Active Employees BENEFITS GUIDE - Okaloosa County School District
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2022
BENEFITS GUIDE
Active Employees
Introducing...
OCSD 2022 BENEFIT RESOURCES PAGE
Visit the link below for helpful information about your benefits.
okaloosaschools.com/depts/rm/open-enrollment
CONTACT
INFO
Open Enrollment Period: Benefits Service Center:
1-800-906-9159
th
October 11 Self-enroll online using the
web enrollment system at:
- thru - mybensite.com/okaloosa.
th
November 9
Table of Contents
2 Benefit Resources
Important Dates to Remember:
Your open enrollment dates are:
3 Table of Contents Oct. 11, 2021 through Nov. 9, 2021
Your plan year dates are:
4 Key Things To Know Jan. 1, 2022 through Dec. 31, 2022
6 Frequently Asked Questions
7 How to Enroll
ONLINE RESOURCES:
>>Click to view important information
on how to enroll, the enrollment link,
10 Medical Rates plan information, and more!
• OCSD Benefit Resources Page:
okaloosaschools.com/depts/rm/
14 UnitedHealthcare
open-enrollment
• OCSD Benefits Website:
20 Healthcare Reimbursement Account (HRA) okaloosaschools.com/depts/rm
• Enroll Online:
mybensite.com/okaloosa
21 Flexible Spending Accounts (FSA)
22 Dental Plan
IMPORTANT NOTES:
26 Vision Plan • Additional Life Special Enrollment Opportunity:
Standard Insurance Company (The Standard) is
allowing a special enrollment opportunity on
28 Group Life/AD&D Insurance the Additional Employee Life (Active) program.
Employees may elect initial coverage or
increase existing coverage up to $150,000
30 Long-Term Disability Insurance guaranteed issue amount effective 1/1/2022
without Evidence of Insurability (EOI). This is a
one time opportunity.
33 Beyond Your Benefits
• You CANNOT enroll online until Open
Enrollment begins on Oct. 11, 2021.
35 Creditable Coverage Notice
37 CHIP Notice
If you (and/or your dependents) have
38 Health Insurance Marketplace Coverage
Medicare or will become eligible for
Medicare in the next 12 months, a Federal
40 Benefits Directory law gives you more choices about your
prescription drug coverage. Please see
page 35 for more details.
mybensite.com/okaloosa 3
Key Things To Know
Medical Coverage
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For a complete list of IRS qualifying life events, please visit
Welcome To Your 2022 OCSD healthcare.gov./glossary/qualifying-life-event/.
Benefits Open Enrollment!
Open Enrollment is your one-time opportunity to review About Your Open Enrollment
your current benefit elections and make any changes If you wish to make a plan change, you MUST log in to
that might be needed for you and your family – unless mybensite.com/okaloosa. Please note that you will have
you have a qualifying life-change event during the 2022 access at the beginning of Open Enrollment on Oct. 11,
calendar year. Please take the time to familiarize yourself 2021.
with the guide’s contents. We hope that after you review
this guide, you will have clear understanding of the
• Be sure to check your December pay statement to
changes that will be effective Jan. 1, 2022, and how they
ensure your elections have been properly applied.
may impact you and your covered dependents.
• If you elect Health FSA or Dependent Care FSA, your
Enrollment Deadlines election will be reflected on your January pay statement.
• The Healthcare Reimbursement Account is
The deadline for all elections, including Flexible automatically funded with $750 for single coverage,
Spending Accounts (FSAs), is Nov. 9, 2021. The benefit $1,100 for Employee
elections you currently have in place will roll over + Spouse or Employee + Child(ren), and $1,500 for
automatically, with the exception of FSAs (Health & family coverage for all medical plans. If you enroll in a
Dependent Care), which require re-enrollment. Your district medical plan no action is required.
deductions will reflect the 2022 premium amounts. • Be sure to update your beneficiaries. It is important
for your proceeds to go to your intended designees.
Once the deadline passes, you will not be able to add or
delete dependents from any coverage and/or change • Starting on January 1, 2022, Standard Insurance
your plan options without an IRS qualifying life event – Company (The Standard) will be the new provider for
such as marriage or the birth of a child. A spouse the group Life and Accidental Death &
changing jobs (retiring, losing a job, or getting a new job) Dismemberment insurance.
may also qualify as a qualifying life event.
4 mybensite.com/okaloosaKey Things To Know
2022 Benefit Options • Travel Assistance Program - If you have a medical
Okaloosa County School District (OCSD) offers a wide range emergency while you are more than 100 miles away from
of benefits to eligible employees. During Open Enrollment, home, you don’t have to face it alone. With one simple phone
you may make changes to your current elections or add new call, you can be connected to Assist America’s staff of
coverages. To make changes for the calendar year, you MUST medically trained, multilingual professionals who can advise
complete your enrollment elections online at you in a medical emergency, 24 x 7.
mybensite.com/okaloosa.
• Medical Insurance - UnitedHealthcare will offer three Your Travel Assistance Program offers a variety
(3) health plans for 2022: UnitedHealthcare Base Plan, of 24-hour-a-day services in more than 200 countries and
UnitedHealthcare Buy-Up Plan and UnitedHealthcare Copay territories worldwide — and each one is just a phone call away at
Plan. To find a physician or check on your deductible or 1-800-872-1414.
claims, visit myuhc.com. All plans are available with
Employee, Employee + Spouse, Employee + Children, or
Family coverage.
Benefits Eligibility
New Hires - Newly elected employee benefits become
• Dental Insurance - Delta Dental is pleased to continue
effective the first of the month following a 60-day grace period
offering dental insurance for 2022. To find a list of providers,
visit deltadentalins.com. from the day you begin employment.
• Vision - EyeMed will continue as the District’s vision
insurance provider for 2022. You may choose from a low plan
or high plan. Is your dependent a valid
• The Healthcare Reimbursement Account is automatically
funded with $750 for single coverage, $1,100 for Employee + dependent?
Spouse or Employee + Child(ren), and $1,500 for family
coverage for all medical plans. This money is available Jan. 1, If any of the dependents you currently cover are
2022. If you enroll in a district medical plan no action is not your legal dependents or do not meet the
required. eligibility dependent definition requirements,
• Flexible Spending Accounts - To utilize an FSA for
healthcare reimbursement, you MUST enroll each year.
Open Enrollment is an opportunity to remove
Your FSA may be used to fund your authorized out-of-pocket them from your coverage without question.
medical, dental, or vision expenses with pretax dollars. The The School District reserves the right to audit
maximum annual FSA contribution has increased to $2,750 employee benefits enrollment at any time. You
per employee, per plan year.
• Dependent Care Reimbursement - To utilize an FSA for must enter a valid Social Security number in your
dependent care reimbursement, you MUST enroll each Web Benefits profile for every dependent. This is
year. The annual amount you can contribute is $5,000 per mandatory and required by the IRS. Please log
household, per plan year. Dependent Care FSA may be used
for both eligible children and eligible adults. into your account and ensure all the Social
• Long-Term Disability (LTD) - All benefit eligible employees Security numbers associated with your family
may elect to participate in the voluntary, employee-paid 90- members are listed correctly.
day or 180-day Long-Term Disability Insurance program, but
will be subject to medical underwriting. District-paid disability
Eligible Dependents include:
coverage is available to employees who do not elect the • Spouse
district-provided medical insurance. Current employees • Children
applying for voluntary disability coverage MUST complete an
Evidence of Insurability (EOI) application and go through • Newborn Children
medical underwriting. You MUST print, complete, and return • Disabled Children
this form to the LTD provider. The provider will send you a • Stepchildren
letter regarding your approval status. • Grandchildren if under court-ordered
• Group Life and AD&D Insurance - The District provides
$25,000 of basic term life insurance to all employees. Full- legal custody
time employees have the option to purchase Additional Life
and Dependent Life insurance coverage with EOI approval.
mybensite.com/okaloosa 5Frequently Asked Questions
Top FAQs for 2022:
A. Because this is a changes-only enrollment, you are not required to login.
However, if you wish to start or continue participation in a Flexible Spending
or Dependent Care Account, you MUST enroll at mybensite.com/okaloosa. If
you do not enroll, you will not be able to participate in the FSA for 2022.
Q. Who do I contact if I am having trouble getting logged in to
mybensite.com/okaloosa?
A. Contact the Benefits Service Center at 1-800-906-9159.
Q. How do I add family coverage through mybensite.com/okaloosa?
A. In order to elect family coverage, you MUST first enroll each family member
by adding their date of birth and SSN on the dependents tab found in your
profile. Check the box next to their name within each of the coverage tabs.
Evidence of Eligibility (EOE) is required. It is a legal requirement to provide
dependent documentation to OCSD Risk Management.
Q. When can I log into mybensite.com/okaloosa to make my insurance changes
for 2022?
A. You can make changes during Open Enrollment from Oct. 11, 2021 through
Nov. 9, 2021. You can access your profile at any time during the year.
Q. How do I verify that the changes I elect are completed?
A. Once you have completed a review of your elections, you will have the
opportunity to print or email a copy of your Benefits Confirmation Statement.
Be sure to review your December paystub to verify that any changes made
are correctly reflected in your deductions. Please note that FSA elections will
not be reflected until your paycheck is received at the end of January. Please
immediately contact the Risk Management office at (850) 833-3190 if any
errors are found.
6 mybensite.com/okaloosaHow to Enroll
mybensite.com/okaloosa
Before You Start Your Web Enrollment
Thoroughly review your enrollment materials. If you need enrollment assistance, contact the Benefits Service Center
at 1-800-906-9159. You may enroll online at mybensite.com/okaloosa. Please note that online enrollment is only
available during Open Enrollment.
Be sure to have the following information available before you begin the enrollment process:
• Dates of birth and Social Security numbers for all your dependents.
• Beneficiary names, date of birth, relationship, Social Security number, address and telephone number.
• You can upload dependent documentation such as marriage licenses and birth certificates at
this time.
mybensite.com/okaloosa 7How to Enroll
mybensite.com/okaloosa
1 Create an Account/Log in
Go to mybensite.com/okaloosa
You will need to create an account. You will need:
• Your last name
• Your date of birth
• The last four digits of your SSN
• A valid email address (personal or work email)
If you already created an account, enter your
email address and password in the employee log
in section. If you forget your password, click the
“Forgot your password” link or contact the
Benefits Service Center at 1-800-906-9159.
2 Benefits Website
Inside the benefits website, you will find important
information, such as:
• Benefit summaries
3
• Forms
• Summary plan descriptions Personal Information
• Provider search directories Please verify that all the information is
• Frequently asked questions accurate. If you see any blank fields or need
• Health and wellness resources to make changes, please update the information
on the screen.
Review this information thoroughly before entering
the enrollment section of the website. It is important
that you understand your benefit options BEFORE
starting the enrollment process.
Once logged in, select the “Enroll Now” tab and then
“Continue.” Next, you will be guided through a series
of screens, each taking only a few moments to
complete. All your benefit elections will be displayed
on a cost “per paycheck” basis, based on your
specific benefit options.
8 mybensite.com/okaloosaHow to Enroll
mybensite.com/okaloosa
4 Dependent Information
THIS IS MANDATORY.
If you have a spouse or child(ren) that
you wish to cover, you must enter their
information in this section. Remember
that you will need correct names, dates of
birth and Social Security numbers for all
covered individuals. The IRS requires valid
Social Security numbers for ALL covered
dependents. Evidence of Eligibility (EOE)
is required for all dependents on the
plan. EOE is the proof of relationship
documentation to establish a dependent’s
eligibility for insurance coverage. Provide
dependent documentation to OCSD Risk
Management.
5 Benefits Selections
View the benefits selections by product (medical, dental,
vision, life insurance, disability, etc.). Each page will show
your benefits eligibility along with a cost per paycheck.
Click on the “Learn More” button for more options, such
as: expanded benefit summaries, forms, provider links and
more. After you’ve made your selection, click “continue to
next section” to save and go to the next benefit.
You MUST print, complete, and return this form to the LTD AHIO
& Life providers. The providers will then send you a letter
regarding the status of your approval for LTD and Voluntary
Life insurance.
6 Review and Submit Benefits
This is the final step. Please review your benefit selections and costs. To change your selections, click on the “Edit”
button to update your information. Once you complete your review, agree to the terms, and hit “Continue,” you can
print and/or email a Benefits Confirmation Statement for your personal records. Print and keep a record of your new
selections in a safe place as proof. We do not keep a record of your summary of selections. It is your responsibility.
mybensite.com/okaloosa 9Medical Rates
This is what YOU PAY:
SINGLE BUY-UP PLAN FAMILY BUY-UP PLAN
Buy-Up Plan (BWKB) (BWKB) (AFTER DEDUCTIBLE MET)
BUY-UP PLANS (BWKB) In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible $1,500 $3,000 $3,000 $6,000
Coinsurance Employee Pays NO COINSURANCE 20% NO COINSURANCE 20%
(After Deductible Met)
Prescription Employee Pays 0% 0% 0% 0%
(After Deductible Met)
Max Out-of-Pocket $1,500 $6,000 $3,000 $12,000
Buy-Up Rates 12-MONTH EMPLOYEE (BWKB) 9-MONTH EMPLOYEE (BWKB)
Employee OCSD Employee OCSD
BUY-UP RATES (BWKB) Rate Contribution
TOTAL
Rate Contribution
Total
Employee Only $163.60 $1,031.38 $1,194.98 $218.13 $1,375.17 $1,593.30
Employee + Spouse $758.94 $1,233.94 $1,992.88 $1,011.92 $1,645.25 $2,657.17
Employee + Child(ren) $594.99 $1,233.94 $1,828.93 $793.32 $1,645.25 $2,438.57
Employee + Family $1,750.55 $1,233.94 $2,984.49 $2,334.07 $1,645.25 $3,979.32
10 mybensite.com/okaloosaMedical Rates
Base Plan SINGLE BASE PLAN (BWQM) FAMILY BASE PLAN (BWQM)
BASE PLANS (BWQM) In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible $1,250 $2,500 $2,500 $5,000
Coinsurance Employee Pays 20% 40% 20% 40%
(After Deductible Met)
Prescription Employee Pays
20% / 30% / 50% 20% / 30% / 50% 20% / 30% / 50% 20% / 30% / 50%
(After Deductible Met)
Max Out-of-Pocket $5,000 $10,000 $5,000 $10,000
Base Plan Rates 12-MONTH EMPLOYEE (BWQM) 9-MONTH EMPLOYEE (BWQM)
Employee OCSD Employee OCSD
BASE RATES (BWQM) Rate Contribution
TOTAL
Rate Contribution
TOTAL
Employee Only $0.00 $1,031.38 $1,031.38 $0.00 $1,375.17 $1,375.17
Employee + Spouse $561.25 $1,233.94 $1,795.19 $748.33 $1,645.25 $2,393.58
Employee + Child(ren) $417.91 $1,233.94 $1,651.85 $557.21 $1,645.25 $2,202.46
Employee + Family $1,428.24 $1,233.94 $2,662.18 $1,904.32 $1,645.25 $3,549.57
Copay Plan SINGLE COPAY PLAN (BWNG) FAMILY COPAY PLAN (BWNG)
COPAY PLAN (BWNG) In-Network* Out-of-Network In-Network* Out-of-Network
Calendar Year Deductible $2,000 $4,000 $4,000 $8,000
Coinsurance Employee Pays 20% 40% 20% 40%
(After Deductible Met)
Prescription Employee Pays $15 / $40 / 50% $15 / $40 / 50% $15 / $40 / 50% $15 / $40 / 50%
(After Deductible Met)
Max Out-of-Pocket $5,000 $10,000 $5,000 $10,000
*PCP (Primary Care Physician) office services will only cost $40 per visit for in-network doctors.
Copay Rates 12-MONTH EMPLOYEE (BWNG) 9-MONTH EMPLOYEE (BWNG)
Employee OCSD Employee OCSD
COPAY RATES (BWNG) Rate Contribution
TOTAL
Rate Contribution
Total
Employee Only $0.00 $1,001.25 $1,001.25 $0.00 $1,335.00 $1,335.00
Employee + Spouse $508.80 $1,233.94 $1,742.74 $678.40 $1,645.25 $2,323.65
Employee + Child(ren) $369.65 $1,233.94 $1,603.59 $492.87 $1,645.25 $2,138.12
Employee + Family $1,350.48 $1,233.94 $2,584.42 $1,800.64 $1,645.25 $3,445.89
mybensite.com/okaloosa 11USING AN OUT-OF-NETWORK PROVIDER WILL INCUR ADDITIONAL OUT-OF-POCKET COST.
2021
2022 MEDICAL
MEDICAL PLAN
PLAN OPTION
OPTION IN-NETWORK
IN-NETWORK COMPARISON
COMPARISON CHARTS
CHARTS
UNDERSTANDING YOUR SINGLE FAMILY
MEDICAL OPTIONS BUY-UP PLAN (BWKB) BUY-UP PLAN (BWKB)
• All three medical plans provide the same benefit coverage. The differences
in the plans are your monthly premiums and out-of-pocket expenses. “YOU PAY” “YOU PAY”
BENEFIT CATEGORY
COST SHARING MAXIMUMS ARE SHOWN PER BENEFIT PERIOD (BPM) UNLESS NOTED
Deductible (DED) (Per Person/Family*) $1,500 $3,000
Coinsurance (Member Responsibility) NO COINSURANCE NO COINSURANCE
Out-of-Pocket Maximum (Per Person/Family) $1,500 $3,000
PROFESSIONAL PROVIDER SERVICES
Virtual Visits
Family Physician DED DED
Specialist DED DED
Office Services
Family Physician DED DED
Specialist DED DED
Provider Services at Hospital and ER
Family Physician DED DED
Specialist DED DED
PREVENTIVE CARE
Adult Wellness Office Services
Family Physician $0 $0
Specialist $0 $0
AGE 50+ THEN FREQUENCY SCHEDULE AGE 50+ THEN FREQUENCY SCHEDULE
Colonoscopies (Routine) APPLIES APPLIES
Covered at 100% of Allowed Amount $0 $0
Mammograms (Routine and DX) $0 $0
Well Child Office Visits (No BPM)
Family Physician $0 $0
Specialist $0 $0
EMERGENCY/URGENT/CONVENIENT CARE
Ambulance DED DED
Convenient Care Centers (CCC) DED DED
Emergency Room Facility Services
(Also see Professional Provider Services) DED DED
Urgent Care Centers (UCC) DED DED
FACILITY SERVICES - HOSP/SURG/ICL/IDTF - Unless otherwise noted, physician services are in addition to facility services. See Professional Provider Services.
Independent Clinical Lab - X-rays $0 $0
Independent Diagnostic Testing Facility - Advanced Imaging Diagnostics
(Includes Physician Services) DED DED
Inpatient Hospital (per admit) DED DED
Independent Rehab Maximum (Physical, Speech, Occupational/Cardiac/Pulmonary) (20 / 36 / 20 visits) (20 / 36 / 20 visits)
Outpatient Hospital (per visit) DED DED
Therapy at Outpatient Hospital DED DED
PRESCRIPTION DRUGS
DEDUCTIBLE NETWORK HEALTH PLAN DED NETWORK HEALTH PLAN DED
In-Network – Retail (30 days) IN-NETWORK DED THEN IN-NETWORK DED THEN
Generic/Preferred Brand/Non-Preferred $0 / $0 / $0 $0 / $0 / $0
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient Hospitalization
In-Network DED DED
Outpatient Hospitalization (per visit)
In-Network DED DED
Physician Fees for Surgical & Medical Services
In-Network DED DED
Physician Office Visit
In-Network Family Physician or Specialist DED DED
Emergency Room Facility Services (per visit)
In-Network DED DED
Provider Services at Locations other than Hospital and ER
In-Network Family Physician DED DED
In-Network Specialist DED DEDUSING AN OUT-OF-NETWORK PROVIDER WILL INCUR ADDITIONAL OUT-OF-POCKET COST.
2021 MEDICAL
2022 MEDICAL PLAN
PLAN OPTION
OPTION IN-NETWORK
IN-NETWORK COMPARISON
COMPARISON CHARTS
CHARTS
UNDERSTANDING YOUR SINGLE/FAMILY SINGLE/FAMILY
MEDICAL OPTIONS BASE PLAN (BWQM) COPAY PLAN (BWNG)
• All three medical plans provide the same benefit coverage. The differences
in the plans are your monthly premiums and out-of-pocket expenses. “YOU PAY” “YOU PAY”
BENEFIT CATEGORY
COST SHARING MAXIMUMS ARE SHOWN PER BENEFIT PERIOD (BPM) UNLESS NOTED
Deductible (DED) (Per Person/Family) $1,250 / $2,500 $2,000 / $4,000
Coinsurance (Member Responsibility) 20% 20%
Out-of-Pocket Maximum (Per Person/Family) $5,000 / $5,000 $5,000 / $5,000
PROFESSIONAL PROVIDER SERVICES
Virtual Visits
Family Physician DED + 20% $10, NO DED
Specialist DED + 20% $10, NO DED
Office Services
Family Physician DED + 20% $40 copayment
Specialist DED + 20% DED + 20%
Provider Services at Hospital and ER
Family Physician DED + 20% DED + 20%
Specialist DED + 20% DED + 20%
PREVENTIVE CARE
Adult Wellness Office Services
Family Physician $0 $0
Specialist $0 $0
AGE 50+ THEN FREQUENCY SCHEDULE AGE 50+ THEN FREQUENCY SCHEDULE
Colonoscopies (Routine) APPLIES APPLIES
Covered at 100% of Allowed Amount $0 $0
Mammograms (Routine and DX) $0 $0
Well Child Office Visits (No BPM
Family Physician $0 $0
Specialist $0 $0
EMERGENCY/URGENT/CONVENIENT CARE
Ambulance DED + 20% DED + 20%
Convenient Care Centers (CCC) DED + 20% DED + 20%
Emergency Room Facility Services
(Also see Professional Provider Services) DED + 20% DED + 20%
Urgent Care Centers (UCC) DED + 20% DED + 20%
FACILITY SERVICES - HOSP/SURG/ICL/IDTF - Unless otherwise noted, physician services are in addition to facility services. See Professional Provider Services.
Independent Clinical Lab - X-rays DED + 20% DED + 20%
Independent Diagnostic Testing Facility - Advanced Imaging Diagnostics
(Includes Physician Services) DED + 20% DED + 20%
Inpatient Hospital (per admit) DED + 20% DED + 20%
Independent Rehab Maximum (per year) 60 days 60 days
Outpatient Hospital (per visit) DED + 20% DED + 20%
Therapy at Outpatient Hospital DED + 20% DED + 20%
PRESCRIPTION DRUGS
DEDUCTIBLE NETWORK HEALTH PLAN DED NETWORK HEALTH PLAN DED
In-Network – Retail (30 days) IN-NETWORK DED + IN-NETWORK DED +
Generic/Preferred Brand/Non-Preferred 20% / 30% / 50% $15 / $40 / 50% COINSURANCE
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient Hospitalization
In-Network DED + 20% DED + 20%
Outpatient Hospitalization (per visit)
In-Network DED + 20% DED + 20%
Physician Fees for Surgical & Medical Services
In-Network DED + 20% DED + 20%
Physician Office Visit
In-Network Family Physician or Specialist DED + 20% DED + 20%
Emergency Room Facility Services (per visit)
In-Network DED + 20% $500
Provider Services at Locations other than Hospital and ER
In-Network Family Physician DED + 20% DED + 20%
In-Network Specialist DED + 20% DED + 20%UnitedHealthcare Digital Support | myuhc.com
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tools. You can save an average of 36%1 when you compare costs for providers
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*Virtual Visits phone and video chat with a doctor are not an insurance product, health care provider or a health plan. Unless otherwise
required, benefits are available only when services are delivered through a Designated Virtual Network Provider. Virtual Visits are not intended
to address emergency or life threatening medical conditions and should not be used in those circumstances. Services may not be available at
all times, or in all locations, or for all members. Check your benefit plan to determine if these services are available.
**Available only for insured plans and self-funded plans with Optum Rx integrated pharmacy benefits.
continued
14 mybensite.com/okaloosa1 Go to myuhc.com > Register Now
UnitedHealthcare
2 Fill out the required fields and create your username/password
3 Enter your contact information and security questions
Agree to the website’s policies and be sure to opt-in for email updates.
4
Activation is quick
We promise you’ll only see our name in your inbox with relevant news
and wellness updates
1 Go to myuhc.com > Register Now
2 Fill out the required fields and create your username/password
3 Enter your contact information and security questions
Agree to the website’s policies and be sure to opt-in for email updates.
4 We promise you’ll only see our name in your inbox with relevant news
and wellness updates
Get started at myuhc.com
1
UnitedHealthcare Internal Claims Analysis, 2019.
All UnitedHealthcare members can access a cost estimate online or on the mobile app. None of the cost estimates are intended to be a guarantee of your costs or benefits. Your actual costs may vary. When
accessing a cost estimate, please refer to the Website or Mobile application terms of use under Find Care & Costs section.
The UnitedHealthcare® app is available for download for iPhone® or Android®. iPhone is a registered trademark of Apple, Inc. Android is a registered trademark of Google LLC.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.
B2C EI20236611.1 3/21 © 2021 United HealthCare Services, Inc. All Rights Reserved. 21-527099-A
Get started at myuhc.com
mybensite.com/okaloosa 15UnitedHealthcare
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keep it off, at no additional cost.
Real Appeal® is an online weight loss program that provides personal coaching to help you and
eligible family members lose weight and keep it off. On average, participants lose 10 pounds after
attending just 4 online sessions.*
Get support to help reach your goals.
1-on-1 coaching.
Get help to stay on track to reach your goals with online, coach-led group sessions.
$0 out-of-pocket.
Real Appeal is offered at no additional cost, as part of your health plan benefits.
Success kit.
Get scales, recipes, fitness equipment and more delivered to your door.
Sandy
It has given me the tools to eat healthfully and taught me the right amount
60 lbs. of exercise that will make a difference. With personal coaching and weekly
lost education on living a healthy lifestyle, I lost 60 pounds, and I feel great.
Learn more and start today at success.realappeal.com
*Real Appeal is a voluntary weight loss program that is offered to eligible participants over age 18 at no additional cost as part of their plan benefits. The information provided under this program is for general informational
purposes only and is not intended to be nor should be construed as medical and/or nutritional advice. Participants should consult an appropriate health care professional to determine what may be right for them. Any items/tools
that are provided may be taxable and participants should consult an appropriate tax professional to determine any tax obligations they may have from receiving items/tools under the program. Talk to your doctor before starting
any weight loss program.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.
Facebook.com/UnitedHealthcare Twitter.com/UHC Instagram.com/UnitedHealthcare YouTube.com/UnitedHealthcare
B2C 9963309.0 11/19 ©2019 United HealthCare Services, Inc. 19-13912
16 mybensite.com/okaloosaUnitedHealthcare
Resources | Check. Choose. Go.®
Compare quick care options
to help keep costs down.
Call 911 or go to an emergency room (ER) if you have a life-threatening condition. For everything else, see your primary care
physician (PCP) or family doctor first. If seeing your PCP isn’t possible, it’s important to know your quick care options, especially
before heading to an ER.
Getting care at the best place for your condition could save you up to $1,900 compared to an ER visit.
For more details on quick care options, visit uhc.com/checkchoosego.
START HERE
Quick Care
Options
PCP Virtual Visits Convenience Care Urgent Care Emergency Room
Care from the See a doctor Basic conditions Serious conditions Life- and limb-threatening
doctor who knows whenever, wherever. that aren’t that aren’t emergencies.
you best. life-threatening. life-threatening.
Varies by
Average Cost* Less than $50** $95 $180 $2,100
plan type
Varies by location —
Hours Varies by location 24/7 Varies by location may be open nights/ 24/7
weekends
How to Connect Contact your PCP myuhc.com/virtualvisits myuhc.com® myuhc.com myuhc.com
indicates the recommended place for care for the following common conditions:
Broken bone
Chest pain
Cough
Fever
Muscle strain
Pinkeye
Shortness of breath
Sinus problems
Sore throat
Sprain
Urinary tract infection
Need to find a network provider or PCP? Visiting an out-of-network
provider could end up costing you more for care. To find a PCP, urgent care
centers and emergency rooms in your network, go to myuhc.com.
Not sure where to go for care? Call the number on your health plan
ID card.
CONTINUED
mybensite.com/okaloosa 17UnitedHealthcare
Get on-the-go access
to your health plan.
The UnitedHealthcare® app puts
your plan at your fingertips.
When you’re out and about, you can do everything from managing your
plan to getting convenient care. Just download the app to:
• Find nearby care options in your network.
• Estimate costs. Get the app and log on
• Video chat with a doctor 24/7.* with Touch ID®.
• View and share your health plan ID card.
• See your claim details and view progress toward your deductible.
The UnitedHealthcare app is available
for download for iPhone® or Android®.
*Data rates may apply.
The UnitedHealthcare® app is available for download for iPhone® or Android®. iPhone and Touch ID are trademarks of Apple, Inc., registered in the U.S. and other countries. Android is a registered trademark of Google LLC.
All UnitedHealthcare members can access a cost estimate online or on the mobile app. None of the cost estimates are intended to be a guarantee of your costs or benefts. Your actual costs may vary. When accessing a cost
estimate, please refer to the Website or Mobile application terms of use under Find Care & Costs section.
Virtual Visits phone and video chat with a doctor are not an insurance product, health care provider or a health plan. Unless otherwise required, benefts are available only when services are delivered through a Designated Virtual
Network Provider. Virtual Visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times, or in all locations, or for all
members. Check your beneft plan to determine if these services are available.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its afliates. Administrative services provided by United HealthCare Services, Inc. or their afliates.
B2C EI20241509.0 8/20 ©2020 United HealthCare Services, Inc. All Rights Reserved. 20-241510-B
18 mybensite.com/okaloosaVisit with a doctor
24/7 — whenever,
wherever
With a Virtual Visit, you can talk — by phone1 or video — to
a doctor who can diagnose common medical conditions
and even prescribe medications, if needed.2
Virtual Visits may make it easier
than ever to get treated by a doctor
Whether using myuhc.com® or the UnitedHealthcare® app, Virtual Visits let you
video chat with a doctor 24/7 — without setting up additional accounts or apps.
But, if you’d rather just speak with a doctor, you can simply do a Virtual Visit over the
phone. With a UnitedHealthcare plan, your cost for a Virtual Visit is $49 or less.3
$
49
An estimated 25% of ER
cost
visits could be treated
Use a Virtual Visit for these common conditions: with a Virtual Visit —
• Allergies • Flu • Sore throats bringing a potential
• Bronchitis • Headaches/migraines • Stomachaches $2,000 4 cost down to $49.
• Eye infections • Rashes • and more
Get started Sign in at myuhc.com/virtualvisits | Call 1-855-615-8335
Download the UnitedHealthcare app
1 Data rates may apply.
2 Certain prescriptions may not be available, and other restrictions may apply.
3 The Designated Virtual Visit Provider’s reduced rate for a Virtual Visit is subject to change at any time.
4 Source 2019: Average allowed amounts charged by UnitedHealthcare Network Providers and not tied to a specific condition or treatment. Actual payments may vary depending upon benefit coverage. (Estimated
$2,000.00 difference between the average emergency room visit and the average urgent care visit.) The information and estimates provided are for general informational and illustrative purposes only and is not
intended to be nor should be construed as medical advice or a substitute for your doctor’s care. You should consult with an appropriate health care professional to determine what may be right for you. In an
emergency, call 911 or go to the nearest emergency room.
The UnitedHealthcare® app is available for download for iPhone® or Android®. iPhone is a registered trademark of Apple, Inc. Android is a registered trademark of Google LLC.
Virtual Visits phone and video chat with a doctor are not an insurance product, health care provider or a health plan. Unless otherwise required, benefits are available only when services are delivered through a
Designated Virtual Network Provider. Virtual Visits are not intended to address emergency or life threatening medical conditions and should not be used in those circumstances. Services may not be available at all
times, or in all locations, or for all members. Check your benefit plan to determine if these services are available.
Insurance coverage provided by or through UnitedHealthcare Insurance Company and its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or
through a UnitedHealthcare company.
B2C EI2061906.2 5/21 © 2021 United HealthCare Services, Inc. All Rights Reserved. 21-660117-D
19Healthcare Reimbursement Account (HRA)
$750 Single Up To $1,500 Family Automatic District-Paid Contribution
Healthcare Reimbursement Expenses must have been incurred prior to the policy
termination date. After 90 days, any remaining account
Account (HRA) balance will be forfeited.
The Healthcare Reimbursement Account (HRA) is Although your card cannot be used at dental or vision
automatically funded with: providers, you may file a paper claim for reimbursement for
• $750 for single coverage dental and vision expenses by visiting the Risk Management
• $1,100 for Employee + Spouse, Employee + Child(ren) page, under HRA at Okaloosaschools.com.
• $1,500 for family coverage for all medical plans.
If you are covered under the group medical insurance, you Send Claim forms to:
are automatically a participant in the HRA and you do not Fax: 850-479-2923
need to enroll in the HRA. By registering at
Mail: Lockard & Williams Insurance Services, Inc.
myflexonline.com, you can check your account balance,
view transactions, or file a claim for reimbursement. The site DBA 90 Degree Benefits
also provides a generic list of the types of expenses that are PO Box 1028
eligible for reimbursement through the plan. Gonzalez, FL 32560
Do not discard your current HRA/Take Care Flex Benefits Email: kenny.anderson@90degreebenefits.com
card until you verify the expiration date. These cards are Once Lockard & Williams Insurance Services, Inc. DBA
good for three years. If your card is expiring on 12/2021, you 90 Degree Benefits receives a receipt of your claim, a
will automatically receive a replacement card by mail at your reimbursement check will be issued within two business
home address during winter break. Make sure the Human days.
Resources (HR) Department has your current address. Only
the HR Department can update addresses. You may contact
them at (850) 833-5800.
Account Access
Participants in the HRA and the FSA can go to
If you cancel your medical insurance with the Okaloosa myflexonline.com to view their account.
County School District, you will have 90 days from the date
of termination to file claims under the HRA plan. For additional assistance, please contact the Account
Representative for the Okaloosa County School District,
Kenny Anderson at 850-516-7043 or email at
kenny.anderson@90degreebenefits.com.
20 mybensite.com/okaloosaFlexible Spending Accounts (FSA)
Employee Pretax Payroll Contribution
Flexible Spending Account (FSA) The following expenses may be paid
Flexible Spending Accounts are funded by the employee from FSA:
through pretax payroll deductions and MUST be elected • The Flexible Spending Account can be used to pay for
each year. out-of-pocket medical, dental, and vision expenses.
Some points to keep in mind: • The Dependent Care Reimbursement Account can be
used to pay for qualified child and adult care expenses.
• The FSA year is Jan. 1, 2022 – Dec. 31, 2022. If you have
nine monthly deductions, the annual election amount will
The FSA may not be used for the
be divided by nine. If you have 12 monthly deductions, following expenses:
the annual election amount will be divided by 12. • Cosmetic dental procedures, i.e., teeth whitening
• Everyone participating in the FSA for Healthcare
Reimbursement MUST re-enroll online using
mybensite.com/okaloosa. The maximum annual amount
you may contribute is $2,750 per employee, per plan
year.
• Everyone participating in the FSA for Dependent Care
Reimbursement MUST re-enroll online using
mybensite.com/okaloosa. The maximum annual amount
you may contribute is $5,000 per household, per plan
year.
• During the year, if you have an IRS-qualifying event that
allows for a change in your tax-deferred premium, you
MUST contact Risk Management at 850-833-3190.
12/24
• If you make an FSA Healthcare Reimbursement election
for 2022, the total annual election amount will be loaded
on your Take Care Flex Benefits card and available for
use on Jan. 1, 2022.
Did You Know?
There is a “use it or lose it” rule that
is part of the IRS rules that govern
how Flexible Spending Accounts operate. If you
participate in a Health FSA, you will be allowed
to carry over – instead of forfeit – up to $550 of
unused FSA funds remaining in your FSA at the
end of the plan year.
mybensite.com/okaloosa 21Dental Plan
Delta Dental (PPO) If you elected dental coverage for 2021, you will automatically
be enrolled in the same coverage for calendar year 2022.
Strong, healthy teeth create beautiful smiles. To give your
If you would like to enroll or make changes for 2022, you
smile the care and attention it deserves, Delta Dental offers
MUST go online to mybensite.com/okaloosa.
you their Indemnity dental care plans.
With Delta Dental, you have complete freedom of choice in
selecting a dentist. You may choose a dentist from the Delta
Dental Premier® or Delta Dental PPOSM networks or a dentist
who does not participate in either network. Your choice of a Dental SINGLE
PLAN
FAMILY
PLAN
dentist can determine your cost savings.
Delta Dental PPO dentists will accept the Delta Dental
Rates
PPO Maximum Plan Allowance (MPA) or the dentist’s fee – 12-Month $0.00 $60.81
whichever is less (the PPO Allowed Amount) – as payment in Employees
full for covered services. Copayments and deductibles may 9-Month
also apply. Employees $0.00 $81.08
Delta Dental Premier dentists will accept the Delta Dental
Premier MPA (a slightly higher MPA) or the dentist’s total *OCSD Board contributes $33.30 toward your monthly
charge – whichever is less (Premier Allowed Amount) – premiums if you elect single coverage.
as payment in full for covered services. Copayments and
deductibles may also apply.
Out-of-network dentists do not contract with Delta Dental.
Basic restorative care includes the treatment of caries,
commonly referred to as cavities and tooth decay. Your plan Did You Know?
offers coverage for anterior composite, resin fillings and A list of dental providers can be found at
posterior amalgam fillings. But what does this mean? deltadentalins.com by clicking the “Find a Dentist”
Your mouth is comprised of two sections of teeth: anterior option or on the Risk Management page of the OCSD
and posterior. Anterior teeth are the six upper and six lower website under the Delta Dental tab.
front teeth. All other teeth are considered posterior teeth.
Your plan provides coverage for composite resin fillings
(tooth-colored fillings) on your anterior teeth and amalgam
coverage (silver-colored fillings) on your posterior teeth.
However, this does not mean you cannot select a composite
resin filling for a posterior tooth. If you choose a composite
resin filling on a posterior tooth, your plan will reimburse
you at the amalgam level. You will be responsible for the
difference between the dentist’s fees for the composite filling
vs. the amalgam filling.
22 mybensite.com/okaloosaDental Plan
Delta Dental PPOSM
Eligibility Primary enrollee, spouse and eligible dependent children until the end of the year the dependent turns age 26.
$125 per year, per individual/ $375 per year, per family. Deductibles waived for Diagnostic & Preventive Services
Deductible* (D&S) for In-network Providers only.
Calendar Year Maximum $2,000 per year, individually. Diagnostic & Preventive Services (D&P) count towards maximum.
In-Network Out-of-Network
Benefits and Delta Dental Non-Delta Dental
Dentists** Dentists**
Covered Services** “YOU PAY” “YOU PAY”
Diagnostic & Preventive Services (D&P) 0% Deductible + Balance Billed
Exams, Cleanings, X-Rays and Sealants
Basic Services 20% 20% + Balance Billed
Fillings
Endodontics 20% 20% + Balance Billed
(Root Canals)
Non-Surgical Periodontics 20% 20% + Balance Billed
(Treatment of gums and bones supporting teeth)
Oral Surgery 20% 20% + Balance Billed
(Extractions including pre- and post-operative care)
Crown and Cast Restorations 20% 20% + Balance Billed
Major Services 50% 50%
Bridges and Implants
Surgical Periodontics 50% 50%
(Treatment of gums and bones supporting teeth)
Orthodontic Benefits Not Covered Not Covered
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances
and not necessarily each dentist’s submitted fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Delta Dental Premier® contracted fees for Premier dentists and Premier contracted fees for non-Delta
Dental dentists.
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the
benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.
Set Up an Account Online
Get information about your plan anytime,
anywhere by signing up for an online services
account at deltadentalins.com.
This free service, available once your coverage
becomes effective, lets you check benefits and
eligibility information, find a network dentist and more.
mybensite.com/okaloosa 23Dental Plan
Stay
Stay
Connected
Connected
At deltadentalins.com, all the information you need is at your fingertips. You can check
your plan details, find an in-network dentist and more.
Create
At an account
deltadentalins.com, all the information you need is at your fingertips. You can check
your plan details, find an in-network dentist and more.
1. Go to deltadentalins.com.
Create anon
2. Click account
Register Today in the Online
Services section.
1. Go to deltadentalins.com.
With an online
2. Click account,
on Register you in
Today can:
the Online
Services section.
• Check your plan details and eligibility
With an online
• Review account,
claim you can:
statements and plan
documents
• Check your plan details and eligibility
•• Review
View orclaim
print statements
your ID cardand plan
documents
• View or print your ID card
Find a dentist
1. Go to deltadentalins.com.
Find
2. Inathe
dentist
Find a Dentist section, enter
your address and select your network
1. Go to deltadentalins.com.
from the drop-down menu.
2. In the Find a Dentist section, enter
3. your Search. and select your network
Click address
fromYelp
Browse the drop-down menu.
reviews, check office hours
and see the
3. Click address on a map.
Search.
Browse Yelp reviews, check office hours For more online resources,
and see the address on a map. turn the page.
For more online resources,
turn the page.
deltadentalins.com/enrollees
24 mybensite.com/okaloosaDental Plan
Download the app
1. Open the App Store or Google Play.
Download the app
2. Search for “Delta Dental.”
Download
1. Open thetheApp
appStore or Google Play.
3. Open
1. Download the free
the App app
Store or titled
Google Play.
2. Search for “Delta
Delta Dental Dental.”
by Delta Dental Plans
2. Search for “Delta Dental.”
3. Association.
Download the free app titled
Delta
Review Dental
3. Download
your theby
plan Delta
free app
details, Dental
titled
pull PlansID
up your
Association.
Delta Dental by Delta Dental Plans
card and try out the musical toothbrush
Association.
timer.
Review your plan details, pull up your ID
card andyour
Review try out
planthe musical
details, pulltoothbrush
up your ID
timer.
card and try out the musical toothbrush
timer.
Get answers
Got a question? We’ve got answers.
Get answers
Learn how your dental plan works:
Get
Got answers
a question? We’ve got answers.
Visit
Got deltadentalins.com/enrollees
a question? We’ve got answers. for
the 101how
Learn on dental benefits.
your dental plan works:
Learn how your dental plan works:for
Visit deltadentalins.com/enrollees
Improve your dental health:
the 101
Visit on dental benefits.
deltadentalins.com/enrollees for
Check out mysmileway.com
the 101 on dental benefits. for the
latest
Improverecipes, articleshealth:
your dental and videos.
Improve
Check out your dental health: for the
mysmileway.com
Contact Customer Service:
latest
Checkrecipes, articles and videos.
out mysmileway.com for the
Submit an online question
latest recipes, articles at
and videos.
deltadentalins.com/contact.
Contact Customer Service:
Contact
Submit an Customer Service:at
online question
deltadentalins.com/contact.
Submit an online question at
deltadentalins.com/contact.
Website available on
desktop, mobile and tablet
Website available on
desktop, available
Website mobile andon tablet
desktop, mobile and tablet
Our Delta Dental enterprise includes these companies in these states: Delta Dental of California — CA, Delta Dental of the District of Columbia — DC, Delta Dental of
Pennsylvania — PA & MD, Delta Dental of West Virginia, Inc. — WV, Delta Dental of Delaware, Inc. — DE, Delta Dental of New York, Inc. — NY, Delta Dental Insurance
Company — AL, DC, FL, GA, LA, MS, MT, NV, TX and UT. These enterprise companies are members, or affiliates of members, of the Delta Dental Plans Association, a
network of 39 Delta Dental companies that together provide dental coverage to 78 million people in the U.S. The website deltadentalins.com is the home of the
Our
DeltaDelta Dental
Dental enterprise
companies includes
listed above.these companies
For other in these
Delta Dental states: Delta
companies, visitDental of California
the Delta — CA,
Dental Plans Delta Dental
Association of theatDistrict
website of Columbia — DC, Delta Dental of
deltadental.com.
Pennsylvania — PA & MD, Delta Dental of West Virginia, Inc. — WV, Delta Dental of Delaware, Inc. — DE, Delta Dental of New York, Inc. — NY, Delta Dental Insurance
Our Delta —
Company Dental enterprise
AL, DC, FL, GA,includes these
LA, MS, MT, companies
NV, TX and UT. inThese
these enterprise
states: Delta Dental ofare
companies California
members,— CA, Delta Dental
or affiliates of the District
ofCopyright
members, theof Columbia
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DC, Delta Dental of
©of2019 Delta
Delta Dental. Association,
All rights reserved.a
Pennsylvania
network of 39—Delta
PA &Dental
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companies West
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together Inc. —dental
provide WV, Delta Dental
coverage toof
78Delaware, Inc. —inDE,
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deltadentalins.com is theDental
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Company — AL, DC, FL, GA, LA, MS, MT, EF30 #121175N (rev. 05/19)a
Delta Dental companies listed above. ForNV, TX Delta
other and UT. These
Dental enterprisevisit
companies, companies areDental
the Delta members,
Plansor affiliates ofwebsite
Association members, of the Delta Dental Plans Association,
at deltadental.com.
network of 39 Delta Dental companies that together provide dental coverage to 78 million people in the U.S. The website deltadentalins.com is the home of the
Delta Dental companies listed above. For other Delta Dental companies, visit the Delta Dental Plans Association Copyright website at ©
deltadental.com.
2019 Delta Dental. All rights reserved.
mybensite.com/okaloosa EF30 #121175N (rev. 05/19)
Copyright © 2019 Delta Dental. All rights reserved. 25
EF30 #121175N (rev. 05/19)Vision Plan
You may choose from the Vision Rates
following vision plans: Type of LOW PLAN HIGH PLAN
• EyeMed Vision Low Plan Employee Single Family Single Family
• EyeMed Vision High Plan
12-Month
$5.34 $14.80 $6.55 $18.21
EyeMed Vision Plan Employees
EyeMed Vision is dedicated to helping you see clearly 9-Month
$7.12 $19.73 $8.73 $24.28
and that’s why we’ve built a network that gives you lots of Employees
choices and flexibility. You can choose from thousands of
independent and retail providers to find the one that best Vision Allowances
fits your needs and schedule. No matter which one you
choose, plans are designed to be easy to use and help you LOW PLAN HIGH PLAN
access the care you need. An annual eye exam is about Type
much more than healthy vision. It can help you manage In-Net Out In-Net Out
your overall health and well-being, too. An eye exam Contact
can spot the early signs of serious health conditions like $105 $100 $150 $105
Lenses
diabetes and high blood pressure, so you can be treated
sooner, rather than later. Frames $120 $40 $150 $70
EyeMed offers two (2) plans for your selection. If you
elected vision coverage for the calendar year 2021, you
will automatically be enrolled in the same coverage for the
calendar year 2022. If you would like to enroll or make
changes for 2022, you MUST go online to Did You Know?
mybensite.com/okaloosa. Once you enroll in vision For a complete list of in-network
insurance, you cannot cancel coverage during the year. providers near you, use our Enhanced Provider
A low and high plan is being offered. Both plans offer Locator on eyemed.com or call 1-866-804-0982.
an eye exam once a year with your choice of lenses or For Lasik providers, call 1-877-5LASER6.
contacts. Frames are offered once every two years.
Frequency of Visits
• Examination - Once every 12 Months
• Lenses or Contact Lenses - Once every 12 Months
• Frames - Once every 24 Months
26 mybensite.com/okaloosaVision Plan
Low Plan High Plan
In-Network Out-of-Network In-Network Out-of-Network
Reimbursement Reimbursement
Exam With Dilation as Necessary $10 Co-pay Up to $43 $10 Co-pay Up to $45
Retinal Imaging Up to $39 N/A Up to $39 N/A
$0 Co-pay; $120 $0 Co-pay; $150
Frames allowance; 20% off Up to $40 allowance; 20% off Up to $70
balance over $120 balance over $150
Standard Plastic Lenses
Single Vision $25 Co-pay Up to $26 $25 Co-pay Up to $30
Bifocal $25 Co-pay Up to $43 $25 Co-pay Up to $50
Trifocal $25 Co-pay Up to $60 $25 Co-pay Up to $65
Standard Progressive Lens $90 Up to $43 $90 Up to $50
Premium Progressive Lens* $110 - $135 $110 - $135
Tier 1 $110 Up to $43 $110 Up to $50
Tier 2 $120 Up to $43 $120 Up to $50
Tier 3 $135 Up to $43 $135 Up to $50
$90, 80% of charge less $90, 80% of charge less
Tier 4 Up to $43 Up to $50
$120 allowance $120 allowance
Lenticular $25 Co-pay Up to $91 $25 Co-pay Up to $100
Lens Options (Paid by the member and added to the base price of the lens)
UV Treatment $15 N/A $15 N/A
Tint (Solid and Gradient) $15 N/A $15 N/A
Standard Plastic Scratch Coating $15 N/A $15 N/A
Standard Polycarbonate $40 N/A $40 N/A
Standard Polycarbonate - Kids under 19 $40 N/A $40 N/A
Standard Anti-Reflective Coating $45 N/A $45 N/A
Premium Anti-Reflective Coating* $57 - $68 N/A $57 - $68 N/A
Tier 1 $57 N/A $57 N/A
Tier 2 $68 N/A $68 N/A
Tier 3 80% of charge N/A 80% of charge N/A
Photochromic/Transitions $75 N/A $75 N/A
Polarized 20% off retail price N/A 20% off retail price N/A
Other Add-Ons and Services 20% off retail price N/A 20% off retail price N/A
Contact Lens Fit and Follow Up (Contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed)
Standard Contact Lens Fit & Follow Up Up to $40 N/A Up to $40 N/A
Premium Contact Lens Fit & Follow Up 10% off retail N/A 10% off retail N/A
Contact Lenses
$0 Co-pay; $105 $0 Co-pay; $150
Conventional allowance; 15% off Up to $100 allowance; 15% off Up to $105
balance over $105 balance over $150
$0 Co-pay; $105 $0 Co-pay; $150
Disposable allowance; plus balance Up to $100 allowance; plus balance Up to $105
over $105 over $150
Medically Necessary $0 Co-pay, Paid-in-Full Up to $210 $0 Co-pay, Paid-in-Full Up to $210
Laser Vision Correction
15% off retail or 5% off 15% off retail or 5% off
Lasik or PRK from U.S. Laser Network N/A N/A
promotional price promotional price
* Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on market conditions. Fixed pricing is reflective of brands at the listed
product level . All providers are not required to carry all brands at all levels. Benefits are not provided from services or materials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental
testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye,eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety
eyewear; 4) Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 5) Plano (non-prescription)lenses;
6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or materials provided by any other group benefit plan providing vision care 9) Services rendered after the date an Insured Person ceases to be
covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered. To the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses, frames,
glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit
plans. Standard/Premium Progressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressive as a Standard. Underwritten by Combined Insurance Company of America, 5050 Broadway,
Chicago, IL 60640, except in New York. CICA Form # VN P63007 0801. The Certificate of Insurance is on file with your employer. Benefit allowance provides no remaining balance for future use within the same benefit year. Fees
charged for a non-insured benefit must be paid in full to the Provider. Such fees or materials are not covered.
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