PEAK PLUS QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN UTPPQ861200-B-R10_25_50-C80 Participating Providers Box Elder School District September 1, 2012 ALLERGY CONDITIONS Non-Participating Providers YOU PAY Testing and Treatment 20%* AD 40%* AD Serum 20%* AD 40%* AD Injections 20%* AD 40%* AD OTHER BENEFITS YOU PAY Accident Related Dental Services – Dental services required as the result of an accidental injury. Services include, but are not limited to, crowns, caps, bridges, and root canals. Limited to a combined lifetime maximum of $1,000 per member. 50%* AD Participating Benefit Applies Durable Medical Equipment (DME) – Including corrective 50%* AD 50%* AD 20%* AD 40%* AD 20%* AD 40%* AD 20%* AD 40%* AD 50%* AD Participating Providers Only determined medically necessary by Altius. 20%* AD 50%* AD Neuropsychological Testing 50%* AD 50%* AD Skilled Nursing Facility – Limited to a combined benefit of 60 days per member, per plan year. 20%* AD 40%* AD Sterilization Procedures – Services received at a physician’s office. 20%* AD 40%* AD Sterilization Procedures – Services received at an outpatient facility. 20%* AD 40%* AD Temporomandibular Joint Dysfunction (TMJ) – Evaluation, 50%* AD 50%* AD appliances and prosthetic devices. Home Health Care – Limited to a combined benefit of 60 visits per member, per plan year. Hospice Care – Care for a terminally ill member through a licensed hospice agency. Implantable Contraceptives and Intra-Uterine Devices (IUDs) – Includes charges for insertion and removal. Infertility Services – Evaluation, testing, and diagnostic services. Includes services that are provided for the purpose of ruling out infertility. Limited to $750 per member, per plan year, up to a lifetime maximum of $5,000. Medical Supplies – Disposable medical supplies and accessories as testing and diagnostic services. Limited to a combined lifetime maximum of $1,000. GENERAL INFORMATION Plan Year Deductible – You must satisfy your deductible each plan year before most benefits will be provided under this benefit plan. The deductible does not apply to Designated Preventive Care Services received through participating providers. The single deductible applies when only one member is enrolled. The family deductible applies when two or more members are enrolled. When you have family coverage, the family deductible must be met before benefits for any family member will begin. All deductibles, copays and coinsurance amounts count towards the out-of-pocket maximum. Out-of-Pocket Maximum – All deductibles, copays and coinsurance amounts apply to the Out-of-Pocket Maximum. When you or your family fulfill out-of-pocket maximums during a plan year, then no further out-of-pocket expenses will be required for the remainder of that plan year. This provision does not apply to non-covered services or charges that exceed eligible medical expenses. The single out-of-pocket maximum applies when only one member is enrolled. The family out-of-pocket maximum applies when two or more members are enrolled. When you have family coverage, the maximum is fulfilled when the combined out-of-pocket expenses for one or more family members reach the family out-of-pocket maximum. You are required to keep receipts for out-of-pocket expenses and furnish such proof to the Altius Claims Department when you reach your maximum. Securing Benefits and Payment for Services Through Altius In order for a medical service to be eligible for coverage, it must be defined as a covered benefit and properly coordinated through Altius. Prior authorization is required for certain services (excluding emergency care) in order to verify that the services to be provided are covered by your benefit plan and are medically necessary and appropriate. It is your responsibility to determine that providers and facilities have obtained prior authorization from Altius prior to receiving care. If prior authorization from Altius is not obtained, coverage may be denied. Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com * Applies to out-of-pocket maximum (OOPM), AD = after deductible PQCMPOS3500 Rev. 10-10 20 Limitations & Exclusions When required by federal law, limitations and exclusions will not apply to injuries resulting from an act of domestic violence or a medical condition (including both physical and mental health conditions). The following benefits are limited under this benefit plan: ••• Physiotherapy services (occupational, physical and speech) are limited to medically necessary services for conditions resulting from illness or injury where therapy can be provided in a short-term rehabilitation program that is likely to significantly improve the member’s condition, as determined by Altius. ••• Altius reserves the right to include only one manufacturer’s product on the Altius formulary when the same or similar drug (that is, a drug with the same active ingredient), supply, or equipment is made by two or more different manufacturers. The product or products not listed on the Altius formulary will be excluded from coverage. ••• Altius reserves the right to include only one dosage or form of a drug on the Altius formulary when the same drug is available in different dosages or forms (for example, dissolvable tablets, capsules, etc.), from the same or different manufacturers. The product or products in other forms or dosages that are not listed on the Altius formulary will be excluded from coverage. ••• Implantable contraceptive capsules such as Norplant and Implanon are limited to one implantation and removal during the maximum implantation period of the product, as determined by the product manufacturer. ••• Neuropsychological evaluation and treatment is limited to those services that diagnose or treat an underlying medical condition and is covered only when there is clinically significant brain dysfunction. ••• Accident-related dental services are covered only when required as a result of an accidental injury to sound, natural teeth. Dental services must be received within two years following the accidental injury. ••• A determination by Altius that a service is infertility-related may be based on medical records or other documented evidence, and is not dependent on whether Altius actually receives a claim with a diagnosis of infertility. ••• Certain medications, including those that are administered by a medical professional, are covered only when they are purchased through designated specialty pharmacies. To obtain a current list of these medications, visit the Altius web site or call customer service. ••• Cochlear implants are covered only for those members who meet all of the following criteria: member has been diagnosed with bilateral profound sensorineural hearing loss; member has a functioning auditory nerve; member is less than 18 years old; member has the cognitive ability to communicate effectively with restored hearing; hearing cannot be restored adequately with conventional hearing aids; and member and family are willing and able to participate in post-implant rehabilitation. ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• The following are excluded from coverage under this benefit plan: ••• Services provided outside the United States of America and its territories, except as required for an emergency or urgent condition. ••• New procedures, services, supplies, and medications until they are reviewed for safety, efficacy and cost effectiveness and approved by Altius. ••• Experimental or investigational treatment, procedures, tests, equipment, or facilities, or any health care service which is still undergoing evaluation and review. ••• Services, drugs, and supplies that are not medically necessary, as determined by Altius. ••• Medication amounts in excess of maximum quantity and/or dosage levels indicated by the drug manufacturer and the FDA. ••• Experimental medications; medications for non-approved FDA indications or non-approved indications determined by Altius Health Plans; over-the-counter medications and products, except those specifically listed in the Altius formulary and those for which coverage is required by law; prescription medications that have an ••• ••• ••• ••• ••• ••• over-the-counter equivalent or alternative, unless otherwise specified in the Altius formulary; medications for athletic and mental performance; compounding fees; non-covered ingredients used in a compounded medication; medications for cosmetic indications; hair growth products and medications; homeopathic medications; hypodermic needles; impotence medications; medications for the treatment of infertility; skin patches for motion sickness; medications for the treatment of nail fungus; progesterone cream and suppositories; smoking cessation products, including any medications prescribed for smoking cessation; medications required exclusively for foreign travel; oral vitamins (except prescription prenatal vitamins); medications for shift work sleep disorder; medications or nutritional supplements for weight loss, or for weight gain for non-medical conditions. Replacement of lost, stolen, or damaged prescription drugs. Immunizations required exclusively for foreign travel. Food supplements, food substitutes, medical foods, and formulas when taken orally, except when related to inborn errors of amino acid or urea cycle metabolism. Infertility treatment. In-vitro fertilization, GIFT, ZIFT, artificial insemination, and similar services. This includes any related services such as prescription medications, embryo transport, collection, and preparation costs. Reversal of elective sterilization. Amniocentesis and ultrasonography for sex determination. Predictive genetic testing. Predictive diagnostic testing and screenings, and other preventive services performed in the absence of illness or injury, other than those procedures or tests specifically recommended by Altius, the United States Preventive Services Task Force (USPSTF), the Centers for Disease Control (CDC), and local government public health authorities. Preventive services performed more often than, or outside of the guidelines of Altius, the USPSTF, CDC, and local government health authorities, are excluded. Elective home delivery for childbirth. Procedures, services, drugs, and supplies related to elective abortions, except when the life of the woman would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest, or to prevent the birth of a child that would be born with grave defects. Surgical treatment for obesity (including morbid obesity) and/or complications therefrom, including a reversal of these surgeries. Sex change operations or related health care services. Treatment, services, devices, and supplies related to sexual dysfunction. This exclusion does not apply to implantation of a penile prosthesis or use of an external device for impotence caused by an organic disease such as diabetes mellitus or hypertension, or caused by surgery for genitourinary cancer. Surgery performed in order to prevent the possible onset of a condition or disease with which the member has not been diagnosed. Services, supplies, or treatment in connection with cosmetic or reconstructive procedures which alter appearance but do not restore or improve impaired physical function, or which are performed for psychological or emotional purposes. This exclusion does not apply to: (1) reconstructive surgery required as the result of an accidental injury, infection, or cancer. Services must be rendered (or a planned, staged series of services, as specifically documented in the member’s medical record, must be initiated) within 12 months of the cause or onset of the injury, infection, or cancer; (2) circumcision for a newborn child up to three months of age; or (3) reconstruction of the breast(s) following a medically necessary mastectomy. Treatment of hyperhidrosis (perspiration/sweating) or sialorrhea (drooling). Autopsy procedures. Health education services not closely related to the care and treatment of an illness or injury, except as specifically recommended by the USPSTF and provided within USPSTF guidelines. Services provided by an athletic trainer or a personal trainer. Telephone consultations, electronic mail communication, and communication services that do not require direct face-to-face contact between the patient and the provider. Charges for failure to keep a scheduled appointment. 5 21 PQCMPOS3500 Rev. 10-10 ••• Psychotherapy, counseling or other services in connection with marital or family problems; social, occupational, religious, or other social maladjustments; conduct disorders; chronic adjustment disorders; psychosexual disorders; chronic organic brain syndromes; personality disorders; developmental disorders; learning disabilities; or mental retardation. This exclusion does not apply to the initial assessment for diagnosis of the condition, nor to the medical management of an underlying medical illness which may be contributing to the disability. ••• Electrosleep or electronarcosis therapy, rapid detoxification programs, and milieu therapy. ••• Psychiatric treatments or services performed in the absence of a psychiatric diagnosis. ••• Treatment for mental disorders that are irreversible or for which there is little or no reasonable expectation for improvement. ••• Substance abuse maintenance therapy, such as methadone clinics and similar clinics and services. ••• Evaluation, testing, and treatment provided by public or private schools. ••• Charges in connection with a work-related injury or sickness for which coverage is provided or would be provided under any workers’ compensation, employer’s liability, or occupational disease law. When the employer is required by law to have such coverage, this exclusion applies whether or not such coverage is in effect. ••• Services, supplies, or treatment for which coverage is provided under any motor vehicle no-fault plan. When the member is required by law to have no-fault insurance, this exclusion applies to charges up to the minimum coverage required by law whether or not such coverage is in effect. ••• Expenses for which the member has no legal responsibility to pay or for which the member would not ordinarily be charged in the absence of coverage under this benefit plan. ••• Care for military service connected disability to which the member is legally entitled, and for which facilities are reasonably available to the member. ••• Care or treatment of an illness or injury caused by war or any act of war (whether declared or undeclared), hostilities, or voluntary participation in a riot or civil insurrection. ••• Care for conditions which state or local law requires to be treated in a public facility. ••• Services and treatments provided in connection with, or to comply with, involuntary admissions, police detentions, and similar arrangements. ••• Examinations and services obtained for administrative purposes, such as treatment, care, reports or appearances obtained for, or pursuant to, legal proceedings, court orders, employment, continuing or obtaining insurance coverage, governmental licensure, travel, or military services. ••• Oral surgery, including but not limited to orthognathic surgery, and any services related to the treatment of Temporomandibular Joint Syndrome (TMJ), unless determined medically necessary by Altius for treatment of obstructive sleep apnea or direct treatment of an invasive tumor or acute traumatic injury. This exclusion does not apply to diagnosis and evaluation of TMJ dysfunction. ••• Dental or orthodontic splints or dental prostheses, unless determined medically necessary by Altius for treatment of obstructive sleep apnea or necessitated by accidental injury. ••• Services related to the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth, unless herein provided or necessitated by accidental injury. ••• Acupuncture or acupressure. ••• Holistic and homeopathic treatments. ••• Alternative medicine programs such as hypnosis, massage therapy and biofeedback. ••• Recreational therapy, wilderness therapy, or residential treatment programs. ••• Injury or illness resulting from voluntary participation in an illegal activity. ••• Services for which a provider waives the member’s copay, coinsurance, and/or deductible. ••• Services provided by a member of the patient’s immediate family or household. ••• Interest or finance charges, except as specifically required by law. ••• Prolotherapy (the use of injections to strengthen tendons and ligaments). ••• Services for crossmatching and/or harvesting organs when the organ recipient is not an Altius member. ••• Routine foot care. This exclusion does not apply to members with severe diabetes. ••• Treatment of weak, strained or imbalanced feet. ••• Foot orthotics, wedges or shoe inserts, unless herein provided. This exclusion does not apply to foot orthotics or shoe inserts for members with severe diabetes. ••• Corrective appliances, prostheses, artificial aids and durable medical equipment, including supplies and accessories, are excluded when determined to be primarily for convenience, comfort, nontherapeutic purposes, or in the absence of illness or injury. ••• Helmet therapy for benign positional plagiocephaly. ••• Routine periodic servicing, such as cleaning and regulating, of durable medical equipment, corrective appliances, and prostheses is not covered. Replacement is not covered unless the existing device has become inoperable through normal wear and tear and cannot be repaired, or replacement is prescribed by a physician because of a change in the member’s physical condition. ••• All shipping, handling, or postage charges, except as incidentally provided without a separate charge. ••• Any devices used to aid hearing, including, but not limited to, cochlear implants for members 18 years of age and older and hearing aids, including the fitting of such devices and related hearing examinations. ••• Routine periodic servicing, repairs, batteries and accessories for any hearing aid device. ••• Visual training and vision therapy. ••• Eyeglasses, contact lenses, and examinations for contact lenses. This exclusion does not apply to: (1) the first pair of contact lenses or eyeglasses following the initial diagnosis of aphakia or the surgical removal or surgical replacement of an organic lens; or (2) hydrophilic contact lenses used as a corneal bandage to treat conditions involving the cornea. ••• Eye surgeries performed primarily to correct refractive errors. Examples include, but are not limited to: PRK (photorefractive keratectomy), LASIK (laser-assisted in-situ keratomileusis), RL (refractive lensectomy), ICRS (intracorneal ring segments), Intacs, phakic intraocular lenses (unless related to post-cataract surgery), and astigmatism correction (Limbal Relaxing Procedure). This exclusion does not apply to cornea transplants. ••• Non-emergency follow-up care provided in an emergency room. ••• Charges for transportation, including ambulance, unless determined medically necessary by Altius. ••• Travel expenses, including hotel, motel and other non-medical room and board. ••• Private hospital rooms, unless medically necessary. ••• Hospital take-home drugs and personal, comfort, or convenience items. ••• Private duty nursing. ••• Custodial care, domiciliary care, rest cures, and independent living training. ••• Home health services requested for the convenience of the patient or family that do not require the training and technical skills of a nurse. ••• Hospice services that are not reasonable and necessary for palliation or management of a terminal illness. ••• Vocational testing and treatment. ••• Physiotherapy services (occupational, physical and speech) for psychosocial and/or developmental delays, including, but not limited to speech therapy for stuttering. ••• Physiotherapy services (occupational, physical and speech) for work hardening or for recreational purposes, including, but not limited to sports or vocal performance. ••• Services related to the treatment of sensory processing dysfunction or sensory integration disorder. This exclusion does not apply to the initial assessment for diagnosis of the condition or to the medical management of an underlying medical illness which may be contributing to the condition. 6 22 PQCMPOS3500 Rev. 10-10 ••• Expenses related to non-covered services, including pre- and postoperative evaluation, diagnostic testing, and complications resulting from non-covered services, supplies, and/or medications. When a non-covered procedure is performed as part of the same operation or process as a covered service, then only eligible charges relating to the covered service will be covered. ••• Benefits and services not specified as covered in the Group Service Agreement. ALTIUS HEALTH PLANS 10421 South Jordan Gateway Suite 400 South Jordan, UT 84095 • 800-365-1334 www.AltiusHealthPlans.com 7 23 PQCMPOS3500 Rev. 10-10 Preventive Care Preventive Care helps keep members healthy At Altius Health Plans, we encourage members to receive preventive care items and services. The Affordable Care Act (ACA) provides for specific preventive services when provided by participating providers and specific drugs to be covered at 100 percent. Our fully insured group health plans already provide coverage for many of those preventive services and drugs. Starting on October 1, 2010, for all new plans and for renewing plans that are not grandfathered plans, as of the plan’s effective date/renewal date, members who use our network providers will receive preventive care services and specific drugs paid at 100 percent. The preventive guidelines outlined in this flyer represent general health recommendations from the U.S. Preventive Services Task Force and do not necessarily represent benefits covered by your health plan. Consult your medical benefits information to determine covered benefits. Coverage for Preventive Services Here are some examples of the preventive services that will be covered with no copay, coinsurance or deductible. The list is subject to change as federal guidance is issued. The full list of covered preventive services issued with the Interim Final Rules can be found at http://www.healthcare.gov/center/regulations/prevention/taskforce.html Adult Preventive Child Preventive Exams: Preventive office visits including well child care Exams: Preventive office visits including well woman exam Immunizations: • Influenza (flu) • Pneumonia • Hepatitis A • Hepatitis B • Diptheria, Tetanus, Pertussis • Varicella (chicken pox) • Measles, Mumps, Rubella (MMR) • Polio • Rotavirus • Meningococcal • Human Papilloma virus (HPV) • Shingles Immunizations: • Influenza (flu) • Pneumonia • Hepatitis A • Hepatitis B • Diptheria, Tetanus, Pertussis • Varicella (chicken pox) • Measles, Mumps, Rubella (MMR) • Polio • Rotavirus • Meningococcal • Shingles Screening Tests: Breast cancer screening, Cervical cancer screening, Colorectal cancer screening, Prostate cancer screening, Certain bone density screening, Lipid screening, Screening for sexually transmitted diseases, HIV test, routine blood and urine screenings Screening Tests: Hearing screening, Eye chart screening, PKU screening (newborns), Sickle cell screening (newborns) Newborn Preventive Treatment: Gonorrhea treatment This list is subject to change as Federal guidance is issued. The full list of covered preventive services issued with the Interim Final Rules can be found at http://www.healthcare.gov/center/regulations/prevention/taskforce.html. To learn more about immunizations, visit www.cdc.gov/vaccines. ~ continued ~ CHAL0437 1-11 24 Preventive Care, continued Coverage for specific drugs Here are the specific drugs that will be covered with no copay, coinsurance or deductible. Only the drugs on this list are covered at 100%. You will need a prescription from your doctor to receive the 100% benefit. Take your prescription to one of the 62,000 pharmacy network providers. The pharmacist will submit the claim to us. To find a pharmacy near you, go to the Web address on your member ID card or visit www.medco.com. • • • • Aspirin (over-the-counter) — Dose: 81 mg and 325 mg, men age 45 to 79 and women age 55 to 79. Iron (over-the-counter) — Children up to age one, drops only. Folic Acid (over-the-counter) — Dose: 400 mg and 800 mg, women. Fluoride — Children under the age of six, drops and chewable tablets only. Talking with your provider about Preventive Care We process claims based on your provider’s clinical assessment of the office visit. If a preventive item or service is billed separately, cost-sharing may apply to the office visit. If the primary reason for your visit is seeking treatment for an illness or condition, and preventive care is administered during the same visit, cost-sharing may apply. This means your provider may ask you to pay your appropriate health plan copay, deductible or coinsurance. Certain screening services, such as a colonoscopy or mammogram, may identify health conditions that require further testing or treatment. If a condition is identified through a preventive screening, any subsequent testing, diagnosis, analysis or treatment are not considered preventive services and are subject to the appropriate cost-sharing. If you have questions about a claim or provider visit, please call the customer service number on your Member ID card or speak with your provider. Please regularly check our website for new information about preventive care coverage as the government agencies refine guidance and requirements. CHAL0437 1-11 25 MEDICAL PLANS FOR 2012 - 2013 Altius Health Plans is excited to be offered as the medical health care plan for Box Elder School District effective September 1, 2012. Altius Providers Altius offers you one of the largest panels of providers and hospitals with more than 7,000 participating physicians in Utah. We also have more than 87% of the state's hospitals. You have the freedom to see any participating provider on our panel at any time. You do not need to select a primary care physician or obtain a referral to see a specialist. Altius Health Plans is an experienced managed-care company providing health care coverage to Utahns since 1976. Altius is proud to lead the market in excellent customer service and satisfaction. Altius ranks among the top 3 in Utah for customer satisfaction, and 7 out of 10 members say they would recommend Altius to a friend or family member. Do you have questions or do you want to receive an Altius Provider Directory? Please contact our Customer Service Department at (800) 377-4161. Our customer service hours are Monday – Friday from 8 am to 6 pm. Visit our web site at: www.altiushealthplans.com 26 Utah Hospitals & Surgical Centers Please note that Anesthesiologists, Radiologists, Pathologists, and Emergency Physicians at these contracted hospitals & surgical centers are also contracted by Altius. Beaver County Grand County Beaver Valley Hospital Allen Memorial Hospital 1109 N. 100 W. Beaver 435-438-7100 Milford Valley Memorial Hospital 451 N. Main St. Milford 435-387-2411 719 W. 400 N. Moab 435-259-7191 3741 W. 12600 S. Riverton 801-285-1285 Iron County Riverton Hospital Cedar Orthopaedic Surgery Center1 Box Elder County Bear River Valley Hospital 905 N. 1000 W. Tremonton 435-207-4500 1335 Northfield Rd. Cedar City 435-586-5131 Cedar Surgical Associates 1303 N. Main St. Cedar City 435-586-6587 Cache Valley Specialty Hospital 2380 N. 400 E. Logan 435-713-9700 Logan Regional Hospital 1400 N. 500 E. Logan 435-716-1000 Central Valley Medical Center 10011 Centennial Pkwy., #100 Sandy 801-233-9300 48 W. 1500 N. Nephi 435-623-3000 St. Mark's Outpatient Surgery Center1 Kane County 1250 E. 3900 S., #100 Salt Lake City 801-262-0358 Kane County Hospital 355 N. Main St. Kanab 435-644-5811 Northern Utah Endoscopy Center1 630 E. 1400 N. Logan 435-787-0270 St. Mark’s Hospital 1200 E. 3900 S. Salt Lake City 801-268-7111 Millard County Delta Community Medical Center 126 White Sage Ave. Delta 435-864-5591 Carbon County Castleview Hospital Eastern Utah Surgical Center1 University of Utah Hospital 674 S. Hwy 99 Fillmore 435-743-5591 50 N. Medical Dr. Salt Lake City 801-581-2121 200 N. Fairgrounds Rd. Price 435-637-1744 Salt Lake County Davis County (Oral Surgery Only) Family Surgical Suite Davis Hospital & Medical Center 1600 W. Antelope Dr. Layton 801-807-1000 1544 W. Antelope Dr. Layton 801-773-3339 Lakeview Endoscopy Center1 620 Medical Dr., #200 Bountiful 801-299-6767 Lakeview Hospital 630 Medical Dr. Bountiful 801-292-6231 Wasatch Endoscopy Center1 (Oral Surgery Only) 1220 E. 3900 S., #1B Salt Lake City 801-281-3657 8822 Redwood Rd. #C113 West Jordan 801-495-1064 San Juan County Huntsman Cancer Hospital Blue Mountain Hospital 1950 Circle of Hope Dr. Salt Lake City 801-587-7000 802 S. 200 W. Blanding 435-678-3993 Jordan Valley Hospital San Juan Hospital 3580 W. 9000 S. West Jordan 801-561-8888 364 W. 100 N. Monticello 435-587-2116 Lone Peak Sanpete County Gunnison Valley Hospital Uintah Basin Medical Center 11800 S. State St. Draper 801-545-8100 250 W. 300 N., #75-2 Roosevelt 435-722-4691 Mountain West Endoscopy1 Duchesne County Garfield County Garfield Memorial Hospital 200 N. 400 E. Panguitch 435-676-8811 1 Ambulatory Surgical Center Box Elder School District Utah Surgical Center1 3715 W. 4100 S. Salt Lake City 801-957-0200 151 E. 5600 S. #104 Salt Lake City 801-495-1064 Family Surgical Suite 1 The Center of Surgical Arts1 (Oral Surgery Only) 530 E. 500 S. Salt Lake City 801-747-8017 Fillmore Community Medical Center 300 N. Hospital Dr. Price 435-637-4800 1050 E. South Temple Salt Lake City 801-350-4111 South Towne Surgery Center1 Juab County Cache County 24 S. 1100 E., #103 Salt Lake City 801-355-2988 Salt Lake Regional Medical Center Valley View Medical Center 950 Medical Dr. Brigham City 435-734-9471 3741 W. 12600 S. Riverton 801-285-4000 Salt Lake Endoscopy Center1 1 1811 W. Royal Hunte Dr., #3 Cedar City 435-586-3402 Brigham City Community Hospital Davis Surgical Center Primary Children’s Outpatient Services at Riverton 64 E. 100 N. Gunnison 435-528-7246 6360 S. 3000 E., #320 Salt Lake City 801-944-3166 Pioneer Valley Hospital 3460 Pioneer Pkwy. Salt Lake City 801-964-3100 Primary Children’s Medical Center 100 N. Mario Capecchi Dr. Salt Lake City 801-588-2000 27 Sanpete Valley Hospital 1100 S. Medical Dr. Mount Pleasant 435-462-2441 Sevier County Sevier Valley Medical Center 1100 N. Main St. Richfield 435-896-8271 Utah Hospitals & Surgical Centers, continued Summit County Wasatch County Weber County Park City Medical Center Heber Valley Medical Center Alpine Surgical Center LLC1 900 Round Valley Dr. Park City 435-658-6701 1485 S. Hwy. 40 Heber City 435-654-2500 4403 Harrison Blvd., #3680 Ogden 801-387-3900 Tooele County Heber Valley Hospital Ogden Regional Medical Center Mountain West Medical Center 1485 S. Hwy. 10 Heber City 801-357-7027 2055 N. Main St. Tooele 435-843-3600 Uintah County Ashley Regional Medical Center Washington County Coral Desert Surgery Center1 150 W. 100 N. Vernal 435-789-3342 (Eye Surgeries Only) 1490 E. Foremaster Dr., Bldg. C St. George 435-674-5230 Utah County Dixie Regional Medical Center Central Utah Clinic AF Surgery Center1 544 S. 400 E. St. George 435-634-4000 1175 E. 50 S., #101 American Fork 801-492-5994 Central Utah Surgical Center1 1067 N. 500 W. Provo 801-374-0354 Mountain View Hospital 1000 E. 100 N. Payson 801-465-7000 Timpanogos Regional Hospital 750 W. 800 N. Orem 801-714-6000 Utah Valley Regional Medical Center (To be used only for specialty services not provided at other listed facilities. All services require prior authorization) 1034 N. 500 W. Provo 801-373-7850 5475 S. 500 E. Ogden 801-479-2111 Dixie Regional Medical Center River Road Campus 1380 E. 480 S. St. George 435-251-1000 South Main Surgery Center1 754 S. Main St., #3 St. George 435-628-2671 St. George Surgical Center1 (Eye & Pain Management Services Only) 676 S. Bluff St. St. George 435-673-8080 Zion Eye Institute1 (Eye Surgeries Only) 1791 E. 280 N. St. George 435-656-2020 1 Ambulatory Surgical Center University of Utah Hospital Clinics Davis County UUHC Centerville Center 296 S. Main Street Centerville 801-693-7900 Salt Lake County UUHC Madsen Center 555 S. Foothill Drive Salt Lake City 801-581-8000 UUHC Sugarhouse Center UUHC Greenwood Center 1138 E. Wilmington Ave. Salt Lake City 801-581-2000 7495 S. State Street Midvale 801-887-2400 Summit County UUHC Redwood Center UUHC Redstone Health Center 1525 W. 2100 S. Salt Lake City 801-887-2400 1743 W. Redstone Center Dr., #115 Park City 435-658-9200 UUHC South Jordan Center Tooele County 1091 W. South Jordan Pkwy., #500 South Jordan 801-466-4120 UUHC Westridge Center 3730 W. 4700 S. West Valley 801-964-2300 UUHC Stansbury Center 220 Millpond Rd., #100 Stansbury Park 435-843-3000 Utah County UUHC Parkway Center 145 S. University Parkway Orem 801-226-7555 28 Urgent Care Centers Available to all members, except where otherwise noted. Copperview Medical Center Urgent Care3 Cache County Cache Valley Community Health Center 550 E. 1400 N., #K Logan 435-755-6061 IHC Logan InstaCare 412 N. 200 E. Logan 435-752-1010 Davis County After Hours Urgent Care Layton 1550 N. Main St., #E Layton 801-614-9030 Davis Family Physicians 3225 W. Gordon Ave. Layton 801-773-7232 Davis Family Physicians 2084 N. Robins Dr. (1700 W.), #A Layton 801-773-7232 First Med North Bountiful 214 W. 1500 S. Bountiful 801-295-6483 Layton Family Practice 124 S. Fairfield Rd. Layton 801-546-9441 Tanner Clinic 2121 N. 1700 W. Layton 801-773-4865 Tanner Clinic 380 N. 400 W. Kaysville 801-773-4865 Tanner Clinic 2038 W. 1900 S. Syracuse 801-773-4865 Work Care - North 2084 N. 1700 W., #D Layton 801-773-3400 Express Med Urgent Care Center 3556 W. 9800 S., #101 South Jordan 801-567-9780 415 N. Main St. Spanish Fork 801-798-9700 First Med at Salt Lake Industrial Clinic Riverwoods Urgent Care LLC 441 S. Redwood Rd. Salt Lake City 801-973-2588 280 W. Riverpark Dr., #120 Provo 801-229-2011 First Med East Urgent Care Clinic Tri-City Medical 1950 E. Fort Union Blvd. (7000 S.) Salt Lake City 801-943-3300 830 N. 2000 W. Pleasant Grove 801-756-3511 First Med West Tri-City Medical 8822 S. Redwood Rd., #E122 West Jordan 801-256-0009 275 W. 200 N. Lindon 801-796-1333 First Med Murray LLC Work Care 601 N. 1200 W. Orem 801-224-4211 5911 S. Fashion Blvd. Murray 801-266-6483 Foothill Clinic - South Washington County 6360 S. 3000 E. Salt Lake City 801-365-1032 IHC Hurricane InstaCare Granger Medical Clinic Urgent Care 3725 W. 4100 S. West Valley City 801-965-3608 Health Clinics of Utah 3195 S. Main St. #200 Salt Lake City 801-468-0354 Magna Center for Family Medicine 8211 W. 3500 S. Magna 801-250-9638 Nurse Practitioner Healthcare Associates 4568 S. Highland Dr., #290 Salt Lake City 801-274-6127 Rocky Mountain Care Clinic 4088 W. 1820 S. Salt Lake City 801-975-7799 South Jordan Health Care - January 2012 75 N. 2260 W. Hurricane 435-635-6550 IHC River Road InstaCare 577 S. River Rd. St. George 435-688-6300 IHC Sunset InstaCare 1739 W. Sunset Blvd. St. George 435-634-6000 Night Light Pediatrics 1240 E. 100 S., #14 St. George 435-628-8232 St. George Clinic 736 S. 900 E., #203 St. George 435-673-6131 Weber County Children's Evening Clinic at Pediatric Care of Ogden2 4696 Daybreak Rim Way South Jordan 801-213-4500 3955 Harrison Blvd., #L-1 Ogden 801-479-8444 IHC Cedar City InstaCare University Health Care Redwood Urgent Care Health Clinics of Utah 962 Sage Dr. Cedar City 435-865-3440 1525 W. 2100 S. Salt Lake City 801-213-9900 2540 Washington Blvd., #122 Ogden 801-626-3671 Premier Pediatrics Work Care - South Valley Now Care 1251 Northfield Rd., #301 Cedar City 435-865-7227 12422 S. 450 E. Draper 801-748-1600 1937 W. 5700 S. Roy 801-773-9380 Rich County Work Care Clinic Now Care Iron County Bear Lake Community Health Center 325 W. Logan Hwy. Garden City 425-946-3660 Salt Lake County After Hours Urgent Care Draper 1126 E. Draper Pkwy. (12300 S.) Draper 801-545-0600 After Hours Medical Urgent Care South Jordan 10464 S. Redwood Rd. South Jordan 801-501-0500 After Hours Urgent Care Sandy 7998 S. 1300 E. Sandy 801-255-2000 After Hours Urgent Care West Valley City 698 12th St. Ogden 801-621-3466 2390 S. Redwood Rd. Salt Lake City 801-975-1600 Ogden Clinic - Canyon View Summit County Park City Family Health Center 1159 E. 12th St. Ogden 801-475-3700 (8 am – 9 pm only) 1665 Bonanza Dr. Park City 435-649-7640 Ogden Clinic - Grand View 3485 W. 5200 S. Roy 801-475-3900 Snow Creek Emergency Center 1600 Snow Creek Dr. Park City 435-655-0055 Ogden Clinic - Harrison Blvd. Tooele County Ogden Clinic - Mountain View 4650 Harrison Blvd. Ogden 801-475-3000 Tooele Valley Urgent Care LLC 1244 N. Main St., #201 Tooele 435-882-3968 Ogden Clinic - Skyline 3451 S. 5600 W. West Valley City 801-957-0900 Utah County 2 Appointment Required 3 Appointment Preferred 476 N. 900 W., #C American Fork 801-492-1611 Box Elder School District 1100 W. 2700 N. Pleasant View 801-475-3600 After Hours Urgent Care American Fork 29 6112 S. 1550 E. South Ogden 801-475-3800 South Ogden Center for Family Medicine 5740 Crestwood Dr. Ogden 801-479-7771 Primary Care Centers with Extended Hours Available to all members, except where otherwise noted. Cache County Salt Lake County Budge Clinic After Hours Pediatrics Community Health Centers 1350 N. 500 E. Logan 435-452-0422 Cache Valley Community Health Center 550 E. 1400 N., #K Logan 435-755-6061 8446 S. Harrison Midvale 801-566-5494 Community Health Centers 461 S. 400 E. Salt Lake City 801-539-8634 Davis County Community Health Centers Davis Family Physicians 4745 S. 3200 W. Salt Lake City 801-964-6214 2084 N. Robins Dr. (1700 W.), #A Layton 801-773-7232 Davis Family Physicians 3225 W. Gordon Ave. Layton 801-773-7232 Tanner Clinic 2121 N. Robins Dr. (1700 W.) Layton 801-773-4856 Tanner Clinic 380 N. 400 W. Kaysville 801-773-4865 Tanner Clinic 2038 W. 1900 S. Syracuse 801-773-4865 Wee Care Pediatrics2 1580 W. Antelope Dr., #100 Layton 801-773-8644 Westside Medical Clinic 1792 W. 1800 N. Clinton 801-774-8888 Iron County Premier Pediatrics 1251 Northfield Rd., #301 Cedar City 435-865-7227 Community Health Centers 1365 W. 1000 N. Salt Lake City 801-328-5750 Copperview Medical Center Urgent Care3 3556 W. 9800 S., #101 South Jordan 801-567-9780 Granger Medical Clinic 3725 W. 4100 S. West Valley 801-965-3600 Holladay Family Practice 3920 S. 1100 E., #220 Salt Lake City 801-268-2584 Jordan Meadows Medical Center 3354 W. 7800 S. West Jordan 801-282-2677 Jordan Valley Family Health 3570 W. 9000 S., #100 West Jordan 801-569-1999 Maria A. Oneida Utah County Alpine Pediatrics 1912 W. 930 N. Pleasant Grove 801-492-1999 American Fork Clinic 226 N. 1100 E., #A American Fork 801-763-8340 Art City Clinic 5 E. 400 N. Springville 801-489-8464 Spanish Fork Clinic 325 W. Center St. Spanish Fork 801-798-7301 Tri-City Medical 830 N. 2000 W. Pleasant Grove 801-756-3511 University Health Care Parkway Health Center 145 W. University Parkway Orem 801-234-8600 Utah County Medical Associates 97 S. Professional Way Payson 801-465-4896 Utah Valley Pediatrics Location varies - Call first 801-373-8930 Weber County South Jordan Health Care - January 2012 1937 W. 5700 S. Roy 801-773-9380 4696 Daybreak Rim Way South Jordan 801-213-4500 Southpoint Pediatrics Bear Lake Community Health Center 9071 S. 1300 W., #301 West Jordan 801-565-1162 2 Appointment Required 3 Appointment Preferred 220 Millpond Rd. #100 Stansbury Park 435-843-3000 3570 W. 9000 S., #200 West Jordan 801-566-9211 Rich County 325 Logan Hwy. Garden City 435-946-3660 University Health Care Stansbury Health Center University Health Care Greenwood Health Center 7495 S. State St. Midvale 801-213-9400 Now Care Now Care 698 12th St. Ogden 801-621-3466 Ogden Clinic - Canyon View 1159 E. 12th St. Ogden 801-475-3700 Ogden Clinic - Grand View University Health Care Redwood Health Center 1525 W. 2100 S. Salt Lake City 801-213-9900 Willowcreek Pediatrics 7138 S. 2000 E., #106 Salt Lake City 801-942-1800 3485 W. 5200 S. Roy 801-475-3900 Ogden Clinic - Harrison Blvd. 4650 Harrison Blvd. Ogden 801-475-3000 Ogden Clinic - Mountain View 1100 W. 2700 N. Pleasant View 801-475-3600 Summit County Ogden Clinic - Skyline University Health Care Redstone Health Center 6112 S. 1550 E. South Ogden 801-475-3800 1743 W. Redstone Center #115 Park City 435-658-9200 South Ogden Center for Family Medicine Tooele County PM Pediatrics 196 E. 2000 N., #110 Tooele 435-843-5437 30 5740 Crestwood Dr. Ogden 801-479-7771 Frequently Asked Questions “What is the plan year deductible?” The deductible is the portion of an eligible charge you must pay each year before Altius covers those benefits that are subject to the deductible. “How does the out-of-pocket maximum work?” When you or your family fulfill the out-of-pocket maximums during a plan year, no further out-of-pocket expense will be required for the remainder of that plan year. This provision does not apply to any payment made for benefits such as prescription drugs, durable medical equipment, infertility services, TMJ services, and non-covered services. In addition, you are responsible for the difference between billed charges and Eligible Medical Expenses in addition to your share of coinsurance when using non-participating providers. “When does my plan year deductible and my out-of-pocket maximum start?” Your plan year deductible and out-of-pocket maximum both start September 1st of each year. “How are prescription drugs covered?” Up to a 30-day supply of prescription drugs can be dispensed when prescribed by a participating physician and obtained at a participating pharmacy. The benefit for prescription drugs have a “mandatory generic” requirement. If the member receives a brand name drug when a generic equivalent is available, the member will pay the generic copay or coinsurance plus the difference in cost between the generic and the name brand drug. Regular benefits apply if a generic is not available, or if the member’s physician specifically requires the member to get a brand name drug for medical reasons. Prescription drugs on the Preferred Drug List consist of generic, preferred, and non-preferred drugs. We update the drug list on a regular basis by reviewing pertinent medical literature, provider feedback, and changes/improvements in medical technology. The Preferred Drug List can be found at www.altiushealthplans.com. Mail Order Benefit You can request up to a 90-day supply of maintenance medication through our mail order service. For information regarding the mail order benefit, please contact Altius Customer Service at 801-323-6200 or 800-377-4161. Box Elder School District 31 “What's the difference between Urgent Care and Emergency Care?” If you have a medical emergency, immediately call 911 or another emergency service, or go to the nearest medical facility for treatment. Payment for Emergency Care Services will be based on medical necessity. Emergency care provided by non-participating facilities would be covered as long as the condition continues to be an emergency. Contact us as soon as possible and we will work with you to coordinate your continuing care. If you have an urgent medical problem within the service area, go to a participating urgent care facility listed in your provider directory. Emergency Room Services - $$$$ Urgent Care Services - $$ Emergency room services are those health care services that are provided for a condition of recent onset and sufficient severity, including, but not limited to, severe pain, that would lead you to believe that your condition, sickness or injury is of such nature that failure to obtain immediate medical care could result in: • Placing your health in serious jeopardy • Serious impairment to bodily functions • Serious dysfunction of any bodily organ or part An urgent medical problem is one in which your life is not in danger, but you require immediate medical attention. Examples include, but are not limited to: • Controlled bleeding • Minor fractures • Objects in the eyes, ears, and nose • Abdominal pain • Lacerations If your life is in jeopardy from such situations as: • Heart attack • Major burns • Serious breathing difficulties • Shock • Spinal injuries • Uncontrollable bleeding “What are my mental health benefits?” Mental Health and Substance Abuse Services are covered for short-term detoxification, psychiatric care and alcohol/substance abuse rehabilitation. “Who manages the mental health benefits?” Mental Health Network (MHNet) provides treatment for mental health and substance abuse for Altius members. Please contact MHNet at 800-701-8663 Monday through Friday, 8:00 am to 5:00 pm for prior authorization before accessing care and for other non-emergency information. Also, urgent or emergency guidance is available by calling 800-701-8663, 24 hours a day, 365 days a year. MHNet also offers Life Coaching which is supported by the MHNet network of professional mental health care providers. This program provides confidential and professional assistance with concerns including, but not limited to: • • • • • Depression Anxiety Alcohol and drug addiction Children's issues Grief counseling 32 • • • • Domestic violence Suicidality Smoking cessation Medical management “Does Altius offer support if I have health care needs for chronic conditions?” Yes, Altius offers a Disease Management and Telephonic Coach Outreach Program. Our coaches conduct outreach calls, educational communications, support, and coaching to increase awareness of available benefits as well as to help members who have been diagnosed to manage their condition. This program supports members with any of the following conditions: • • • • • • • Asthma CAD HIV/AIDS Congestive heart failure COPD CKD Diabetes • • • • • • Hemophilia High-risk pregnancy Low back pain Multiple Sclerosis Sickle-Cell Disease Organ transplant “Does Altius support proactive measures such as preventive health screenings?" Absolutely. At Altius Health Plans, we encourage members to receive preventive care services. The Affordable Care Act (ACA) provides for specific preventive services when provided by participating providers and specific drugs to be covered at 100 percent. Your Altius health plan already provides coverage for many of those preventive services and drugs. Starting on October 1, 2010, members who use our network providers will receive preventive care services and specific drugs paid at 100 percent, effective on their renewal date. Here are some examples of the preventive services and drugs that will be covered with no copay, coinsurance or deductible. • Preventive office visits including well child care and well woman exams • Immunizations • Newborn preventive treatment • Screening tests for various conditions including: - Hearing - Eye chart - PKU (newborns) - Sickle cell (newborns) - Breast cancer - Cervical cancer - Colorectal cancer - Prostate cancer - Certain bone density - Lipid screening - Sexually transmitted diseases - HIV - Routine blood and urine Coverage for specific drugs including: • Aspirin (over the counter) • Iron (over the counter) • Folic acid (over the counter) • Fluoride (Children under 6, drops and chewables only) Certain limitations apply. List is subject to change. a full description of ACA rules can be found at www.healthcare.gov/center/regulations/prevention/taskforce.html Box Elder School District 33 "What web-based tools and services are available?" Wellness and Fitness Tools With WellBeing, you can make meaningful lifestyle changes to improve your diet, fitness level, emotional well-being and more. Plus, WellBeing can help you identify risk factors you may have for certain health conditions and give you the information you need to make better choices for your health. WellBeing offers wellness information on our website in a one-stop-shopping format. NEW! CaféWell Through the power of social media, Café Well allows Altius members to create social networks and discussion groups with peers, family and friends in a free, friendly, and secure forum that supports members’ efforts to get well and stay well. Café Well is a free online resource where Altius members can conveniently, actively, and anonymously equip themselves for wellness with helpful information and tools like a health encyclopedia, drug checker, and symptom checker. Altius members can access videos and articles relevant to their health concerns, talk privately with health experts and coaches and create, and join, public and private groups sharing interests or participating in motivating challenges that earn reward points for reaching goals. WellBeing Offerings Altius offers a wide variety of WellBeing Programs designed to target the wellness needs of your employees. You’ll find a summary of each program below. The following services are included at no additional cost: • Online Health Risk Assessment This tool analyzes your responses to questions about your health history and lifestyle, and provides suggestions for reducing or eliminating your risks. • Web MD/Health Information Library The Health Information Library provides a wealth of clinical and health-related information at your fingertips. You may search by health topic, keywords, or via the valuable links to find various healthrelated articles and information. • Adults/Teens/Kids Health Information KidsHealth is organized for 3 different audiences with thousands of articles, movies, tools and games written and presented for 3 distinct age groups. • Disease Management and Telephonic Coach Outreach Program Care support for members with any of the following health concerns: Asthma, CAD, HIV/AIDS, CHF, COPD, CKD, Diabetes, Hemophilia, High-Risk Pregnancy, Low Back Pain, Multiple Sclerosis, Sickle Cell Disease, Transplant. • MHNet Coaching Our Mental Health Network (MHNet) professionals provide help for many kinds of concerns. These include, but are not limited to: depression, anxiety, alcohol and drug addictions, children’s issues, grief counseling, domestic violence, suicidality, smoking cessation, and medication management. 34 Value-Added Benefits “AltiusExtra” is a way for you to get more from your health plan. You and your family can access sizeable discounts on a wide variety of goods and services that may not be covered by your Altius health plan. In addition to ongoing discounts, many of the providers who participate in AltiusExtra offer specials and drawings for free services throughout the year. Discount Goods and Services Include: acupuncture, child safety, cosmetic dentistry, cosmetic dermatology, cosmetic surgery, health-related coupons, day spa, eyewear, fitness routines, relaxation help, health clubs, hearing aids, helmets, LASIK eye surgery, mail order contact lenses, massage therapy, medical alarm, sunglasses, tattoo removal, and weight management. Other web-based tools and services: Consumer Choice Information: Health Education Resources: • Online Health Risk Assessment • Preventive Guidelines • Patient Safety Tips • Health information for kids/parents/teens • E-mail reminders for Preventive Screening Tests Account Management Tools: • Participating Provider and Facility Directory • My Online Services • View claims • Print EOBs • Order ID cards • Change personal information • AltiusExtra Discount Program • Health services pricing tool • Employee budgeting tools / Medical cost estimator Pharmacy Web Tools: • Pharmacy Locator • Drug information and savings • Drug formulary and guidelines • Combines benefit, cost and drug info specific to member • Check personal drug costs, savings opportunities, search for therapeutic alternatives • Prescription drug interaction "How do I access these web-based services?" To log on to these web-based services, go to www.altiushealthplans.com, click on Member Tools, then My Online Services. Access to My Online Services is quick and easy to establish with a valid Altius Member ID Number which can be found on your Member ID Card. You will be asked to select a personal PIN so only you can access your secure member information. Box Elder School District 35 "Do Altius members like to save money?" Save money with discounts on goods and services outside the regular coverage of your Altius Health Plan Access sizable discounts on a wide variety of goods and services that are not covered by your Altius Health Plans medical plan. Enjoy ongoing discounts and in some cases, additional specials throughout the year. All the specials offer superior value and some may include drawings for free services. To find out more about the specialsand for the most up-to-date information, visit www.altius-extra.com or call our customer service hotline at 800-377-4161. Acupuncture Cosmetic Surgery Acupuncture is generally used to maintain or improve wellness, to prevent disease, or to treat health problems. Acupuncturists believe that good health depends on the proper flow of energy, called chi, that follows invisible pathways through our bodies. Inserting fine needles into points along these pathways, they say, can tweak this force into proper balance. Cosmetic Surgery is a combination of art and medical science. The range of cosmetic procedures available to both women and men is remarkable. In fact, men represent the fastest growing part of many cosmetic surgery practices. Cosmetic surgery can enhance body image, increase self-confidence and help you achieve the appearance you’ve always dreamed of. Day Spa Child Safety Products Protecting your children can be expensive. Costs for items like car seats, safety gates, locks, latches and more can add up. Save money on these and other safety items by using your AltiusExtra discount at Safe Beginnings. An escape to a day spa can leave you feeling refreshed, rejuvenated, pampered, and revitalized. Typical services include skin care, body treatments, facial treatments, manicures, pedicures, waxing, dermabrasion, laser hair removal, electrolysis and more. Discount Dental Cosmetic Dentistry Available only in Utah Whiter, straighter teeth are now more affordable than ever through AltiusExtra providers. Save up to 35% on the most common dental services. For details on how to use this fee-for-service dental program, and a complete listing of participating providers, call Altius’ Customer Service at 800-377-4161. Cosmetic Dermatology & Laser Hair Removal Looking your best helps you feel confident in any situation. Cosmetic dermatology procedures can minimize wrinkles, age spots or acne scars. Inquire with AltiusExtra providers about specific procedures such as botox injections, dermabrasion, collagen implants and laser hair removal to create a more confident ‘you.’ Emergency Response Services Available only in Utah With a medical alarm, help is always just a press of a button away. Emergency response systems enable millions of people to live with greater confidence, peace of mind and dignity. Downloadable MP3 files for Relaxation, Weight Loss and Workouts Workout Downloads - http://www.altius-extra.com/facilities.html?category=Fitness+Routines Relaxation Downloads - www.altius-extra.com/facilities.html?category=Relaxation+Help Dieting Tips for Active People Downloads - Nancy Clark, MS, RD - www.altius-extra.com/facilities.html?category=Weight+Management Weight Management Downloads - Nancy Clark, MS, RD - www.altius-extra.com/facilities.html?category=Weight+Management Weight Management Downloads - Faking out the Freshman 15 - www.altius-extra.com/facilities.html?category=Weight+Management Weight Management Downloads - ThinkLight! 1-800-869-6393 - www.thinklight.com/altius 36 Eye Exams & Eyewear Your eye exam is part of your Altius Health Plans medical benefits. However, your hardware — eyeglasses, sunglasses, or contact lenses — is not. Because you’re an Altius member, you’re entitled to save 10 to 30 percent from participating vendors on prescription and nonprescription eyewear. Personal Training Need help getting started on your weight loss or personal fitness goals? A personal trainer develops a wellbalanced fitness program, with step-by-step instructions, giving you the knowledge and tools needed to adopt and maintain a healthy lifestyle. Whether you are just starting a new exercise program or are looking to move to the next level, a personal trainer can help you. Health Clubs Altius is all for smart exercise, because it’s one of the best ways to keep you healthy. So, we’ve arranged discount memberships for you with a number of health clubs. Discounts range from reduced service fees and monthly payments, to corporate rates and first month free. Hearing Aids Sure, hearing aids are not covered under health insurance, but Altius still wants to help. So, we’ve arranged discounts for Altius Health Plans members for powerful, smaller-than-ever hearing aids. LASIK Vision Surgery More and more people are looking into LASIK and the freedom it provides from having to fuss with glasses or contact lenses all the time. And today, LASIK is safer, more effective, and more popular than ever. TTattoo Removal Available only in Utah Have a tattoo that you want to remove? Tattoo pigment is located in the deep layers of the skin, making it permanent and difficult to remove. Lasers are the most effective way to remove tattoos. The only other option is excision (surgical removal). Lasers specifically designed for tattoo removal pass through the top layer of the skin, applying their energy to the tattoo pigment particles, releasing the pigment. New! HandiVan Transportation Services Available only in Utah Do you need assistance with transportation services? A doctor’s appointment, lunch with friends or a trip to the grocery store? Our transportation services provider can help you get there. Limitations and exclusions may apply. Please contact provider for more information. Available in Salt Lake and South Davis counties in Utah. Mail Order Contact Lenses Save time when your contact lenses are delivered directly to your door. Massage Therapy Many of our members love therapeutic massage, and for good reason. It’s one of the most enjoyable forms of health, fitness, and general wellness therapy available. So, Altius Health Plans went to work obtaining better massage therapy rates for our members. And we succeeded! Our participating professionals have agreed to give Altius members $5 off a half-hour massage and $10 off an hour-long massage. Just show them your Altius Health Plans card. Downloads — FREE! Nothing beats formal physical training classes, group exercise, and personal trainers. But, if your schedule doesn’t allow you to attend a class, or if you are travelling, our free downloadable mp3 files are the next best thing. These topics are available: • • • • Workout Downloads Relaxation Downloads Dieting Tips for Active People Downloads Weight Management Downloads To learn more about AltiusExtra discounts, visit the Altius website and click on Discounts through AltiusExtra or simply log on to Utah College of Massage Therapy These AltiusExtra providers are offering gift certificates available for $12.50 for a 1-hour student massage. Memberships are purchased through Paypal only from Basix, LLC. Basix, LLC manages the AltiusExtra program on behalf of Altius. This massage therapy offer is valid only if you purchase through Basix at www.altius-extra.com/facilities. html?category=massage+therapy. www.altius-extra.com Box Elder School District 37 HEALTH SAVINGS ACCOUNT HealthEquity 38 HSAs: A Healthy Choice for Your Savings What Is a Health Savings Account? What Is a Health Savings Account? A health savings account (HSA) is a tax-free savings account that belongs to you. You can use your HSA to pay for your insurance deductible and qualified out-of-pocket medical expenses. Your HSA works with your lower-premium higher-deductible medical plan to cover your major medical expenses. Why Should I Choose an HSA? Paycheck An HSA Puts More Money Into Your Pocket. With an HSA, you get to take some of the money that would have gone to pay for higher health insurance premiums and put it into your own pocket. You can use the HSA to pay for qualified medical expenses, or you can save it and let it grow with tax-free interest from year to year. You don’t lose it if you don’t spend it (like the money you put in an FSA). You don’t have to pay taxes on withdrawals for eligible medical expenses Tax-Free Contributions (like a 401[k]). HSA Even if you lose your qualified lower premium plan, you can still use the remaining funds in your HSA on qualified medical expenses. The HSA, including all the money you and your employer contribute, is yours. You take the account with you when you change jobs, retire, or leave your qualified health plan. An HSA Gives You More Control Over How You Spend Your Health Care Dollars. You Can Keep Your Own Doctor. nlike more restrictive HMOs, an HSA-qualified plan is more flexible and U your doctor is probably in the network. You Can Cover Expenses That Your Health Plan Might Not Include. For example, if your health plan limits the number of chiropractic treatments you can have during the year, you can pay for additional treatments from your HSA. 39 Pay Bills Tax-Free Doctor’s Bill If I’m Healthy, Is an HSA Right for Me? More than 70% of insured people incur less than $1,000 a year in medical expenses (including what both the patient and the health plan pay).* HSA-qualified health plans cover preventive care services at 100% and have a fixed limit on your out-of-pocket costs ($6,050 and $5,950 for individuals for 2012 and 2011 and $12,100 and $11,900 for families for 2012 and 2011). If you take advantage of those preventive care services and adopt healthy lifestyle habits, it’s likely you won’t have to spend much of your HSA. The unspent portion of your HSA can grow tax-free from year to year. Who Is Eligible to Have an HSA? To be eligible to open an HSA, you must meet the following requirements: Be covered under an HSA-qualified health plan on the first day of any month for which eligibility is claimed (as described in IRS Publication 969—Health Savings Accounts and Other Tax-Favored Health Plans). Not be enrolled in Medicare. Not be claimed as a dependent on someone else’s tax return. Have no other insurance except what’s permitted by the IRS (see IRS Publication 969). Why Is an HSA Better Than Other Retirement Plans? Think of an HSA as a Medical 401(k)—Only Better. Here Are the Ways an HSA is Like a 401(k): You and your employer can make pre-tax contributions to your HSA. Your HSA can grow tax-free for as long as you own the account. Here Are the Ways an HSA Is Better: You can keep your money liquid in an FDIC-insured bank account or, when the balance grows You can contribute money up to the IRS yearly limit at any time during the year—as long as If you’re no longer employed, you can still make contributions to your HSA—as long as you’re still You don’t have to be of retirement age to make tax-free withdrawals at any time high enough, invest it in mutual funds. It’s your choice. you’re covered by an HSA-qualified health plan and aren’t on Medicare or covered by other insurance. Even family members can contribute to your account (but only you and your employer can deduct your contributions from your taxes). covered by your HSA-qualified health plan and aren’t on Medicare or covered by other insurance. without tax or penalty—as long as you use the funds for qualified medical expenses.** 40 Withdraw HSA funds with no penalty after age 65 How Can I Build the Balance in My HSA? You and/or Your Employer Can Make Pre-Tax Contributions to Your HSA Up to the Yearly IRS Limits. In 2011, the maximum contribution for individuals as set by the IRS is $3,050. In 2012, the maximum for individuals is $3,100. The maximum contribution limit for family coverage is $6,150 in 2011 and $6,250 in 2012. People aged 55 and over can make an additional “catch-up” contribution of $1,000 per year. Any Third Party Can Make Contributions to Your HSA. Any third party—even non-family members—can contribute to an HSA on behalf of another person who qualifies as an eligible HSA holder. However, the contributor in that case doesn’t receive any tax benefits. (Only account holders and their employers can deduct any HSA contributions they make from their taxes.) 2011 & 2012 Individual HSA Contribution Limit $3,050 (2011) $3,100 (2012) You Can Roll Over Funds From Other Tax-Advantaged Accounts. Transfers from other HSAs or Archer MSAs into an HSA are permitted as long as you’re the owner of both accounts. You can do a once per lifetime transfer from an IRA to your HSA. This transfer is limited to the annual HSA contribution limit set by the IRS. You must remain in your HSA-qualified health plan for the entire period following the month in which the transfer was completed in order to avoid taxes and penalties. 2011 & 2012 Family HSA Contribution Limit $6,150 (2011) $6,250 (2012) Whose Medical Expenses Can I Pay for Out of My HSA? Spouse and Dependents In addition to your own medical expenses, you can use your HSA to pay the medical expenses of any family member who is reported as a dependent on your tax return, even if they’re not covered by your health plan. (However, their expenses won’t be applied toward your health plan’s deductible if they’re not on your plan.) Domestic Partner The law states that money in an HSA can only be used for yourself, your spouse, and your tax dependents. If your domestic partner meets the IRS qualifications to be considered a tax dependent, you can legally use your HSA funds for his/her medical expenses. 41 What Kinds of Medical Expenses Will My HSA Pay For? You can use HSA funds to pay for qualified medical expenses as defined by the IRS. Medical care expenses must be primarily to alleviate or prevent a physical or mental defect or illness. They don’t include expenses that are merely beneficial to general health, such as vitamins or a vacation. Here Are a Few Examples of Qualified Medical Expenses*: • Acupuncture •C rutches •O xygen •A lcoholism (rehab, transportation for medically advised attendance at AA) •D ental treatment • S top-smoking programs • E yeglasses / eye surgery • S urgery •H earing aids • T elephone equipment and repair for hearing-impaired •A mbulance •A nnual physical examination •A rtificial limbs/teeth •H ome care •B ody scan • Medicines (prescribed, not imported from other countries) •B reast reconstruction surgery •N ursing home •C hiropractor •N ursing services ontact lenses •C ptometrist •O •B irth control pills • T herapy • L ong-term care expenses • T ransplants •W eight-loss program (as prescribed by a physician for a specific disease) •W heelchair •W ig Here Are Some of the Expenses That Are Not Qualified by the IRS†: • Babysitting, childcare, and nursing services for a normal, healthy baby •D ancing lessons •D iaper service • E lective cosmetic surgery • E lectrolysis or hair removal • Funeral expenses • Nonprescription drugs and medicines • Future medical care • Nutritional supplements, unless recommended by a medical practitioner as treatment for a specific medical condition diagnosed by a physician • Hair transplant • Health club dues • Insurance premiums other than those explicitly included • Medicines and drugs from other countries • Teeth whitening 2006 claims data from insurers with more than 700,000 lives. There is a 20% penalty for withdrawals other than for medical expenses before the age of 65. † A complete list is found in the IRS Publication 502—Medical and Dental Expenses. * ** www.healthequity.com 42 Copyright © 2011 HealthEquity, Inc. All rights reserved. HealthEquity and the HealthEquity logo are registered trademarks and service marks of HealthEquity, Inc. 866.346.5800 HE HSAHS 20110822/KM/MR DENTAL Dental Select Gold Plan Platinum Plan Indemnity Plan 43 Summary of Benefits For: Box Elder School District Co-Pay Plan Gold Network - 1542 Providers PREVENTIVE Routine exams, cleanings (2 per year), topical fluoride, x-rays Contracted Dentist Non-Contracted Dentist 100% See Out of Network Payment Fixed Co-Pays, Refer to Co-Pay Schedule See Out of Network Payment Fixed Co-Pays, Refer to Co-Pay Schedule See Out of Network Payment BASIC Fillings, extractions, oral surgery MAJOR Crowns, bridges, dentures, endodontics, periodontics ORTHODONTICS All Members Waiting Periods Lifetime Maximum 20% Discount No Coverage No Waiting Period No Maximum MAXIMUM BENEFIT Applies to Preventive, Basic and Major Services No Maximum Per Year: DEDUCTIBLE Applies to Basic and Major Services No Deductible SPECIALISTS Endodontists, Oral Surgeons, Pediatric, Periodontists, Prosthodontists. For pediatric specialists see schedule of copayments. 20% Discount 44 No Discount 2009 Utah Rural Gold PPO Copay ADA Code D1450 D0120 D0140 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0330 D0340 D0470 D1110 D1120 D1203 D1330 D1351 D1510 D1515 D1520 D1525 D1550 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2610 D2620 D2630 D2642 D2643 D2644 D2740 D2750 D2751 D2752 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2915 D2920 D2930 D2931 D2933 D2934 D2940 Procedure Description OSHA Infection and Sterilization Periodic oral examination Limited oral examination Comprehensive oral examination Detailed and extensive oral evaluation Re-evaluation Periodontal evaluation Intraoral - compl ser incl bitewings Intraoral - periapical - first film Intraoral - periapical - each add film Intraoral - occlusal film Extraoral - first film Extraoral - each additional Bitewing - single film Bitewings - two films Bitewing-three films Bitewings - four films Vertical bitewings - 7 to 8 films Panoramic film Cephalometric film Diagnostic casts Prophylaxis - adults Prophylaxis - child Top appl fluor excl prophy (age 14 & under) Oral hygiene instruction Sealant - per tooth (age 14 & under) Space maintainer - fixed unilateral (age 14 & under) Space maintainer - fixed bilateral (age 14 & under) Space maintainer - rem. unilateral (age 14 & under) Space maintainer - rem. bilateral (age 14 & under) Recement of space maintainer (age 14 & under) Amalgam - 1 surface primary or permanent Amalgam - 2 surfaces primary or permanent Amalgam - 3 surfaces primary or permanent Amalgam - 4 + surfaces primary or permanent Resin - 1 surface anterior Resin - 2 surfaces anterior Resin - 3 surfaces anterior Resin - 4 + surf or involving incisal angle anterior Resin based comp. crown - ant. prim. or perm. Resin - 1 surface posterior prim. or perm. Resin - 2 surfaces posterior prim. or perm. Resin - 3 surfaces posterior prim. or perm. Resin - 4 + surfaces - posterior prim. or perm. Inlay - porcelain/ceramic 1 surface Inlay - porcelain/ceramic - 2 surfaces Inlay - porcelain/ceramic - 3 surfaces Onlay - porcelain/ceramic - 2 surfaces Onlay - porcelain/ceramic - 3 surfaces Onlay - porcelain/ceramic - 4 surfaces Crown - porcelain/ceramic substrate (note 3) Crown - porcelain fused to high noble metal (note 2) Crown - porcelain fused to predom. base metal Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal (note 2) Crown - 3/4 cast predominately base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain ceramic (note 3) Crown - full cast high noble metal (note 2) Crown - full cast predominately base metal Crown - full cast noble metal Recement cast or prefabricated post and core Recement crown Prefab. stainless steel crown - prime tooth Prefab. stainless steel crown - permanent tooth Prefab. stainless steel crown w/ resin window Prefab. coated stainless steel crown - primary Sedative fillings General Dentist In-Network Patient Co-Pay General Dentist In & Out-of-Network Plan Payment Pediatric Specialist In-Network Patient Co-Pay or Discount Pediatric Specialist In & Out-of-Network Plan Payment 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18 12 19 20 16 17 37 8 6 6 4 4 6 14 14 17 17 38 0 0 38 26 4 0 9 0 0 0 0 0 33 35 39 39 33 41 45 52 0 33 40 46 49 146 167 189 128 147 153 160 181 150 157 154 154 154 154 157 142 147 0 0 0 0 0 0 0 10 0 0 18 0 19 0 0 0 37 8 6 6 4 4 6 14 14 17 17 38 0 0 38 26 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20% Discount 20% Discount 0 0 0 0 13 84 128 91 140 17 12 21 26 35 33 36 43 52 102 32 50 61 68 210 229 250 210 236 265 271 291 292 293 253 253 253 253 260 213 213 24 24 65 67 105 110 30 45 20% Discount 0 20% Discount 20% Discount 20% Discount 0 0 0 0 0 0 0 0 0 0 0 0 20% Discount 20% Discount 0 0 0 0 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount ADA Code D2950 D2951 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2970 D2999 D3110 D3120 D3220 D3221 D3222 D3230 D3240 D3310 D3320 D3330 D3346 D3347 D3348 D3410 D3421 D3425 D3426 D3430 D4210 D4211 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4266 D4267 D4270 D4271 D4273 D4275 D4276 D4320 D4321 D4341 D4342 D4355 D4381 D4910 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 Procedure Description Core build-up including any pins Pin retenion - per tooth in addition to restoration Cast post & core in addition to crown Each additional cast post - same tooth Prefab. post & core in addition to crown Each additional prefab post - same tooth Anterior bonding per tooth Labial veneer resin laminate (lab) Labial veneer porcelain laminate (lab) Temporary crown (fractured tooth) Lab Fee (notes 2 & 3) Pulp cap - direct excluding final restoration Pulp cap - indirect excluding final restoration Therapeutic pulpotomy excluding final restoration Pulpal debridement primary & permanent teeth Partial pulpotomy apexogenesis Pulpal therapy-anterior-excluding final restoration Pulpal therapy-posterior-excluding final restoration Root Canal - ant. exclud. final restoration Root Canal - bicuspid exclud. final restoration Root Canal - molar exclud. final restoration Retreatment of previous root canal - anterior Retreatment of previous root canal - bicuspid Retreatment of previous root canal - molar Apicoectomy/periradicular surgical - anterior Apico/perirad surgical - bicuspid first root Apico/perirad surgical - molar first root Apico/perirad surgical - each additional root Retrograde filling - per root Gingivectomy/gingivoplasty - 4 + teeth per quad Gingivectomy/gingivoplasty - 1 - 3 teeth per quad Gingival flap proc. incl. root planing - 4 + teeth Gingival flap proc. Incl. root planing 1 - 3 teeth Clinical crown lengthening - hard tissue Osseous surg. & flap entry/closure - 4 + teeth Osseous surg. & flap entry/closure - 1- 3 teeth Bone replacement graft - first site in quad Bone replacement graft - each additional site in quad Guided tissue regen. - resorbable barrier, per site Guided tis. regen. - non resorbable barrier, per site Pedicle soft tissue graft procedure Free soft tissue graft & donor site Subepithelial connnective graft proc. (incl. donor) Soft tissue allograft Comb. connective tissue and double pedicle graft Provisional splinting - intracoronal Provisional splinting - extracoronal Perio. scaling & root planing - 4 + teeth per quad Perio. scaling & root planing - 1 - 3 teeth per quad Full mouth debridement Antimicrobial agents Perio maintenance procedures after active therapy Complete denture - upper (note 6) Complete denture - lower (note 6) Immediate denture - upper (note 6) Immediate denture - lower (note 6) Maxillary Partial Denture - Resin Base (note 7) Mand. Partial Denture - Resin Base (note 7) Max. Partial Denture w/ cast metal base (note 7) Mand. Partial Denture w/ cast metal base (note 7) Rem. unilateral part. denture Adjust complete denture - maxillary Adjust complete denture - mandibular Adjust partial denture - maxillary Adjust partial denture - mandibular Repair broken complete denture base (note 7) Replace missing/broken tooth - ea. tooth (note 7) Repair resin saddle or base (note 7) Repair cast framework (note 7) Repair or replace broken clasp (note 7) Replace broken teeth - per tooth (note 7) Add tooth to existing partial denture (note 7) Add clasp to existing partial denture (note 7) Rebase complete maxillary denture (note 7) Rebase complete mandibular denture (note 7) Rebase maxillary partial denture (note 7) Rebase mandibular partial denture (note 7) Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline complete maxillary denture (lab) (note 7) Reline complete mandibular denture (lab) (note 7) General Dentist In-Network Patient Co-Pay General Dentist In & Out-of-Network Plan Payment Pediatric Specialist In-Network Patient Co-Pay or Discount Pediatric Specialist In & Out-of-Network Plan Payment 82 16 103 47 87 43 240 0 0 0 0 0 0 0 0 0 0 20% Discount 0 0 0 0 0 0 0 0 0 0 20% Discount 20% Discount 0 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 0 See notes 2 & 3 20 15 49 49 49 50 45 167 225 303 168 202 257 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 79 59 54 20% Discount 55 401 401 421 421 326 326 404 404 20% Discount 35 31 29 28 42 25 30 28 33 26 34 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 77 77 74 74 139 139 46 0 0 0 0 0 0 0 84 89 92 52 70 87 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20 18 10 0 18 113 113 113 113 93 93 103 103 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 See notes 2 & 3 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ADA Code D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5899 D6000-6199 D6205 D6210 D6211 D6212 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6930 D6970 D6971 D6972 D6973 D6976 D6977 D6999 D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7270 D7280 D7285 D7286 D7287 D7288 D7290 D7310 D7311 D7320 D7321 D7510 D7511 D7810-7899 D7960 D7971 D9110 D9210 D9220 D9221 D9241 D9242 Procedure Description Reline upper partial denture (lab) (note 7) Reline mandibular partial denture (lab) (note 7) Interim complete denture (maxillary) Interim complete denture (mandibular) Interim partial denture (maxillary) Interim partial denture (mandibular) Tissue conditioning, maxillary - per denture unit Tissue conditioning, mandibular Overdenture - complete by report Overdenture - partial by report Lab Fee (notes 6 & 7) Implants (Does not include parts) Pontic-Indirect resin based composite Pontic - cast high noble metal (note 2) Pontic - cast base metal Pontic - cast noble metal Pontic - porcelain fused to high noble metal (note 2) Pontic - porcelain fused to predominately base metal Pontic - porcelain fused to noble metal Pontic - porcelain/ceramic (note 3) Pontic - resin with high noble metal (note 2) Pontic - resin with predominantly base metal Pontic - resin with noble metal Onlay - porcelain/ceramic - 2 surf. Onlay - porcelain/ceramic - 3 + surf. Onlay - cast high noble metal - 2 surf. (note 2) Onlay - cast high noble metal - 3 +surf. (note 2) Onlay - cast predom. base metal - 2 surf Onlay - cast predom. base metal - 3 + surf. Onlay - cast noble metal - 2 surf. Onlay - cast noble metal - 3 + surf. Crown - resin with high noble metal (note 2) Crown - resin with predominantly base metal Crown - resin with noble metal Crown - porcelain/ceramic (note 3) Crown - porc fused to high noble metal (note 2) Crown - porcelain fused to predom. base metal Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal (note 2) Crown - 3/4 cast base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic (note 3) Crown - full cast high noble metal (note 2) Crown - full cast predominantly base metal Crown - full cast noble metal Recement bridge Cast post and core Cast post as part of fixed partial denture retainer Prefab post and core Core build up for retainer, including pins Each additional cast post - same tooth Each additional prefab post - same tooth Lab Fee (notes 2 & 3) Extraction of primary tooth Extraction of erupted tooth or exposed tooth Surgical removal of erupted tooth Removal impacted tooth - soft tissue Removal impacted tooth - partial bony Removal impacted tooth - completely bony Removal impacted tooth Surgical removal residual tooth roots Tooth reimplantation/stabilization Surgical access of an unerupted tooth Biopsy of oral tissue-hard (bone, tooth) Biopsy of oral tissue-soft (all others) Cytology sample Brush biopsy - transepithelial sample collection Surgical repositioning of teeth Alveoloplasty in conj. w/ extraction - per quad Alveolaplasty in conj. w/ extractions - 1 - 3 teeth Alveoloplasty, no extraction - per quad Alveolaplasty not in conj. w/ exts. -1 - 3 teeth I&D abscess - intraoral soft tissue I&D abscess - intraoral soft tissue, complicated TMJ Treatment Frenulectomy - separate procedure Excision of pericoronal gingiva Palliative - emerg. treatment of pain - minor proc. Local anesthetic General Anesthesia, first 30 minutes General Anesthesia, additional 15 minutes Intravenous sedation, first 30 minutes Intravenous sedation, each add 15 minutes General Dentist In-Network Patient Co-Pay General Dentist In & Out-of-Network Plan Payment Pediatric Specialist In-Network Patient Co-Pay or Discount Pediatric Specialist In & Out-of-Network Plan Payment 124 124 0 0 0 0 0 0 0 0 0 0 20% Discount 0 0 0 0 0 0 0 0 0 0 20% Discount 20% Discount 20% Discount 20% Discount 35 35 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount See notes 6 & 7 20% Discount 110 270 240 240 280 285 285 270 280 260 260 195 220 130 140 130 140 130 140 270 270 270 270 295 295 295 270 250 250 255 280 250 250 45 108 75 80 20% Discount 20% Discount 20% Discount 0 90 160 144 149 157 147 147 147 152 152 152 94 127 95 95 95 95 95 95 155 152 152 147 157 147 147 152 153 153 157 152 142 142 0 0 0 0 0 0 0 See notes 6 & 7 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount See notes 2 & 3 23 28 59 79 99 117 121 66 135 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 63 72 20% Discount 95 20% Discount 30 0 47 18 21 27 28 35 35 40 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 See notes 2 & 3 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 N/C N/C N/C N/C N/C N/C N/C N/C ADA Code D9248 D9430 D9440 D9940 D9951 D9972 D9973 D8010-8680 Procedure Description Non-intraven. conscious sedation (age 7 & under) Office visit obs. - scheduled hrs - no other servs. Office visit - after regular scheduled hours Occlusal guards by report (note 5) Occlusal adjustment - limited External Bleaching per Arch External Bleaching per Tooth Orthodontics (note 8) General Dentist In-Network Patient Co-Pay General Dentist In & Out-of-Network Plan Payment Pediatric Specialist In-Network Patient Co-Pay or Discount N/C 25 37 152 29 100 10 20% Discount 48 0 0 0 0 0 0 0 Pediatric Specialist In & Out-of-Network Plan Payment N/C 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 0 0 0 0 0 0 0 Summary of Benefits For: Box Elder School District Co-Pay Plan Platinum Network - 2068 Providers PREVENTIVE Routine exams, cleanings (2 per year), topical fluoride, x-rays Contracted Dentist Non-Contracted Dentist 100% See Out of Network Payment Fixed Co-Pays, Refer to Co-Pay Schedule See Out of Network Payment Fixed Co-Pays, Refer to Co-Pay Schedule See Out of Network Payment BASIC Fillings, extractions, oral surgery MAJOR Crowns, bridges, dentures, endodontics, periodontics ORTHODONTICS All Members Waiting Periods Lifetime Maximum 20% Discount No Coverage No Waiting Period No Maximum MAXIMUM BENEFIT Applies to Preventive, Basic and Major Services No Maximum Per Year: DEDUCTIBLE Applies to Basic and Major Services No Deductible SPECIALISTS Endodontists, Oral Surgeons, Pediatric, Periodontists, Prosthodontists 20% Discount 49 No Discount 2009 Utah Rural Platinum ADA Code D1450 D0120 D0140 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0330 D0340 D0470 D1110 D1120 D1203 D1330 D1351 D1510 D1515 D1520 D1525 D1550 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2610 D2620 D2630 D2642 D2643 D2644 D2740 D2750 D2751 D2752 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2915 D2920 D2930 D2931 D2933 D2934 D2940 Procedure Description OSHA Infection and Sterilization Periodic oral examination Limited oral examination Comprehensive oral examination Detailed and extensive oral evaluation Re-evaluation Periodontal evaluation Intraoral - compl ser incl bitewings Intraoral - periapical - first film Intraoral - periapical - each add film Intraoral - occlusal film Extraoral - first film Extraoral - each additional Bitewing - single film Bitewings - two films Bitewing-three films Bitewings - four films Vertical bitewings - 7 to 8 films Panoramic film Cephalometric film Diagnostic casts Prophylaxis - adults Prophylaxis - child Top appl fluor excl prophy (age 14 & under) Oral hygiene instruction Sealant - per tooth (age 14 & under) Space maintainer - fixed unilateral (age 14 & under) Space maintainer - fixed bilateral (age 14 & under) Space maintainer - rem. unilateral (age 14 & under) Space maintainer - rem. bilateral (age 14 & under) Recement of space maintainer (age 14 & under) Amalgam - 1 surface primary or permanent Amalgam - 2 surfaces primary or permanent Amalgam - 3 surfaces primary or permanent Amalgam - 4 + surfaces primary or permanent Resin - 1 surface anterior Resin - 2 surfaces anterior Resin - 3 surfaces anterior Resin - 4 + surf or involving incisal angle anterior Resin based comp. crown - ant. prim. or perm. Resin - 1 surface posterior prim. or perm. Resin - 2 surfaces posterior prim. or perm. Resin - 3 surfaces posterior prim. or perm. Resin - 4 + surfaces - posterior prim. or perm. Inlay - porcelain/ceramic 1 surface Inlay - porcelain/ceramic - 2 surfaces Inlay - porcelain/ceramic - 3 surfaces Onlay - porcelain/ceramic - 2 surfaces Onlay - porcelain/ceramic - 3 surfaces Onlay - porcelain/ceramic - 4 surfaces Crown - porcelain/ceramic substrate (note 3) Crown - porcelain fused to high noble metal (note 2) Crown - porcelain fused to predom. base metal Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal (note 2) Crown - 3/4 cast predominately base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain ceramic (note 3) Crown - full cast high noble metal (note 2) Crown - full cast predominately base metal Crown - full cast noble metal Recement cast or prefabricated post and core Recement crown Prefab. stainless steel crown - prime tooth Prefab. stainless steel crown - permanent tooth Prefab. stainless steel crown w/ resin window Prefab. coated stainless steel crown - primary Sedative fillings General Dentist In-Network Patient Co-Pay General Dentist In & Out-of-Network Plan Payment Pediatric Specialist In-Network Patient Co-Pay or Discount Pediatric Specialist In & Out-of-Network Plan Payment 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 112 91 0 0 0 0 17 124 167 113 171 34 12 21 28 40 36 41 45 52 116 46 54 66 71 227 235 269 280 279 302 317 370 323 366 282 282 282 282 338 286 324 32 37 109 119 122 128 49 0 30 33 42 33 26 34 64 16 14 17 24 18 13 29 29 37 45 51 0 0 47 36 12 0 11 0 0 0 0 0 40 43 45 49 35 44 51 55 0 44 48 52 54 133 173 192 150 163 151 174 210 171 195 169 169 169 169 210 190 223 0 0 0 0 0 0 0 0 0 0 30 0 42 0 0 0 64 16 14 17 24 18 13 29 29 37 45 51 0 0 47 36 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 50 20% Discount 0 20% Discount 20% Discount 20% Discount 0 0 0 0 0 0 0 0 0 0 0 0 20% Discount 20% Discount 0 0 0 0 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount ADA Code D2950 D2951 D2952 D2953 D2954 D2957 D2960 D2961 D2962 D2970 D2999 D3110 D3120 D3220 D3221 D3222 D3230 D3240 D3310 D3320 D3330 D3346 D3347 D3348 D3410 D3421 D3425 D3426 D3430 D4210 D4211 D4240 D4241 D4249 D4260 D4261 D4263 D4264 D4266 D4267 D4270 D4271 D4273 D4275 D4276 D4320 D4321 D4341 D4342 D4355 D4381 D4910 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 Procedure Description Core build-up including any pins Pin retenion - per tooth in addition to restoration Cast post & core in addition to crown Each additional cast post - same tooth Prefab. post & core in addition to crown Each additional prefab post - same tooth Anterior bonding per tooth Labial veneer resin laminate (lab) Labial veneer porcelain laminate (lab) Temporary crown (fractured tooth) Lab Fee (notes 2 & 3) Pulp cap - direct excluding final restoration Pulp cap - indirect excluding final restoration Therapeutic pulpotomy excluding final restoration Pulpal debridement primary & permanent teeth Partial pulpotomy apexogenesis Pulpal therapy-anterior-excluding final restoration Pulpal therapy-posterior-excluding final restoration Root Canal - ant. exclud. final restoration Root Canal - bicuspid exclud. final restoration Root Canal - molar exclud. final restoration Retreatment of previous root canal - anterior Retreatment of previous root canal - bicuspid Retreatment of previous root canal - molar Apicoectomy/periradicular surgical - anterior Apico/perirad surgical - bicuspid first root Apico/perirad surgical - molar first root Apico/perirad surgical - each additional root Retrograde filling - per root Gingivectomy/gingivoplasty - 4 + teeth per quad Gingivectomy/gingivoplasty - 1 - 3 teeth per quad Gingival flap proc. incl. root planing - 4 + teeth Gingival flap proc. Incl. root planing 1 - 3 teeth Clinical crown lengthening - hard tissue Osseous surg. & flap entry/closure - 4 + teeth Osseous surg. & flap entry/closure - 1- 3 teeth Bone replacement graft - first site in quad Bone replacement graft - each additional site in quad Guided tissue regen. - resorbable barrier, per site Guided tis. regen. - non resorbable barrier, per site Pedicle soft tissue graft procedure Free soft tissue graft & donor site Subepithelial connnective graft proc. (incl. donor) Soft tissue allograft Comb. connective tissue and double pedicle graft Provisional splinting - intracoronal Provisional splinting - extracoronal Perio. scaling & root planing - 4 + teeth per quad Perio. scaling & root planing - 1 - 3 teeth per quad Full mouth debridement Antimicrobial agents Perio maintenance procedures after active therapy Complete denture - upper (note 6) Complete denture - lower (note 6) Immediate denture - upper (note 6) Immediate denture - lower (note 6) Maxillary Partial Denture - Resin Base (note 7) Mand. Partial Denture - Resin Base (note 7) Max. Partial Denture w/ cast metal base (note 7) Mand. Partial Denture w/ cast metal base (note 7) Rem. unilateral part. denture Adjust complete denture - maxillary Adjust complete denture - mandibular Adjust partial denture - maxillary Adjust partial denture - mandibular Repair broken complete denture base (note 7) Replace missing/broken tooth - ea. tooth (note 7) Repair resin saddle or base (note 7) Repair cast framework (note 7) Repair or replace broken clasp (note 7) Replace broken teeth - per tooth (note 7) Add tooth to existing partial denture (note 7) Add clasp to existing partial denture (note 7) Rebase complete maxillary denture (note 7) Rebase complete mandibular denture (note 7) Rebase maxillary partial denture (note 7) Rebase mandibular partial denture (note 7) Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline complete maxillary denture (lab) (note 7) Reline complete mandibular denture (lab) (note 7) General Dentist In-Network Patient Co-Pay General Dentist In & Out-of-Network Plan Payment Pediatric Specialist In-Network Patient Co-Pay or Discount Pediatric Specialist In & Out-of-Network Plan Payment 99 22 183 61 154 60 0 0 0 0 0 0 0 0 0 0 20% Discount 0 0 0 0 0 0 0 0 0 0 20% Discount 20% Discount 20% Discount 0 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount See notes 2 & 3 22 21 65 58 65 64 68 232 290 387 246 279 360 268 315 359 119 83 249 86 230 179 261 359 272 281 220 300 317 261 261 443 268 377 138 119 122 81 78 20% Discount 77 628 628 694 694 598 598 600 600 310 40 35 31 31 63 69 70 96 95 82 95 94 226 226 215 215 126 126 114 114 226 226 51 0 0 0 0 0 0 0 114 120 125 75 94 120 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27 23 13 0 24 169 169 182 182 174 174 157 157 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 See notes 2 & 3 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ADA Code D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5899 D6000-6199 D6205 D6210 D6211 D6212 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6930 D6970 D6971 D6972 D6973 D6976 D6977 D6999 D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7270 D7280 D7285 D7286 D7287 D7288 D7290 D7310 D7311 D7320 D7321 D7510 D7511 D7810-7899 D7960 D7971 D9110 D9210 D9220 D9221 D9241 D9242 Procedure Description Reline upper partial denture (lab) (note 7) Reline mandibular partial denture (lab) (note 7) Interim complete denture (maxillary) Interim complete denture (mandibular) Interim partial denture (maxillary) Interim partial denture (mandibular) Tissue conditioning, maxillary - per denture unit Tissue conditioning, mandibular Overdenture - complete by report Overdenture - partial by report Lab Fee (notes 6 & 7) Implants (Does not include parts) Pontic-Indirect resin based composite Pontic - cast high noble metal (note 2) Pontic - cast base metal Pontic - cast noble metal Pontic - porcelain fused to high noble metal (note 2) Pontic - porcelain fused to predominately base metal Pontic - porcelain fused to noble metal Pontic - porcelain/ceramic (note 3) Pontic - resin with high noble metal (note 2) Pontic - resin with predominantly base metal Pontic - resin with noble metal Onlay - porcelain/ceramic - 2 surf. Onlay - porcelain/ceramic - 3 + surf. Onlay - cast high noble metal - 2 surf. (note 2) Onlay - cast high noble metal - 3 +surf. (note 2) Onlay - cast predom. base metal - 2 surf Onlay - cast predom. base metal - 3 + surf. Onlay - cast noble metal - 2 surf. Onlay - cast noble metal - 3 + surf. Crown - resin with high noble metal (note 2) Crown - resin with predominantly base metal Crown - resin with noble metal Crown - porcelain/ceramic (note 3) Crown - porc fused to high noble metal (note 2) Crown - porcelain fused to predom. base metal Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal (note 2) Crown - 3/4 cast base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic (note 3) Crown - full cast high noble metal (note 2) Crown - full cast predominantly base metal Crown - full cast noble metal Recement bridge Cast post and core Cast post as part of fixed partial denture retainer Prefab post and core Core build up for retainer, including pins Each additional cast post - same tooth Each additional prefab post - same tooth Lab Fee (notes 2 & 3) Extraction of primary tooth Extraction of erupted tooth or exposed tooth Surgical removal of erupted tooth Removal impacted tooth - soft tissue Removal impacted tooth - partial bony Removal impacted tooth - completely bony Removal impacted tooth Surgical removal residual tooth roots Tooth reimplantation/stabilization Surgical access of an unerupted tooth Biopsy of oral tissue-hard (bone, tooth) Biopsy of oral tissue-soft (all others) Cytology sample Brush biopsy - transepithelial sample collection Surgical repositioning of teeth Alveoloplasty in conj. w/ extraction - per quad Alveolaplasty in conj. w/ extractions - 1 - 3 teeth Alveoloplasty, no extraction - per quad Alveolaplasty not in conj. w/ exts. -1 - 3 teeth I&D abscess - intraoral soft tissue I&D abscess - intraoral soft tissue, complicated TMJ Treatment Frenulectomy - separate procedure Excision of pericoronal gingiva Palliative - emerg. treatment of pain - minor proc. Local anesthetic General Anesthesia, first 30 minutes General Anesthesia, additional 15 minutes Intravenous sedation, first 30 minutes Intravenous sedation, each add 15 minutes General Dentist In-Network Patient Co-Pay General Dentist In & Out-of-Network Plan Payment Pediatric Specialist In-Network Patient Co-Pay or Discount Pediatric Specialist In & Out-of-Network Plan Payment 218 218 0 0 0 0 0 0 0 0 0 0 20% Discount 0 0 0 0 0 0 0 0 0 0 20% Discount 20% Discount 20% Discount 20% Discount 51 51 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount See notes 6 & 7 20% Discount 169 324 282 303 333 308 333 270 281 260 266 293 283 234 248 234 248 234 248 293 279 288 376 347 314 356 306 256 269 289 339 287 325 47 128 107 109 85 69 60 0 138 203 188 209 190 162 183 147 157 157 162 135 158 163 161 163 161 163 161 175 167 172 206 196 168 189 183 153 162 179 203 192 217 0 0 0 0 0 0 0 See notes 6 & 7 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount See notes 2 & 3 25 32 75 102 121 143 145 100 144 185 20% Discount 20% Discount 20% Discount 20% Discount 124 82 50 165 96 70 91 20% Discount 168 60 47 0 20 24 32 36 42 43 50 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 N/C N/C N/C N/C 52 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 See notes 2 & 3 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 N/C N/C N/C N/C ADA Code D9248 D9430 D9440 D9940 D9951 D9972 D9973 D8010-8680 Procedure Description Non-intraven. conscious sedation (age 7 & under) Office visit obs. - scheduled hrs - no other servs. Office visit - after regular scheduled hours Occlusal guards by report (note 5) Occlusal adjustment - limited External Bleaching per Arch External Bleaching per Tooth Orthodontics (note 8) General Dentist In-Network Patient Co-Pay General Dentist In & Out-of-Network Plan Payment Pediatric Specialist In-Network Patient Co-Pay or Discount N/C 38 48 195 38 20% Discount 20% Discount 20% Discount 53 0 0 0 0 0 0 0 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount Pediatric Specialist In & Out-of-Network Plan Payment N/C 0 0 0 0 0 0 0 Summary of Benefits For: Box Elder School District 80% R&C Indemnity Classic Plan - Max Plan PREVENTIVE Routine exams, cleanings (2 per year), topical fluoride, x-rays Platinum Network - 2068 Providers Contracted Dentist Non-Contracted Dentist 80% 80% of R&C 80% 60% of R&C BASIC Fillings, extractions, oral surgery 3 Month Waiting Period MAJOR 50% 40% of R&C Crowns, bridges, dentures, endodontics, periodontics 12 Month Waiting Period ORTHODONTICS Children under 19 Waiting Period 20% Discount No Benefit No Waiting Period Lifetime Maximum No Maximum All Members 20% Discount No Discount MAXIMUM BENEFIT Applies to Preventive, Basic and Major Services Benefit Period is: $1000.00 DEDUCTIBLE Per Benefit Period Applies to Basic and Major Services Per Person: Family Maximum: $75.00 $225.00 $75.00 $225.00 SPECIALISTS Contracted Specialist payment: 1) You receive a 20% discount off the Specialist fee 2) Plan pays according to the General Dentists Schedule of Fees Endodontists, Oral Surgeons, Pediatric, Periodontists, Prosthodontists 3) Member pays the difference between plan payment and discounted Specialist fee Non-contracted Specialist payment: Paid the same as non-contracted dentists 54 VISION Opticare of Utah Plan 70C Plan 120C 55 Opticare Plan: 70C Box Elder School District Select Network Broad Network Out-ofnetwork 100% Covered 100% Covered 100% Covered $20 Co-pay $20 Co-pay $20 Co-pay ♦$70 Allowance for lenses, options, and coatings $50 Co-pay 20% Discount 15% Discount $40 Co-pay $80 Co-pay $75 Co-pay No Discount 15% Discount 25% Discount 25% Discount 100% Covered 100% Covered Up to 25% Discount $10 Co-pay $10 Co-pay Up to 25% Discount $70 Allowance $60 Allowance Up to 50% Off Retail Up to 25% Off Retail $70 Allowance $60 Allowance Up to 20% off Up to 10% off Retail Retail Every 12 months Every 12 months Every 12 months $250 Off Per Eye Not Covered Not Covered Eye Exam No Eye Examination Benefit Standard Plastic Lenses Single Vision Bifocal (FT 28) Trifocal (FT 7x28) Lens Options *Progressive (Standard plastic no-line) *Premium Progressive Options *Glass lenses Polycarbonate High Index Coatings Scratch Resistant Coating Ultra Violet protection Other Options A/R, edge polish, tints, mirrors, etc. Frames Allowance Based on Retail Pricing ♦$50 Allowance Additional Eyewear **Additional Pairs of Glasses Throughout the Year Contacts Contact benefits is in lieu Of lens and frame benefit. Additional contact purchases: ***Conventional ***Disposables ♦$50 Allowance Frequency Exams, Lenses, Frames, Contacts Refractive Surgery LASIK *Co-pays for Progressive lenses may vary. This is a summary of plan benefits. The actual Policy will detail all plan limitations and exclusions. Discounts Any item listed as a discount in the benefit outline above is a merchandise discount only and not an insured benefit. Providers may offer additional discounts. ** 50% discount at Standard Optical locations only. All other Network discounts vary from 20% - 35%. ***Must purchase full year supply to receive discounts on select brands. See provider for details. ****LASIK(Refractive surgery) Standard Optical Locations ONLY. LASIK services are not an insured benefit – this is a discount only. All pre & post operative care is provided by Standard Optical only and is based on Standard Optical retail fees. Out of Network – Allowances are reimbursed at 75% when discounts are applied to merchandise. Promotional items or Online purchases not covered. For more Information please visit www.opticareofutah.com or call 800-363-0950 56 OOU.GRP.POL.C.70C Opticare Plan: 120C Box Elder School District Select Network Broad Network Out-ofnetwork 100% Covered 100% Covered 100% Covered $10 Co-pay $10 Co-pay $10 Co-pay ♦$85 Allowance for lenses, options, and coatings $30 Co-pay 20% Discount 15% Discount $40 Co-pay $80 Co-pay $50 Co-pay No Discount 15% Discount 25% Discount 25% Discount 100% Covered 100% Covered Up to 25% Discount $10 Co-pay $10 Co-pay Up to 25% Discount $120 Allowance $100 Allowance Up to 50% Off Retail Up to 25% Off Retail $120 Allowance $100 Allowance Up to 20% off Up to 10% off Retail Retail Every 12 months Every 12 months Every 12 months $250 Off Per Eye Not Covered Not Covered Eye Exam No Eye Examination Benefit Standard Plastic Lenses Single Vision Bifocal (FT 28) Trifocal (FT 7x28) Lens Options *Progressive (Standard plastic no-line) *Premium Progressive Options *Glass lenses Polycarbonate High Index Coatings Scratch Resistant Coating Ultra Violet protection Other Options A/R, edge polish, tints, mirrors, etc. Frames Allowance Based on Retail Pricing ♦$80 Allowance Additional Eyewear **Additional Pairs of Glasses Throughout the Year Contacts Contact benefits is in lieu Of lens and frame benefit. Additional contact purchases: ***Conventional ***Disposables ♦$80 Allowance Frequency Exams, Lenses, Frames, Contacts Refractive Surgery LASIK *Co-pays for Progressive lenses may vary. This is a summary of plan benefits. The actual Policy will detail all plan limitations and exclusions. Discounts Any item listed as a discount in the benefit outline above is a merchandise discount only and not an insured benefit. Providers may offer additional discounts. ** 50% discount at Standard Optical locations only. All other Network discounts vary from 20% - 35%. ***Must purchase full year supply to receive discounts on select brands. See provider for details. ****LASIK(Refractive surgery) Standard Optical Locations ONLY. LASIK services are not an insured benefit – this is a discount only. All pre & post operative care is provided by Standard Optical only and is based on Standard Optical retail fees. Out of Network – Allowances are reimbursed at 75% when discounts are applied to merchandise. Promotional items or Online purchases not covered. For more Information please visit www.opticareofutah.com or call 800-363-0950 57 OOU.GRP.POL.C.120C Visit Our Providers Want to visit an Opticare of Utah participating preferred provider? We have over 90 providers located in the State of Utah and over 13,000 nationwide. To locate a provider in your area, view our website: www.opticareofutah.com From the home page, click an Opticare Provider and search by network choice (Select or Broad). There you will find a selection of optical chains and independent private practice offices. Needing to visit one of our nationwide providers? Simply find a provider by searching with the Out-of-State network option searchable by zip code. Need help or have questions? Contact us: (801) 869-2020 or (800) 363-0950 [email protected] 58 LIFE The Hartford 59 Basic Life and AD&D and Supplemental Life Insurance Benefit Highlights Box Elder School District What is Basic and Supplemental Life Insurance? Your employer provides, at no cost to you, Basic Life and AD&D Insurance in an amount equal to $50,000 for Class 1, and $30,000 for Class 2. Supplemental Life Insurance is coverage that you pay for. Life Insurance pays your beneficiary (please see below) a benefit if you die while you are covered. This highlight sheet is an overview of your Basic Life and AD&D Insurance and Supplemental Life Insurance. Once a group policy is issued to your employer, a certificate of Insurance will be available to explain your coverage in detail. Why do I need Life Insurance? Life Insurance provides affordable financial security for your loved ones, although when it comes down to it, contemplating some pretty unpleasant things is hard to do. But when you consider the fact that between 1995 and 1997, almost 40% of all deaths that occurred were people between the ages of 25 and 641, it’s harder to ignore. Especially when your family depends on your income. 1 Death Rates by Age, Sex and Race: 1970 to 1997, U.S. Census Bureau, Statistical Abstract of the United States, 1999, page 95. Am I eligible? How much Supplemental Life Insurance can I purchase? You are eligible if you are an active full time or part time contracted Teacher, Administration Employee, or Contracted Classified Employee.. You can purchase Supplemental Life Insurance in increments of $5,000. The maximum amount you can purchase cannot be more than $300,000, the minimum amount you can purchase cannot be less than $20,000. Basic AD&D Coverage AD&D provides benefits due to certain injuries or death from an accident. The covered injuries or death can occur up to 365 days after that accident. The Insurance pays: 100% of the amount of coverage you purchase in the event of accidental loss of life, two limbs, the sight of both eyes, one limb and the sight of one eye, or speech and hearing in both ears or quadriplegia. 75% for paraplegia or triplegia (paralysis of three limbs). One-half (50%) for accidental loss of one limb, sight of one eye, or speech or hearing in both ears or hemiplegia. One-quarter (25%) for accidental loss of thumb and index finger of the same hand or uniplegia. Your total benefit for all losses due to the same accident will not be more than 100% of the amount of coverage you purchase. Spouse and Dependent Children are not eligible for coverage under the Accidental Death and Dismemberment plan. Am I guaranteed coverage? The guaranteed issue amount is the amount of Insurance that you may elect without providing evidence of insurability. You are eligible to enroll for coverage up to the guaranteed issue amount of $200,000 no medical information is required. You must provide evidence of insurability and be approved by The Hartford to receive coverage above the guaranteed issue amount. You may need to complete a Personal Health Application. These are available from The Hartford or your employer. What is Life Conversations? Life Conversations is a comprehensive life planning program with tools, information and services you need to begin difficult life conversations with your family. Life conversations Includes Funeral Planning and Concierge Services, Estate Guidance, Beneficiary Assist and Travel Assistance. Are there other limitations to enrollment? If you do not enroll in Supplemental Life within 31 days of your first day of eligibility, you will be considered a “late entrant.” Typically, late entrants must show evidence of insurability and may be responsible for the cost of physical exams or other associated costs if they are required. Spouse Supplemental Life Insurance If you elect Supplemental Life Insurance for yourself, you may choose to purchase Spouse Supplemental Life Insurance in increments of $5,000 to a maximum of $200,000 and a minimum of $10,000. Coverage cannot exceed 100% of the amount of your combined Employee Basic and Voluntary/Supplemental Life Insurance coverage. You may not elect coverage for your Spouse if they are an active member of the armed forces of any country or international authority, or is already covered as an Employee under this policy. Spouse premium rates are based on spouse’s age. If your Spouse is confined in a hospital or elsewhere because of disability on the date his or her Insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days. Your Spouse is guaranteed coverage of up to $75,000. Your Spouse must provide evidence of insurability and be approved by The Hartford to receive coverage above the guaranteed issue amount. Your Spouse may need to complete a Personal Health Application. These are available from The Hartford or your employer. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. 60 Box Elder School District Rev 06/08 Child(ren) Supplemental Life Insurance If you elect Supplemental Life Insurance for yourself, you may choose to purchase Child(ren) Supplemental Life Insurance coverage in the amount(s) of $5,000 or $10,000 for each Child– no medical information is required. You may not elect coverage for your Child if your Child is an active member of the armed forces of any country or international authority. If your dependent Child is confined in a hospital or elsewhere because of disability on the date his or her Insurance would Children are covered from 1 Day to 26 years old Children age 26 or older may be covered if they were disabled prior to attaining age 26. normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer Income Protection confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days. Spouse Basic Life Insurance Child(ren) Basic Life Insurance Your employer provides, at no cost to you, Spouse Basic Life Insurance in an amount equal to $10,000. Your employer provides, at no cost to you, Child(ren) Basic Life Insurance in an amount equal to $10,000 for each child–no medical information is required. Children are covered from 1 Day to 26 years old. Does my coverage reduce as I get older? Your benefit will be reduced by 35% at age 65, by 60% of the original amount at age 70, and by 75% of the original amount at age 75. All coverage cancels at retirement. Can I keep my Life coverage if I leave my employer? Yes, subject to the contract, you have the option of: Converting your group Life coverage to your own individual policy (policies). If you leave your employer, Portability is an option that allows you to continue your Supplemental Life Insurance coverage. To be eligible, you must terminate your employment prior to Social Security Normal Retirement Age. This option allows you to continue all or a portion of your Supplemental Life Insurance coverage under a separate Portability term policy. Portability is subject to a minimum of $5,000 and a maximum of $250,000 and does include coverage for your Spouse and Child(ren). To elect Portability, you must apply and pay the premium within 31 days of the termination of your Life Insurance. Evidence of Insurability will not be required. Dependent Spouse Portability is subject to a maximum of $50,000. Dependent Child Portability is subject to a maximum of $10,000. What is the Living Benefits Option? Do I still pay my Life Insurance premiums if I become disabled? If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to receive payment of a portion of your Life Insurance. The remaining amount of your Life Insurance would be paid to your beneficiary when you die. If you become totally disabled before age 60 and your disability lasts for at least 6 months, your Supplemental Life Insurance premium may be waived. The premium for your dependent's coverage will also be waived if you are disabled and approved for waiver of premium. Important Details As is standard with most term life Insurance, this Insurance coverage includes certain limitations and exclusions: Death by suicide (two years). AD&D Insurance does not cover losses caused by or contributed by: Sickness; disease; or any treatment for either; Any infection, except certain ones caused by an accidental cut or wound; Intentionally self-inflicted injury, suicide or suicide attempt; War or act of war, whether declared or not; Injury sustained while in the armed forces of any country or international authority; Taking prescription or illegal drugs unless prescribed for or administered by a licensed physician; Injury sustained while committing or attempting to commit a felony; The injured person’s intoxication. Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of Insurance will be available to explain your coverage in detail. This Benefit Highlights Sheet is an overview of the Insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the Insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your Insurance coverage. In the event of any difference between the Benefit Highlights Sheet and the Insurance policy, the terms of the Insurance policy apply. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. 61 Box Elder School District Rev 06/08 LONG TERM DISABILITY EMI Health (Reliance Standard) 62 Plan Highlights Contributory Long Term Disability Insurance Box Elder School District COVERAGE FEATURES Disability income protection insurance provides a benefit for long term disability resulting from a covered injury or sickness. Benefits begin at the end of the elimination period and continue while you are disabled up to the maximum benefit duration. Cost of Living Adjustment Extended Disability Benefit FMLA Continuation Mental/Nervous Illness Limitation 24 month out-patient Own Occupation Coverage 24 months Offsets (such as, but not limited to, Social Security, Workers Compensation, State Disability Plans) Pre-Existing Condition Limitation 3/12 Rehabilitation provision Residual and Partial Disability Substance Abuse Limitation 24 months Survivor Benefit 3 months Work Incentive & Child Care provisions ELIGIBILITY Each Active, Full-time employee working 20 or more hours per week, earning an annual salary of at least $15,000, except any person working on a temporary or seasonal basis. BENEFIT AMOUNT You may elect a monthly benefit equal to 66.67% of your covered earnings, up to a maximum benefit of $10,000 per month. ELIMINATION PERIOD 180 consecutive days of total disability VALUE ADDED SERVICES Travel Assistance Service MAXIMUM BENEFIT DURATION Benefits will not extend beyond the longer of: Social Security Normal Retirement Age or Duration of Benefits below: EXCLUSIONS Benefits will not be payable for any disability caused by: an intentionally selfinflicted injury; an act of war (declared or undeclared); commission of a felony; injury or sickness occurring while confined in any penal or correctional institution. Age at Disablement Duration of Benefits 61 or less to age 65 62 63 3 years 64 65 2 years 66 67 68 69 or more 1 year For a comprehensive list of exclusions, limitations, and any applicable benefit offsets, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefits. This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS-6564, et al. CONTRIBUTION REQUIREMENTS Coverage is 100% employee paid. 63 EF-0021 (LTD) www.RelianceStandard.com FLEXIBLE SPENDING PLAN (SECTION 125) National Benefit Services 64 CAFETERIA PLAN Box Elder School District Box Elder School District has established a "Cafeteria Plan" to help you pay for your out-of-pocket medical expenses. One of the most important features of our Plan is that the benefits being offered are generally ones that you are already paying for, but normally with money that has first been subject to income and Social Security taxes. Under our Plan, these same expenses will be paid for with a portion of your pay before Federal income or Social Security taxes are withheld. This means that you will pay less tax and have more money to spend and save. However, if you received a reimbursement for an expense under the Plan, you cannot claim a Federal income tax credit or deduction on your return. GENERAL PLAN INFORMATION Plan Name: Box Elder School District Cafeteria Plan Address: .................................. 960 South Main Street Brigham City, UT 84302 Telephone: ............................................. (435)734-4800 Tax I.D. Number:....................................... 87-6000480 Plan Number: ......................................................... 501 Plan Effective Date: ....................................... 9/1/1996 Amended:....................................................... 9/1/2012 Plan Year End: ......................................... August 31st Maximum Medical Limit: ................................. $7,500 Maximum Dependent Care Limit: .................. $5,000 Grace Period: .................................................. 75 Days Run-out Period: .............................................. 75 Days Plan Administrator: .......... Box Elder School District Company Contact: ............................ Maegan Heiner CONTRIBUTIONS Before each Plan Year begins, you will select the benefits you want and how much of the contributions should go toward each benefit. It is very important that you make these choices carefully based on what you expect to spend on each covered benefit or expense during the Plan Year. Generally, you cannot change the elections you have made after the beginning of the Plan Year. However, there are certain limited situations when you can change your elections if you have a “change in status”. Please refer to your Summary Plan Description for a change in status listing. ELIGIBILITY You will be eligible to join the Plan following your date of employment. You will enter the Plan on the first day of the month following your date of employment. BENEFITS HIGHLIGHTS Under our Plan, you can choose the following benefits. Health Flexible Spending Account: The Health Flexible Spending Account (FSA) enables you to pay for expenses allowed under Section 105 and 213(d) of the Internal Revenue Code which are not covered by our insured medical plan and save taxes at the same time. The most that you can contribute to your Health Flexible Spending Account each Plan Year is $7,500. If you participate in a Health Savings Account (HSA) benefit you cannot participate in the Full Health Flexible Spending Account benefit, but you can participate in the Limited Health Flexible Spending Account Benefit. Health Savings Account Benefit: You may contribute to a Health Savings Account, which enables you to pay for expenses which are not covered by a Qualified High Deductible Health Insurance Plan and save taxes at the same time. If you participate in this benefit you cannot participate in the Health Flexible Spending Account benefit, only the Limited FSA. Limited Health Flexible Spending Account: If you participate in a Health Savings Account, the Health FSA allows you to be reimbursed by the Employer for out-of-pocket preventative care, dental and/or vision expenses incurred by you and your dependents. You may not, however, be reimbursed for the cost of other health care coverage maintained outside of the Plan, or for long-term care expenses. Dependent Care Flexible Spending Account: The Dependent Care Flexible Spending Account enables you to pay for out-of-pocket, work-related dependent day-care cost with pre-tax dollars. Please see Summary Plan Description for definition of eligible dependent. The law places limits on the amount of money that can be paid to you in a calendar year. Generally, your reimbursement may not exceed the lesser of: (a) $5,000 (if you are married filing a joint return or you are head of a household) or $2,500 (if you are married filing separate returns; (b) your taxable compensation; (c) your spouse’s actual or deemed earned income. Also, in order to have the reimbursements made to you from this account be excludable from your income, you must provide a statement from the service provider including the name, address, and in most cases, the taxpayer identification number of the service provider on your tax form for the year, as well as the amount of such expense as proof that the expense has been incurred. Premium Expense Account: A Premium Expense Account allows you to use taxfree dollars to pay for certain premium expenses under various insurance programs that we offer you. Please note: Policies other than company sponsored 65 policies (i.e. spouse's or dependents' individual policies etc.) may not be paid through the Cafeteria Plan. Furthermore, qualified long-term care insurance plans may not be paid through the Cafeteria Plan. BENEFITS PAYMENT During the course of the Plan Year, you may submit requests for reimbursement of expenses you have incurred. Expenses are considered “incurred” when the service is performed, not necessarily when it is paid for. You can get a claim form at www.NBSbenefits.com for reimbursement. Any monies left at the end of the Plan year will be forfeited. You must submit claims no later than 75 Days after the end of the Plan Year for the Health Flexible Spending Account and the Dependent Care Flexible Spending Account. However, if you have unused contributions in your Health Care Expense Account from the immediately preceding plan year, and you incur qualified medical care expenses during the grace period; you may be reimbursed for those expenses as if the expenses had been incurred in the prior plan year. HIGHLY COMPENSATED & KEY EMPLOYEES Under the Internal Revenue Code, "highly compensated employees" and "key employees" generally are Participants who are officers, shareholders or highly paid. If you are within these categories, the amount of contributions and benefits for you may be limited so that the Plan as a whole does not unfairly favor those who are highly paid, their spouses or their dependents. Please refer to your Summary Plan Description for more information. You will be notified of these limitations if you are affected. FAMILY AND MEDICAL LEAVE ACT Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan becomes subject to the requirements of the Family and Medical Leave Act of 1993 and regulations thereunder, this Plan shall be operated in accordance with proposed Regulation 1.125-3. ADDITIONAL PLAN INFORMATION As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirements Income Security Act of 1974 (ERISA). Please refer to your Summary Plan Description for more information on your ERISA rights. Updated June 5, 2012 (801) 532-4000 - Salt Lake City, UT 66 ADDITIONAL INFORMATION 67 IMPORTANT INFORMATION REGARDING HEALTH CARE REFORM AND CHANGES TO YOUR BENEFITS Notice Lifetime Limit No Longer Applies and Enrollment Opportunity The lifetime limit on the dollar value of benefits under Altius Health Plans no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. For more information contact Altius Health Plans or Box Elder School District Human Resources. Notice of Opportunity to Enroll in connection with Extension of Dependent Coverage to Age 26 Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because of the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in Box Elder School District’s group health plan coverage. Individuals may request enrollment for such children for 30 days from the date of notice. Enrollment will be effective September 1, 2012. For more information contact Altius Health Plans or Box Elder School District Human Resources. Health Care Reform Impacts OTC Purchases Beginning Jan. 1, 2011 The Health care reform Legislation signed into law in March 2010 by the President will impact over the counter (OTC) purchases with Health Care FSA, HRA and HSA accounts beginning January 1, 2011. OTC drugs, medicines and biological remain eligible with a directive from a provider. You may still be reimbursed for these items; however, you must obtain a letter of medical necessity from your provider and submit a copy of the letter along with the receipt as a manual reimbursement. It is important to note that not all OTC items will be affected; items such as band aids, contact lens cleaning solution, thermometers, etc. will remain eligible without a letter of medical necessity. The items affected include items in the following categories: o o o o o o o Acid Controllers Allergy & Sinus Antibiotic Products Anti-Diarrheal Anti-Gas Anti-Itch & Insect Bite Baby Rash Ointments / Cream o o o o Cold Sore Remedies Cold, Cough & Flu Digestive Aids Feminine Anti-Fungal / Anti-Itch o Hemorrhoid Preps o Laxatives o o o o o Motion Sickness Pain Relief Respiratory Treatment Sleep Aids & Sedatives Stomach Remedies Please be sure to take these changes into account when making your election. 68 Medicare Part D IF… − You or your spouse are age 65 or older; − You or your spouse are eligible for Medicare due to having end stage renal disease, or − You or your spouse are eligible for Medicare due to disability – Then this information is for you Box Elder School District has determined that the prescription drug coverage offered by Altius Health Plans is expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage. Because your existing coverage is at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in Medicare prescription drug coverage. Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from October 15th – December 7th. You should also know that if you drop or lose your coverage through Box Elder School District and don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more to enroll in Medicare prescription drug coverage later. If you go 63 days or longer without prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage, your monthly premium will go up at least 1% per month for every month that you did not have coverage. For example, if you go nineteen months without coverage, your premium will always be at least 19% higher than what many other people pay. You’ll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to enroll. For more information about this notice or your current prescription drug coverage… If you have questions about this notice, check with your medical carrier at an Open Enrollment meeting or contact Human Resources. You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage changes. You also may request a Certificate of Creditable Coverage. For more information about your options under Medicare prescription drug coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more information about Medicare prescription drug plans: − Visit www.medicare.gov − Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help. − Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 69 Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage To Children And Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of January 31, 2011. You should contact your State for further information on eligibility – ALABAMA – Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-800-362-1504 ALASKA – Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA – CHIP Website: http://www.azahcccs.gov/applicants/default.aspx Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437 ARKANSAS – CHIP Website: http://www.arkidsfirst.com/ Phone: 1-888-474-8275 GEORGIA – Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid Phone: 1-800-869-1150 IDAHO – Medicaid and CHIP Medicaid Website: www.accesstohealthinsurance.idaho.gov Medicaid Phone: 1-800-926-2588 CHIP Website: www.medicaid.idaho.gov CHIP Phone: 1-800-926-2588 INDIANA – Medicaid Website: http://www.in.gov/fssa Phone: 1-800-889-9948 IOWA – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 KANSAS – Medicaid Website: https://www.khpa.ks.gov Phone: 1-800-792-4884 CALIFORNIA – Medicaid Website: http://www.dhcs.ca.gov/services/Pages/ TPLRD_CAU_cont.aspx Phone: 1-866-298-8443 COLORADO – Medicaid and CHIP Medicaid Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943 CHIP Website: http:// www.CHPplus.org CHIP Phone: 303-866-3243 FLORIDA – Medicaid Website:http://www.fdhc.state.fl.us/Medicaid/index.shtml Phone: 1-877-357-3268 MISSOURI – Medicaid Website:http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 MONTANA – Medicaid Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml Phone: 1-800-694-3084 NEBRASKA – Medicaid Website: http://www.dhhs.ne.gov/med/medindex.htm Phone: 1-877-255-3092 NEVADA – Medicaid and CHIP Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900 CHIP Website: http://www.nevadacheckup.nv.org/ CHIP Phone: 1-877-543-7669 70 KENTUCKY – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUISIANA – Medicaid Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-342-6207 MAINE – Medicaid Website: http://www.maine.gov/dhhs/OIAS/publicassistance/index.html Phone: 1-800-321-5557 NEW HAMPSHIRE – Medicaid Website: www.dhhs.nh.gov/ombp/index.htm Phone: 603-271-4238 NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 1-800-356-1561 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 MASSACHUSETTS – Medicaid and CHIP Medicaid & CHIP Website: http://www.mass.gov/MassHealth Medicaid & CHIP Phone: 1-800-462-1120 MINNESOTA – Medicaid Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone (Outside of Twin City area): 800-657-3739 Phone (Twin City area): 651-431-2670 NEW YORK – Medicaid NEW MEXICO – Medicaid and CHIP Medicaid Website: http://www.hsd.state.nm.us/mad/index.html Medicaid Phone: 1-888-997-2583 CHIP Website: http://www.hsd.state.nm.us/mad/index.html Click on Insure New Mexico CHIP Phone: 1-888-997-2583 TEXAS – Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 NORTH CAROLINA – Medicaid Website: http://www.nc.gov Phone: 919-855-4100 NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 OKLAHOMA – Medicaid UTAH – Medicaid Website: http://health.utah.gov/upp Phone: 1-866-435-7414 VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 VIRGINIA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Medicaid Website: http://www.dmas.virginia.gov/rcp-HIPP.htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1-866-873-2647 OREGON – Medicaid and CHIP Medicaid & CHIP Website: http://www.oregonhealthykids.gov Medicaid & CHIP Phone: 1-877-314-5678 PENNSYLVANIA – Medicaid Website:http://www.dpw.state.pa.us/partnersproviders/medicalas sistance/doingbusiness/003670053.htm Phone: 1-800-644-7730 RHODE ISLAND – Medicaid Website: www.dhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 WASHINGTON – Medicaid Website: http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA – Medicaid Website: http://www.wvrecovery.com/hipp.htm Phone: 304-342-1604 WISCONSIN – Medicaid Website: http://www.badgercareplus.org/pubs/p-10095.htm Phone: 1-800-362-3002 WYOMING – Medicaid Website: http://www.health.wyo.gov/healthcarefin/index.html Phone: 307-777-7531 To see if any more States have added a premium assistance program since January 31, 2011, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Ext. 61565 OMB Control Number 1210-0137 (expires 09/30/2013) 71 PREMIUMS 72 Altius Premiums September 1, 2012 through August 31, 2013 Box Elder School District employees will pay the health premiums as described below ADMINISTRATORS Total Monthly Premium Employee Monthly Cost Single $330.71 $82.68 1000/3000 Altius Two-Party $744.10 $186.03 Family $1071.51 $267.88 Single $345.25 $103.58 750/2250 Altius Two-Party $776.81 $233.04 Family $1118.61 $335.58 CERTIFIED Total Monthly Premium Contract (FTE) 0.50 0.60 0.75 0.80 1.00 Single $330.71 $187.58 $158.95 $116.01 $101.70 $44.45 1000/3000 Altius Two-Party Family $744.10 $1071.51 Employee Monthly Cost $422.05 $607.76 $357.64 $515.01 $261.03 $ 375.89 $228.83 $329.51 $100.01 $144.01 750/2250 Altius Single Two-Party Family $345.25 $776.81 $ 1118.61 Employee Monthly Cost $203.59 $458.08 $659.64 $175.26 $394.34 $567.85 $132.77 $298.72 $430.16 $118.60 $266.85 $384.26 $61.94 $139.36 $200.68 CLASSIFIED 1000/3000 Altius Total Monthly Premium Hours Per Week 20 27.5 30 32.5 35 37.5+ Single $ 330.71 $ 187.58 $ 173.27 $ 158.95 $ 144.64 $ 130.33 $ 44.45 750/2250 Altius Two-Party Family $ 744.10 $ 1071.51 Employee Monthly Cost $ 422.05 $ 607.76 $ 389.85 $ 561.39 $ 357.64 $ 515.01 $ 325.44 $ 468.64 $ 293.23 $ 422.26 $ 100.01 $ 144.01 Single Two-Party Family $ 345.25 $ 776.81 $ 1118.61 Employee Monthly Cost $ 203.59 $ 458.08 $ 659.64 $ 189.43 $ 426.21 $ 613.75 $ 175.26 $ 394.34 $ 567.85 $ 161.10 $ 362.47 $ 521.95 $ 146.93 $ 330.59 $ 476.06 $ 61.94 $ 139.36 $ 200.68 High Deductible Health Plan / HSA ADMINISTRATORS Total Monthly Premium Employee Monthly Cost Single $299.46 $74.87 1200/2400 Altius Two-Party $673.78 $168.45 Family $970.25 $242.56 CERTIFIED Total Monthly Premium Contract (FTE) 0.50 0.60 0.75 0.80 1.00 1200/2400 Altius Two-Party Family $ 673.78 $ 970.25 Employee Monthly Cost $ 163.95 $ 368.89 $ 531.21 $ 136.85 $ 307.92 $ 443.40 $ 96.20 $ 216.45 $ 311.69 $ 82.65 $ 185.96 $ 267.79 $ 28.45 $ 64.01 $ 92.17 Single $ 299.46 73 CLASSIFIED 1000/3000 Altius Single $ 299.46 Two-Party Family $ 673.78 $ 970.25 Employee Monthly Cost $ 163.95 $ 368.89 $ 531.21 $ 150.40 $ 338.41 $ 487.31 $ 136.85 $ 307.92 $ 443.40 $ 123.30 $ 277.43 $ 399.50 $ 109.75 $ 246.94 $ 355.60 $ 28.45 $ 64.01 $ 92.17 Total Monthly Premium Hours Per Week 20 27.5 30 32.5 35 37.5+ COBRA 1000/3000 Altius Total Monthly Premium Single $ 337.32 Total Monthly Premium Single $ 305.44 Two-Party $ 758.98 750/2250 Altius Family $ 1092.94 Single $ 352.15 Two-Party $ 792.35 Family $ 1140.98 HSA Altius Two-Party $ 687.25 Family $ 989.65 Dental Select Premiums Single Two-Party Family Gold $ 29.63 $ 51.69 $ 79.51 Platinum $ 35.97 $ 62.60 $ 96.37 Indemnity $ 54.31 $ 99.91 $ 157.52 Opticare Premiums 70C 120C Single $ 3.11 $ 4.35 Two Party $ 6.03 $ 8.44 74 Family $ 7.91 $ 11.07 GBS B E N E F I T S, I N C. 465 South 400 East, Suite 300 Salt Lake City, UT 84111 Phone: (801) 364-7233