View Bene t Information & Download Forms at: www.markiiibrokerage.com/culpepercountyschoolsva OR scan this QR with your smartphone!* *-3rd party iOS or Android app required Arranged and Enrolled by Mark III Brokerage, Inc. Plan Year: October 1, 2018 - September 30, 2019 Arranged and Enrolled by Mark III Brokerage, Inc. 114 E. Unaka Ave. Johnson City, TN 37601 Ginger Durbin [email protected] (800) 532-1044 x207 Employee learn more at: www.markiiieb.com Benefits Table of Contents Pre-Tax Benefits Anthem HMO Plan 2 Anthem Lumenos Plan 13 Benefit Plan Options with Rates 24 Anthem Prescription Drug Plan 27 Anthem Blue View Vision Plan ��������������������������������������������������������������������30 FBA Flexible Spending Accounts ����������������������������������������������������������������32 Ameritas Vision Plan ������������������������������������������������������������������������������������38 Ameritas Dental Plan (Low Option) 40 Ameritas Dental Plan (High Option) 42 Ameritas Dental Plan (PPO Option) 44 Aflac Group Accident Plan 46 Allstate Benefits Group Cancer Plan 52 After-Tax Benefits Aflac Group Critical Illness without Cancer Plan 58 Aflac Group Critical Illness with Cancer Plan ��������������������������������������������63 AUL Short Term Disability 68 Minnesota Life Basic Term Life 72 Minnesota Life Optional Term Life 74 Texas Life Whole Life 78 For Your Reference Continuation of Benefits 83 Contact Information for Questions and Claims ������������������������������������������85 If you wish to add or make changes to your insurance coverage(s), please consult a Benefits Representative during your scheduled enrollment period. You will not be able to make any changes once the enrollment period is over unless you experience a qualified event outlined by the IRS (i.e., marriage, divorce, birth of a child, etc.) If you should experience a qualified event, you have 31 days from the date of the event to make any changes. All information in this booklet is a brief description of your coverage and is not a contract. Please refer to your policy or certificate for each product for the exact terms and conditions. auth Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2018– 09/30/2019 Culpeper County and Schools: HMO 25/1000 Open Access Coverage for: Individual + Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (833) 592-9956 to request a copy. Important Questions Answers Why This Matters: What is the overall $1,000/individual or Generally, you must pay all of the costs from providers up to the deductible amount before deductible? $2,000/family for In-Network this plan begins to pay. If you have other family members on the plan, each family member Providers. must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services Yes. Prescription Drugs, This plan covers some items and services even if you haven’t yet met the deductible amount. covered before you Preventive care, Chiropactic But a copayment or coinsurance may apply. For example, this plan covers certain preventive meet your deductible? care and Routine Vision exam services without cost-sharing and before you meet your deductible. See a list of covered Page 2 for In-Network Providers. preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of‐ $4,000/ individual or The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for this $8,000/family for In-Network other family members in this plan, they have to meet their own out-of-pocket limits until the plan? Providers. overall family out-of-pocket limit has been met. What is not included Costs associated with routine Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket vision care, the cost of care limit? when the benefit limits have been reached, Premiums, Balance-Billing charges, and Health Care this plan doesn't cover. Will you pay less if Yes, HealthKeepers. See This plan uses a provider network. You will pay less if you use a provider in the plan’s you use a network www.anthem.com or call (833) network. You will pay the most if you use an out-of-network provider, and you might receive provider? 592-9956 for a list of network a bill from a provider for the difference between the provider’s charge and what your plan providers. pays (balance billing). Be aware your network provider might use an out-of-network provider VA/L/A/CulpeperCountyandSchools251000OA-H/NA/JJ9JQ/NA/10-17 for some services (such as lab work). Check with your provider before you get services. Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Out-of-Network Limitations, Exceptions, & Other Services You May Need In-Network Provider Medical Event Provider Important Information (You will pay the least) (You will pay the most) Primary care visit to treat an $25/visit Not covered --------none-------- injury or illness If you visit a Specialist visit $50/visit Not covered --------none-------- health care You may have to pay for services that provider’s office aren't preventive. Ask your provider if Preventive care screening or clinic / / No charge Not covered the services needed are preventive. immunization Then check what your plan will pay for. Diagnostic test (x-ray, blood Page 3 $50/visit Not covered --------none-------- If you have a test work) Imaging (CT/PET scans, MRIs) $150/visit Not covered --------none-------- $10/prescription (retail) $10/prescription (retail) $20/prescription (home $20/prescription (home Tier 1 - Typically Generic delivery) delivery) If you need drugs $30/prescription (retail $30/prescription (retail maintenance) maintenance) *See Prescription Drug section. Note to treat your that if you visit an out of network $30/prescription (retail) $30/prescription (retail) illness or pharmacy, you will pay the full cost of $60/prescription (home $60/prescription (home condition Tier 2 - Typically Preferred / your prescription at the pharmacy then More information delivery) delivery) Brand file a claim for reimbursement. about $90/prescription (retail $90/prescription (retail prescription Reimbursement will be based on what is maintenance) maintenance) drug coverage a participating pharmacy would receive available at $50/prescription or 20% $50/prescription or 20% had the prescription been filled at a http://www.anthe coinsurance, whichever is coinsurance, whichever is participating pharmacy. Most specialty m.com/pharmacyin greater up to greater up to drugs are limited to a 30 day supply formation/ $200/prescription (retail) $200/prescription (retail) Tier 3 - Typically Non-Preferred and must be obtained from the $100/prescription or 20% $100/prescription or 20% / Specialty Drugs specialty pharmacy. National coinsurance, whichever is coinsurance, whichever is greater up to greater up to $400/prescription (home $400/prescription (home delivery) delivery) * For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. What You Will Pay Common Out-of-Network Limitations, Exceptions, & Other Services You May Need In-Network Provider Medical Event Provider Important Information (You will pay the least) (You will pay the most) $150/prescription or 20% $150/prescription or 20% coinsurance, whichever is coinsurance, whichever is greater up to greater up to $600/prescription (retail $600/prescription (retail maintenance) maintenance) Facility fee (e.g., ambulatory $150/visit Not covered --------none-------- If you have surgery center) outpatient surgery Physician/surgeon fees $25/PCP, $50/Specialist Not covered --------none-------- Emergency room care $250/visit Not covered --------none-------- If you need Emergency medical $100/transport Not covered --------none-------- immediate transportation medical attention Urgent care $25/PCP, $50/Specialist Not covered --------none-------- $300/day up to $1,500 Facility fee (e.g., hospital room) Not covered --------none--------