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Table of Contents 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) 41 Ameritas Dental Plan (PPO Option) 42 Aflac Group Accident Plan 43 Allstate Benefits Group Cancer Plan 52 After-Tax Benefits Aflac Group Critical Illness without Cancer Plan 61 Aflac Group Critical Illness with Cancer Plan ��������������������������������������������70 AUL Short Term Disability 79 Minnesota Life Basic Term Life 83 Minnesota Life Optional Term Life 85 Texas Life Whole Life 89 For Your Reference Continuation of Benefits 92 Contact Information for Questions and Claims ������������������������������������������94 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. HMO ) will ) plan . , amount. until the or call (800) plan’s 09/30/2018 09/30/2018 expenses paid – benefits/ - amount before before amount premium network provider - Plan Type: Plan in the pocket limit deductible care - coinsurance of | - - , glossary/ of - pocket limits - , and you might receive, and you - , each member family eductible d of covers certaincovers preventive - out . See a list of covered a of . See list deductible plan provider (called the(called out charge andyour what plan lance billing lance plan ba . , deductible up to the up to the might use anmight use out provider’s network provider Individual + Family - of - . The SBC shows you how you and the . The SBC the showsyou and you how eductible d Coverage Period: 10/01/2017 Period: Coverage www.healthcare.gov/sbc provider providers plan 17 - until the total amount of until the total allowed amount network Coverage for: for: Coverage for specific services. for . You will pay less if you use a if you use . You less will pay has beenhas met. , they have to meet their own their , they have to meet may apply. For example, this apply. example, this may For deductible and before you meet your your youand before meet plan H/NA/JJ9JQ/NA/10 network - deductibles you have If is you could a pay year the most covered in services. for https://www.healthcare.gov/coverage/preventive for the for difference between the sharing pocket limit pocket - - coinsurance ). Be aware your ). Be of or - cost provider ling out provider pocket limit - covers some items the haven’t some covers and even services yet if you met a uses begins to pay. If you have other family members on the begins to pay. you have If other family members of . You will pay the most if you use an if out most . You the will pay - copayment balance bil plan plan out plan For more information about your coverage, or to get a copy of the complete terms aboutterms information more aFor your coverage,copycomplete get of the or to Why This Matters: from of the costs payyou must Generally, all this meet own individual their must the overall meets familyby all family members This a But without services preventive at services You don't have to meet The in this other family members overall family toward the expenses, they don’t count Even these though you pay This network a a bill from pays ( Page 2 Covers & What You Pay For Covered & WhatFor Covers Services You Pay terms see the Glossary. see the Glossary. You at canterms the Glossary view . For general definitions of common terms, such as such general of common terms, For definitions , actic actic , r . VA/L/A/CulpeperCountyandSchools251000OA Plan doesn't doesn't network Network Network - - ly a summary. See or or call (800) or call (800) or Vision exam exam Vision plan Chirop Providers charges, and and charges, , underlined 25/1000 Open Access Premiums What this What this the cost of care care of cost the Keepers . Routine individual Billing individual - HMO /family for In /family for / In /family for Network / - , or other , or other Prescription Drugs Prescription Health and 1880 for a list of a 1880 list for - Answers $1,000 $2,000 Providers Yes. Preventive care care In for No. $4,000 $8,000 Providers with associated routineCosts care,vision when have the benefit limits been reached, Balance Health Care this cover. Yes, www.anthem.com 421 providers provider ? , - of - would share the cost for covered health care cost of about health cost the covered this share the would for services. NOTE: Information pocket for this for - for out https://eoc.anthem.com/eocdps/aso deductible deductible ? of , network network The Summary of Benefits and Coverage (SBC) document will help you of Benefits document (SBC) choose a health Coverage and The Summary plan separately. This is be provided on - ? not included included not out ? ? 1880 to request a copy. 1880 to request - the Culpeper County and Schools: County Culpeper of coverage, copayment 421 Questions Important overall is the What deductible services there Are you before covered your meet other there Are deductibles services? specific is the What limit pocket plan is What in limit Will pay less you if a you use provider auth of and Benefits Summary Coverage: 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--------
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