altius peak plus traditional plan

Transcription

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
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
GBS Benefits, Inc.
465 South 400 East, Ste 300
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).
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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
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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.
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MEDICAL
Altius Health Plans
Traditional $750 Deductible Plan
Traditional $1,000 Deductible Plan
QHDHP $1,200 Deductible Plan
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ALTIUS PEAK PLUS TRADITIONAL PLAN
UTLPPT87 750-R15_30_60B-C80 NSB
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,
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%*
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
UTLPPT87 750-R15_30_60B-C80 NSB
Participating
Providers
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.
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
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
10
UTLPPT87 750-R15_30_60B-C80 NSB
Participating
Providers
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
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.
11
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
September 1, 2012
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
20%* AD
30%* AD
20%* AD
30%* AD
20%* AD
30%*
year.
20%* AD
Participating
Providers Only
10%* AD
30%* AD
20%* AD
30%* AD
20%* AD
30%* AD
20%* AD
30%* AD
20%* AD
30%* AD
20%* AD
30%* AD
year.
EMERGENCY CARE
YOU PAY
20%* AD
20%* AD
20%* AD
30%*
20%* AD
Participating
Benefit Applies
12
1
UTLPPT87 1000-R15_30_60B-C80 NSB
Participating
Providers
September 1, 2012
INPATIENT SERVICES
Non-Participating
Providers
YOU PAY
speech therapy provided on an inpatient basis. Limited to 60 days per member per
Anesthesiologist
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.
20%* AD
30%* AD
20%* AD
30%* AD
20%* AD
Participating
Benefit Applies
coinsurance.
YOU PAY
20%* / 30%*
30%* AD / 40%* AD
20%* / 30%*
Participating
Providers Only
PRESCRIPTION DRUGS
YOU PAY
pharmacy: insulin, Imitrex, Symlin, Byetta, glucagon, Lovenox, and epinephrine kits Non-Preferred: $60
(such as Epi-Pen).
Participating
Providers Only
Non-Preferred: $180
Participating
Providers Only
Prescription Drugs Mail Order – 90-day supply of maintenance
medication.
YOU PAY
Inpatient Services
20%* AD
30%* AD
Outpatient Services
20%* AD
30%* AD
13
UTLPPT87 1000-R15_30_60B-C80 NSB
Participating
Providers
September 1, 2012
ALLERGY CONDITIONS
Serum
Injections
Non-Participating
Providers
YOU PAY
20%* AD
20%* AD
20%* AD
OTHER BENEFITS
30%* AD
30%* AD
30%* AD
YOU PAY
member.
50% AD
Participating
Benefit Applies
50% AD
50% AD
20%* AD
30%* AD
20%* AD
30%* AD
20%* AD
30%* AD
50% AD
Participating
Providers Only
20% AD
50% AD
50%* AD
50%* AD
20%* AD
30%* AD
20%* AD
20%* AD
30%* AD
30%* AD
50% AD
50% AD
agency.
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.
* 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
••• 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
ALTIUS PEAK PLUS QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN
UTPPQ861200-B-R10_25_50-C80
September 1, 2012
Participating
Providers
Non-Participating
Providers
$1,200* / $2,400*
$2,400* / $4,800*
$3,500 / $7,000
$7,000 / $14,000
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
20%* AD
40%* AD
20%* AD
40%* AD
20%* AD
40%*
After Participating
Deductible
year.
20%* AD
Participating
Providers Only
20%* AD
40%* AD
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.
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
UTPPQ861200-B-R10_25_50-C80
Participating
Providers
September 1, 2012
EMERGENCY CARE
Non-Participating
Providers
YOU PAY
20%* AD
20%* AD
20%* AD
40%*
After Participating
Deductible
20%* AD
Participating
Benefit Applies
INPATIENT SERVICES
YOU PAY
20%* AD
40%* AD
20%* AD
40%* AD
Anesthesiologist
20%* AD
40%* AD
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
speech therapy provided on an inpatient basis. Limited to 60 days per member, per
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.
YOU PAY
20%* AD
40%* AD
20%* AD
40%* AD
20%* AD
Participating
Benefit Applies
coinsurance.
YOU PAY
20%* AD / 30%* AD
40%* AD / 50%* AD
20%* AD / 30%* AD
Participating
Providers Only
PRESCRIPTION DRUGS
YOU PAY
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
YOU PAY
Inpatient Services
20%* AD
40%* AD
Outpatient Services
20%* AD
40%* AD
19
UTPPQ861200-B-R10_25_50-C80
Participating
Providers
September 1, 2012
ALLERGY CONDITIONS
Non-Participating
Providers
YOU PAY
20%* AD
40%* AD
Serum
20%* AD
40%* AD
Injections
20%* AD
40%* AD
OTHER BENEFITS
YOU PAY
member.
50%* AD
Participating
Benefit Applies
50%* AD
50%* AD
20%* AD
40%* AD
20%* AD
40%* AD
20%* AD
40%* AD
50%* AD
Participating
Providers Only
20%* AD
50%* AD
50%* AD
50%* AD
20%* AD
40%* AD
20%* AD
40%* AD
20%* AD
40%* AD
50%* AD
50%* AD
agency.
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.
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
••• 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
••• 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
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.
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.
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.
Wasatch Endoscopy Center1
(Oral Surgery Only)
1220 E. 3900 S., #1B
8822 Redwood Rd. #C113
West Jordan 801-495-1064
San Juan County
Huntsman Cancer Hospital
Blue Mountain Hospital
1950 Circle of Hope Dr.
802 S. 200 W.
Blanding 435-678-3993
Jordan Valley Hospital
San Juan Hospital
3580 W. 9000 S.
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
Utah Surgical Center1
3715 W. 4100 S.
151 E. 5600 S. #104
Family Surgical Suite
1
The Center of Surgical Arts1
(Oral Surgery Only)
530 E. 500 S.
Fillmore Community
Medical Center
300 N. Hospital Dr.
Price 435-637-4800
1050 E. South Temple
South Towne Surgery Center1
Juab County
Cache County
24 S. 1100 E., #103
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
Pioneer Valley Hospital
3460 Pioneer Pkwy.
Primary Children’s Medical Center
100 N. Mario Capecchi Dr.
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
UUHC Sugarhouse Center
UUHC Greenwood Center
1138 E. Wilmington Ave.
7495 S. State Street
Midvale 801-887-2400
Summit County
UUHC Redwood Center
UUHC Redstone Health Center
1525 W. 2100 S.
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
2084 N. Robins Dr. (1700 W.), #A
Layton 801-773-7232
First Med North Bountiful
214 W. 1500 S.
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
415 N. Main St.
Spanish Fork 801-798-9700
First Med at Salt Lake Industrial Clinic
Riverwoods Urgent Care LLC
441 S. Redwood Rd.
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.)
830 N. 2000 W.
Pleasant Grove 801-756-3511
First Med West
Tri-City Medical
8822 S. Redwood Rd., #E122
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.
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
Magna Center for Family Medicine
8211 W. 3500 S.
Magna 801-250-9638
Nurse Practitioner Healthcare Associates
4568 S. Highland Dr., #290
Rocky Mountain Care Clinic
4088 W. 1820 S.
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
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.
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.
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.
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
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
461 S. 400 E.
Davis County
4745 S. 3200 W.
2084 N. Robins Dr. (1700 W.), #A
Layton 801-773-7232
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
1365 W. 1000 N.
Copperview Medical Center Urgent Care3
3556 W. 9800 S., #101
Granger Medical Clinic
3725 W. 4100 S.
West Valley 801-965-3600
Holladay Family Practice
3920 S. 1100 E., #220
Jordan Meadows Medical Center
3354 W. 7800 S.
Jordan Valley Family Health
3570 W. 9000 S., #100
Maria A. Oneida
Utah County
Alpine Pediatrics
1912 W. 930 N.
American Fork Clinic
226 N. 1100 E., #A
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.
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
Southpoint Pediatrics
Bear Lake Community Health Center
9071 S. 1300 W., #301
2 Appointment Required
3 Appointment Preferred
220 Millpond Rd. #100
Stansbury Park 435-843-3000
3570 W. 9000 S., #200
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.
Willowcreek Pediatrics
7138 S. 2000 E., #106
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.
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
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.
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
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
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
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:
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
Schedule
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 - 4 + surfaces primary or permanent
Resin - 1 surface anterior
Resin - 2 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 - 4 + surfaces - posterior prim. or perm.
Inlay - porcelain/ceramic 1 surface
Inlay - porcelain/ceramic - 2 surfaces
Onlay - porcelain/ceramic - 2 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
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
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
In-Network Patient
Co-Pay or Discount
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
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
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 - 3/4 cast base metal
Crown - 3/4 porcelain/ceramic (note 3)
Crown - full cast predominantly base 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
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
In-Network Patient
Co-Pay or Discount
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
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
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
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
Co-Pay Plan
Platinum Network - 2068 Providers
PREVENTIVE
Contracted Dentist
100%
Schedule
Schedule
BASIC
MAJOR
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
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
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 - 4 + surfaces primary or permanent
Resin - 1 surface 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 - 4 + surfaces - posterior prim. or perm.
Inlay - porcelain/ceramic 1 surface
Crown - porcelain/ceramic substrate (note 3)
Crown - porcelain fused to high noble metal (note 2)
Crown - 3/4 cast predominately base metal
Crown - 3/4 porcelain ceramic (note 3)
Crown - full cast predominately base 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
In-Network Patient
Co-Pay or Discount
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
Core build-up including any pins
Pin retenion - per tooth in addition to restoration
Cast post & core in addition to crown
Prefab. post & core in addition to crown
Anterior bonding per tooth
Labial veneer resin laminate (lab)
Labial veneer porcelain laminate (lab)
Temporary crown (fractured tooth)
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
In-Network Patient
Co-Pay or Discount
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
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
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 - 3/4 cast base metal
Crown - 3/4 porcelain/ceramic (note 3)
Crown - full cast predominantly base 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
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
In-Network Patient
Co-Pay or Discount
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
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
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
In & Out-of-Network
Plan Payment
N/C
0
0
0
0
0
0
0
80% R&C
Indemnity Classic Plan - Max Plan
PREVENTIVE
Platinum Network - 2068 Providers
Contracted Dentist
80%
80% of R&C
80%
60% of R&C
BASIC
3 Month Waiting Period
MAJOR
50%
40% of R&C
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
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
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
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
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
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
Rev 06/08
LONG TERM
DISABILITY
EMI Health
(Reliance Standard)
62
Plan Highlights
Contributory Long Term Disability Insurance
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 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/
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/
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
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
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
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
$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
$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
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
$ 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
$ 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
Single
$299.46
$74.87
1200/2400 Altius
Two-Party
$673.78
$168.45
Family
$970.25
$242.56
CERTIFIED
Contract (FTE)
0.50
0.60
0.75
0.80
1.00
1200/2400 Altius
Two-Party
Family
$ 673.78
$ 970.25
$ 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
$ 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
Hours Per Week
20
27.5
30
32.5
35
37.5+
COBRA
1000/3000 Altius
Single
$ 337.32
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
Phone: (801) 364-7233

altius peak plus traditional plan

Transcription

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