Benefits Enrollment & eferen e i e - Harford County Public ... › departments › docs › human... · Benefits Enrollment & eferen e i e Open Enrollment Period May 1, 2019–May

EFFECTIVE JULY 1, 2019–JUNE 30, 2020

Benefits Enrollment &eferen e i e

Open Enrollment PeriodMay 1, 2019–May 22, 2019

ContentsWelcome . . . . . . . . . . . . . . . . . . . . . 1

What’s New for this Plan Year . . . 2

Benefits and Eligibility. . . . . . . . . . 4

Medical and Dental Deductions—Active Employees. . . . . . . . . . . . . . 6

Medical and Dental Deductions—Active Part Time HCEA and HCESCRepresented Employees. . . . . . . . 7

Be an Informed Health CareConsumer . . . . . . . . . . . . . . . . . . . . 8

Enrollment Instructions . . . . . . . 10

BlueChoice HMO OpenAccess . . . . . . . . . . . . . . . . . . . . . . 11

Away From Home Care . . . . . . 14

Triple Option . . . . . . . . . . . . . . . . 15

Preferred ProviderOrganization . . . . . . . . . . . . . . . . 17

BlueCard & Global Core . . . . . . . 19

CareFirst Prescription DrugProgram . . . . . . . . . . . . . . . . . . . . 21

Rx Choice Pharmacy Network . . 23

Maintenance Choice AllAccess . . . . . . . . . . . . . . . . . . . . . . 24

CareFirst Drug ProgramSummary of Benefits . . . . . . . . . 25

Prescription Drug Program . . . . 26

BlueVision. . . . . . . . . . . . . . . . . . . 30

BlueVision Summary ofBenefits . . . . . . . . . . . . . . . . . . . . . 31

Medical Benefits Options . . . . . . 32

Patient-Centered MedicalHome. . . . . . . . . . . . . . . . . . . . . . . 38

Take the Call . . . . . . . . . . . . . . . . . 39

Know Before You Go. . . . . . . . . . 41

My Account . . . . . . . . . . . . . . . . . . 43

Find a Doctor, Hospital orUrgent Care . . . . . . . . . . . . . . . . . 45

Health & Wellness . . . . . . . . . . . . 46

Mental Health Support . . . . . . . . 48

Delta Dental . . . . . . . . . . . . . . . . . 49

Flexible Spending Account (FSA)Highlights . . . . . . . . . . . . . . . . . . . 56

Basic Life Insurance and AccidentalDeath and Dismemberment(AD&D) Insurance . . . . . . . . . . . . 62

Employee Assistance Program . 65

Savings & Retirement Benefits . 67

Frequently Asked Questions . . 71

COBRA. . . . . . . . . . . . . . . . . . . . . . 73

Health Insurance PortabilityAccountabilityþAct (HIPAA) . . . . . 75

Family and Medical Leave Act(FMLA) . . . . . . . . . . . . . . . . . . . . . . 76

Privacy Notice. . . . . . . . . . . . . . . . 77

New Health InsuranceMarketplace Coverage Optionsand Your Health CoverageSample Form . . . . . . . . . . . . . . . . 78

Definitions . . . . . . . . . . . . . . . . . . 80

Fully-Insured vs. Self-Insured. . . 81

Notice of Nondiscriminationand Availability of LanguageAssistance Services . . . . . . . . . . . 82

o t nt eso es e e e ese e one e e o C s n ess

CareFirst BlueCross BlueShieldMedical Claims 800-628-8549 carefirst.com

Mailroom AdministratorPO Box 14115Lexington, KY 40512

Mental Health 800-245-7013 carefirst.com mentalhealth

CVS Caremark andMail Order Pharmacy 800-241-3371 carefirst.com rx

Delta Dental 800-932-0783 deltadentalins.comPO Box 2105Mechanicsburg, PA17055-2105

Flexible Benefit Administrators,Inc. (FBA) 800-437-3539 ex-admin.com

https fba.wealthcareportal.com

KEPRO (EAP) 866-795-5701 EAPHelplink.com company code—HCPS

State Retirement Agency 800-492-5909 sra.state.md.us

Lincoln Financial Tax DeferredCompensation Plan (457b) (403b)

800-234-3500Press

hcps.org departments humanresources benefitsretirement.aspxlincolnfinancial.com

Harford County Public SchoolsBenefits O ce 410-588-5275

Benelogic 844-796-4086 https hcps.benelogic.com

Employee Incentiveshttps hcps365.sharepoint.com sitesHumanResources Sta ng RecruitmentandRetentiondefault.aspx

Harford County Public Schools—Benefits Enrollment & Reference Guide ■

As a Harford County Public Schools (HCPS) employee, you have access to a wide varietyof benefits. HCPS benefit programs are designed to help keep you and your familyhealthy and financially secure with coverage options that feature choice, flexibility, andtax-savingsÿopportunities.

Welcome

VisionHarford County Public Schools ill be a community of learnersin hich our ublic schools families ublic o cials businessescommunity or ani ations and other citi ens or collaborati elyto re are all of our students to succeed academically and sociallyin a di erse democratic chan e oriented and lobal society

issionhe mission of the Harford County Public Schools is to romote

e cellence in instructional leadershi and teachin and toro ide facilities and instructional materials that su ort

teachin and learnin for the st century he Harford CountyBoard of Education ill su ort this mission by fosterin aclimate for deliberate chan e and monitorin ro ress throu hmeasurable indicators

o so re are e ery student for success in ostsecondary

education and a career

o encoura e and monitor en a ement bet een the schoolsystem and the community to su ort student achie ement

o hire and su ort s illed sta ho are committed toincreasin student achie ement

o ro ide safe secure and healthy learnin en ironmentsthat are conduci e to e ecti e teachin and learnin

It is up to you to make the mostof these benefits. You havean opportunity now to enrollin or change specific benefitplan selections. To help youchoose wisely, HCPS providesthis Enrollment and ReferenceGuide. Please take time to readthis Enrollment Guide carefullyand share it with other familymembers to help you makeinformed benefits decisions.

Every effort has been made toensure that the informationin this Guide is accurate;however, the provisions ofthe actual contracts for eachplan will govern in the event ofany discrepancy. Copies of theEmployee Benefit Guides andplan contracts are availableat our SharePoint (https://hcps365.sharepoint.com/sites/humanresources/benefits) or theBenelogic website (https://hcps.benelogic.com).

■ Harford County Public Schools—Benefits Enrollment & Reference Guide2

Open Enrollment is the time each year when you get to make your benefi t choices for thefollowing fiscal year. During this period, it’s important that you set aside some time to learn allyou can about your Harford County Public Schools benefit options for 2019–20, and decidewhich ones make the most sense for you and your family.

What’s New for this Plan YearChanges for 2019–2020

ll current 2 medical dental and lifebenefits ill automatically roll o er for 2 leS endin elections must be made each lan year

a e this o ortunity to

■ Re ie or chan e your medical and dentalinsurance o tions

■ Re ie and u date eli ible de endentsas a ro riate

■ Re ie ne 2 remium information

■ Start or rene artici ation in Health and ore endent Care S s

■ Enroll increase or decrease life insuranceBenefits Statement of Health re uired forall enrollments

Health insurance benefit changes forthe coming 2019-20 plan yearDrug Formulary—Pharmacy Benefits ill mo efrom ormulary to ormulary for all lans

Mandatory Choice All Access for maintenancedru rescri tions E ecti e there aret o ays you can fill your three month su ly ofmaintenance medications ith C S Caremar

ail Ser ice or 2 at a C S Pharmacy retaillocation

Pharmacy Network is changing to “Rx ChoicePharmacy Network” hich allo s you to urchaseyour rescri tion medications from any ofin net or harmacies located around the cornerand across the country ote al reens is not inthe R Choice net or

Deductibles— ll lan deductible ill increase byindi idual and family ri le o tion ill

no ha e a deductible on e el & 2

Copays—Emer ency Room co ays ill increase by2 Prescri tions co ays ill increase by at all

le els ll non emer ency isit co ays ill increaseby includin r ent Care and all o ce isitco ays

ife nsurance enhancementsEm loyees ill ha e the o tion to elect u totheir salary in su lemental life u to an increased

lan limit of combined ith Basic ifeou ill also be able to elect de endent s ouse

life 2 and or de endent child ren lifeRates are outlined on a es 2 and


Health Flexible Spending limitincrease for 2019E ecti e uly HCPS em loyees cancontribute u to to their health S s

n increase of from the current limithe e endent Care limit remains at

le ible S endin ccounts re uire annualenrollments o artici ate you must lo intoBenelo ic to enroll for a S healthcareand or de endent care s endin account

Sharecare ellnessCare irst has artnered ith Sharecare nc tobrin you a ne ellness ro ram that includesa ealth of tools and resources as ell as easyto understand recommendations and insi htsthat re ect your indi idual interests and needs—all tailored to hel you li e your healthiest lifencluded is a Real e est to determine thehysical a e of your body com ared to your

calendar a e health trac ers to monitor dailyhabits a e Ramsey inancial nner y ei ht

ana ement Pro ram uitnet obacco CessationPro ram Health Coachin and rela ation andmeditation tools ry it out today by isitinwww.carefirst.com/sharecare.

e ins rance premi mse insurance remiums are detailed

on a es of this uide e remiums aree ecti e uly


Benefits and EligibilityBasic benefits

ith the e ce tion of the defined benefit ensionlans the costs for the basic benefits for all

re ular art time and full time em loyees are aidin full by Harford County Public Schools Basicbenefits include

■ Sic ea e

■ amily Berea ement ea e

■ Personal Business

■ iability nsurance

■ uition Reimbursement

■ Em loyee ssistance Pro ram

■ Pension Plan

embershi in the aryland State eachers andEm loyees Pension System is mandatory andre uires a contribution based on your annualcom ensation

ti na benefitsn eneral full and art time hours eree em loyees may choose to enroll in any

combination of the follo in benefits HCPScontributes a lar e ortion to ard the urchaseof health and elfare benefits his allo s youthe e ibility to choose the benefi t lans that bestmeet your needs

he Benefits Pro ram for HCPS is a SectionPlan as defined by the nternal Re enue CodeSection allo s you to ay for certain em loyeebenefits ith re ta deductions from your

aychec ou ay for most benefits on a beforeta basis hich lo ers the ta es ta en out ofeach aychec

our before ta benefits include

■ edical

■ ental

■ Grou ife insurance

■ le ible S endin ccounts

■ 4 b 4 b Plans

our after ta benefits include

■ S Sa in s Bonds

■ ife nsurance—amounts o er

■ Roth 4 b Plans

i ibi itees

ou are eli ible to artici ate in the HCPS BenefitsPro ram if you are a

■ Re ular full time em loyee

■ Part time em loyee or in E orhours er ee or more

e en entsEli ible family members include your

■ e al s ouse

■ e endent children until the end of themonth in hich they reach a e

■ nmarried de endent children o er thea e limit if

hey are de endent on you for rimaryfinancial su ort and maintenance due toa hysical or mental disability

hey are inca able of self su ort and

he disability e isted before reachina e or hile co ered under the lan

Eli ible children include your

■ atural children

■ Ste children

■ e ally ado ted children

■ oster children

■ child for hom you ha e le al uardianshiincludin randchildren

■ Child for hom the court has issueda SC ualified edical ChildSu ort rder

* You must submit verification of eligibility for all dependents on your account within 30 days of enrollment.

Benefits and Eligibility


Ineligibilityny ineli ible de endents should be remo ed from

your co era e as soon as they become ineli ibles a reminder e ha e included a fe e am les of

ineli ible de endents

■ nyone ho is not your le al s ousee s ouse fianc common la s ouse etc

■ e endents no lon er co ered by acourt order

■ i e in artners

■ Children of li e in artners

■ Ste children follo in di orce fromnatural arent

■ Parents of em loyees

ote he Board ill not ro ide t o insurancero rams e Care irst PP C RE and BlueChoice

H ro ram for any eli ible em loyees oreli ible members of their families his a liesto all em loyees and eli ible members of theirfamilies hose s ouses are also em loyees of theschool system

e en ent eligibility ent ti n e i e ent

el ti n i tl yee ligibility e niti n ent ti n e i ti n el ti n i

Spouse erson to hom you are le allymarried

Co y of arria e certificate co y of Social Security cardand most recent ederal a orm or thatidentifies em loyee s ouse relationshi attach st a eonly & blac out financial information

f marria e occurred in current year ta form is not neededDependentChild(ren)

e endent children until the end of themonth in hich they reach a e

Natural Child—Provide a copy of Social Security card andone of the following:■ Co y of birth certificate sho in em loyee s name or■ Hos ital erification of birth must include child s name

date of birth and arents names or■ Certificate of li e birthStep Child—Provide a copy of Social Security card and oneof the a ove sho in em loyee s s ouse name and a co yof marria e certificate sho in the em loyee and arent sname

egal uardian doption randchild(ren) or osterChild(ren)—Co y of inal Court rdered Custody ith

residin ud e s si nature and seal or do tion inalecree ith residin ud e s si nature and seal and a co y

of Social Security cardChild for who the court has issued a SC — co yof the ualified edical Child Su ort rder and a co y ofSocial Security card

Disa ledDependents

nmarried de endent children o erthe a e limit if

hey are de endent on you forrimary financial su ort and

maintenance due to a hysical ormental disability

hey are inca able of self su ortand

he disability e isted before reachina e or hile co ered under the

lan

Co y of Social Security disability a ard if a disability rulinby Social Security is endin include a current co y of thea lication for disability and ederal a Return for yearust filed and co y of Social Security card and Com letedisability orm Re uest from Benefits ce


Medical and Dental Deductions—Active Employees

Plan Total AnnualPremium

EmployeeMonthly

Premium at100%

BOE % ofAnnual Cost

Employee% of Annual

Cost

Biweekly Payroll Deduction12 Month

Employees(24ÿpays) Your

Bi-WeeklyDeduction

10 MonthEmployees

(20ÿpays) YourBi-WeeklyDeduction

Medical Insurance Rates

MO 95% 5%

ndi idual 6 6 6

Parent & Child 6 6

Em loyee &S ouse

6 6 6

amily 6 6

Preferred Pro ider Core Plan 9 % %

ndi idual 6 66 6 6 6

Parent & Child 6 66 6 6

Em loyee &S ouse

6 6 6

amily

Triple Option 5% 5%

ndi idual 6 6 6 6

Parent & Child 6 6

Em loyee &S ouse

6 6

amily 6 6 6

Dental Insurance Rates

Delta Premier 9 % %

ndi idual 66

Parent & Child 6

Em loyee &S ouse

6

amily 6 66

Delta PPO 9 % %

ndi idual

Parent & Child 6

Em loyee &S ouse

6 6 6 6 6

amily 6

Premium deductions ill be in in uly Se tember for ten month em loyees and co era e ill be e ecti e uly e hires co era eill start on the first ay of the month follo in the date of hire and enrollment in the lan eductions ill be in ith the first ay of the

month follo in the date of hire and enrollment in the lan


Medical and Dental Deductions—Active PartTime HCEA and HCESC Represented EmployeesHired or transferred to a P osition of less than hours er ee on or after

Plan Total AnnualPremium

EmployeeMonthly

Premium at100%

BOE % ofAnnual Cost

Employee% of Annual

Cost

Biweekly Payroll Deduction12 Month

Employees (24pays) YourBi-WeeklyDeduction

10 MonthEmployees (20

pays) YourBi-WeeklyDeduction

Medical Insurance Rates

MO 47.5% 52.5%

ndi idual

Parent & Child

Em loyee &S ouse

amily

Preferred Pro ider Core Plan 45. % 55. %

ndi idual

Parent & Child

Em loyee &S ouse

amily

Triple Option 42.5% 57.5%

ndi idual

Parent & Child

Em loyee &S ouse

amily

Dental Insurance Rates

Delta Premier 45. % 55. %

ndi idual

Parent & Child

Em loyee &S ouse

amily

Delta PPO 45. % 55. %

ndi idual

Parent & Child

Em loyee &S ouse

amily

Premium deductions ill be in in uly Se tember for ten month em loyees and co era e ill be e ecti e uly e hires co era eill start on the first ay of the month follo in the date of hire and enrollment in the lan eductions ill be in ith the first ay of the

month follo in the date of hire and enrollment in the lan


Most people are not accustomed to questioning their doctors about the insurance plans theyaccept, or the cost and medical necessity of a treatment. Knowing what questions to ask andwhen to ask them makes the process much easier and less stressful! Asking questions ofyour health care providers helps maintain both the cost and quality of your health care. So it’simportant for everyone, regardless of the health care option elected, to ask about the medicalnecessity of any treatment and if there are alternatives to consider.

Be an Informed Health Care Consumer

Here are some tips to help youbecome a good health care consumer■ s your ro ider or his her business o ce

if they acce t your HCPS health care lan fthey do e aluate hat lan is best for you

■ a e notes in ad ance of your o ce isitabout the thin s you ant to as your doctor

ee a list of any sym toms you ha e had orare currently e eriencin ee a list of themedications you ta e hether rescri tionsor o er the counter Share the list ith allhealth care ro iders

■ Brin a s ouse or friend alon ith youchances are if you don t recall somethin that

as said he or she ill

■ Brin a ad and encil to the doctor s o cedon t rely on your memory for e erythin

■ f your doctor uses a term that you do notunderstand as hat it means and as that itbe s elled hen rite it do n and do somemore research once you lea e the o ce

■ Get a co y of any test results

■ f your doctor rites a rescri tion for youas your doctor and harmacist aboutinteractions ith other dru s you may beta in or about side e ects that you maye erience Remember if you are ta inany maintenance medications re uest one

rescri tion for a day su ly from a retailharmacy and another rescri tion for mail

order for u to a day su ly lus u tothree refills

■ f you ha e access to the nternet use it tolearn about your medications or illnesses

he nternet has e cellent information onmany health related sub ects ne res ectedresource is www.webmd.com s your

hysician hich eb sites they belie e arealuable Be sure to let your hysician no

your findin s

■ isit c . e o .come m e o ce be e or

www.c e .com to lin to our health careendor ebsites for more resources

■ Chec the endor ebsites for details onro iders and other useful information

Help control the cost o health careand promote your ell being

n an almost daily basis the risin cost ofhealth care is in the ne s d ances in medicaltechnolo y e ensi e rescri tion dru sconsumer demand and an a in o ulation areust a fe factors that im act health care costs

hile some factors are beyond the control of theconsumer there are some thin s you can do tohel ee health care costs do n—both for youand for HCPS Belo are a fe ti s to hel youbecome a iser consumer of health care

Be an Informed Health Care Consumer


Maintain a healthy lifestyleaintainin your o n health can hel to minimi e

your health care costs he healthier you arethe less li ely you are to need costly health careser ices— hich means you s end less on co aysdeductibles and other medical costs Eat ri ht and

et lenty of e ercise

et e la he sGet a re ular annual chec u and or hysicale am hich can unco er early arnin si ns of

otential health roblems and can also hel youbuild a ood relationshi ith your doctor

a e the e e en y f e e en iesEmer ency room isits are t o to three times moree ensi e than a isit to the doctor s o ce or anur ent care center hese ER isits are not onlycostly but they can be unnecessarily stressful andtime consumin for you and your family if hatyou need is routine care r ent care facilities area ailable in the area and may be used for a arietyof ur ent health roblems for a lo er co ay thanthe ER

et e la s eenin sGet re ular screenin s e mammo ramsas recommended by your carrier andnational or ani ations such as the mericanCancer Society

isit a i a y a e i e ef e in tsee a s e ialistPrimary care ro iders are usually family

ractitioners eneral ractitioners internists orediatricians rimary care ro ider can treat

many illnesses and in uries at a lo er fee inmany cases at half the cost of a s ecialist s feeor e am le you don t necessarily need to see an

ortho edic s ecialist for bac ain Primary carero iders consider your o erall health hey can

ad ise you about disease re ention and hoto stay healthy hey are also familiar ith your

ersonal health history and needs and ha e yourmedical records on file

s f ene ihen you need a rescri tion as your doctor to

rescribe a eneric if one is a ailable Genericsha e the same chemical e ui alency as brandname dru s and are held to the same standardsby the ood and ru dministration but they costless than brand name dru s

e ie y illsRe ie in your health care bills can hel youidentify and re ent unnecessary health carecosts Here s hat to loo for to determine if a billis correct

■ oes the date of ser ice on the bill match thedate you ent to the doctor or the hos ital

■ id you recei e all the ser ices or rocedureslisted on the bill

■ re you char ed for more rays or lab orthan you recei ed Call your ro ider tore ort any errors you s ot on your bills orE lanation of Benefits forms E B s

■ s your share of the cost correct f not callthe insurance ro ider to discuss f there is areferral in ol ed as the referral rocessed

rior to the claim


Enrollment InstructionsEnroll online with web enrollment

he 01 Harford County Public Schools Benefitsen Enrollment ill ta e lace startin ay 1

01 throu h ay 01 eb enrollment o ersyou the con enience to enroll anytime any herethrou h the internet

New hires must enroll in benefits ithin 0 daysof hire or may be forced to ait for the ne t o enenrollment eriod

Before you enroll:■ amiliari e yourself ith your o tions by

readin your 01 benefit uide his uide isalso a ailable at h s h s e e ior h s h s sh re i si esh res r es e e s

■ Ha e the follo in information about youand your de endents

Social Security umber

ate of birth

nformation on other medical co era ethat you and your de endents ha e

o enroll n your ene :■ sin a com uter ith nternet o to

h s h s e e i Enter in addressfield not search

■ Enter your ser HCPS di it Em loyeee hires should use their Social Security

umber ith no dashes

■ Enter your ass ord or clic on or ot erwor e hires enter the last four di its of

your Social Security umber

■ Chan e your ass ord if you lo into theebsite a ain you ill need this ne ass ord

■ ollo the instructions on the ebsite and enrollin your 01 benefits

■ Re ie your elections to chec for errorshi hli hted in yello

■ Confirm that you ha e lin ed all de endents tothe co era e in hich they are to be enrolled

■ S clic on the bmit button to ha eyour elections rocessed

■ E PR R E R E S R

■ f de endents ha e been added to yourco era e submit the de endent erificationform and re uested documentation to thebenefits o ce see a e

ou may ma e chan es to your benefits on theenrollment ebsite durin o en enrollment from

ay 1 01 until midni ht on ay 01 helast elections that you sa e ill be your benefitsbe innin uly 1st 01

he ebsite may be una ailable eriodically durin yourenrollment eriod for routine maintenance

Remember your selections made durin o enenrollment ill be e ecti e uly 1 01 Benefitsfor all ne hires ill be e ecti e the first of themonth follo in your date of hire

■ f you choose to oin Care irst Health eltaental le ible S endin or et ife nsurance

Pro rams com lete the online enrollmentrocess

■ Remember if you ish to add or chan eco era e you must com lete the onlineenrollment rocess

■ e hires must submit erification of eli ibilityfor all de endents on your account

■ Current em loyees must submit erificationof eli ibility for all ne de endents addedto co era e

ny em loyee needin assistance ith enrollmentshould call the Benefits ce at 10

onday riday 0 a m 0 m

o l e ur y nu er re u reue to ne re ortin re uirement under the

ordable Care ct e are re uired to ro idere orts to the RS he RS re uires that there orts include each co ered erson s includinde endents social security number SS hichis the rimary identifier used by the RS herefore

e must ha e the SS for all enrollees in an HCPShealth lan


BlueChoice HMO Open AccessNo referrals required

Take advantage of your benefits■ net or of almost Care irst BlueChoice

ro iders PCPs nurse ractitioners s ecialistshos itals harmacies ur ent care centerscon enience care clinics and dia nosticcenters in aryland ashin ton C and

orthern ir inia

■ fter hours care includin a free hournurse ad ice line ideo isits con eniencecare clinics and ur ent care centers

■ cost for com rehensi e re enti e healthcare isits

■ Predictable co ays and deductiblesif a licable

■ he ay from Home Care ro ram allo syou to ta e your lan benefits ith you ifyou re out of the area for at least days

■ Co era e for emer ency or ur ent care if youare outside Care irst BlueCross BlueShield sser ice area aryland ashin ton C and

orthern ir inia

With BlueChoice HMO, your primary care provider (PCP) provides routine care and coordinatesspecialty care. This plan also allows you to visit specialists directly—no referrals needed. Wealso offer online tools and resources at carefirst.com that give you the freedom and flexibilityto manage your health care and wellness goals wherever you are.

enefits at a g an erevent ve are and s k o e v s tsou are co ered for all re enti e care asell as sic o ce isits

arge rov der net orkou can choose any doctor from our

lar e net or of ro iders ur net oralso includes s ecialists hos itals and

harmacies— i in you many o tions foryour health care

e a st serv esour co era e includes ser ices from

s ecialists ithout a referral S ecialistsare doctors or nurses ho are hi hlytrained to treat certain conditions suchas cardiolo ists or dermatolo ists

res r t on drug overageour lan co ers rescri tion dru s

os ta serv esou re co ered for o erni ht hos ital

stays ou re also co ered for out atientser ices those rocedures you et inthe hos ital ithout s endin the ni ht

our PCP or s ecialist must ro ide riorauthori ation for all hos ital ser ices

abs rays or s e a ty ag ng Co ered ser ices include ro iderordered lab tests rays and others ecialty ima in tests R C scanPE scan etc

BlueChoice HMO Open Access


Well-child visitsll ell child isits and immuni ations

are co ered

te it d e c c eou are co ered for doctor isits before

and after your baby is born includinhos ital stays f needed e also co erhome isits after the baby s birth

e t l he lth ds st ce se dis de

our co era e includes beha ioral healthtreatment such as sychothera y andcounselin mental and beha ioral healthin atient ser ices and substance usedisorder treatment

l sCare irst BlueCross BlueShield has the re ion slar est net or for doctors harmacies hos italsand other health care ro iders that acce t ourhealth lans Because net or s ary amonCare irst health lans ma e sure you re familiar

ith your s ecific lan s net or

e e tste elect

Establishin a relationshi ith one doctor isthe best ay to recei e consistent uality healthcare hen you enroll in a BlueChoice H en

ccess lan you select a PCP—either a hysicianor nurse ractitioner—to mana e your rimarymedical care a e sure you select a PCP foryourself and each of your co ered family members

our PCP must artici ate in the Care irstBlueChoice ro ider net or and must s eciali ein family ractice eneral ractice ediatrics orinternal medicine

o ensure that you recei e the hi hest le el ofbenefits and ay the lo est out of oc et costsfor all ser ices see your PCP for re enti e androutine care

te eet ded cti le i lic lef your lan re uires you to meet a deductible youill be res onsible for the cost of your medical care

u to the amount of your deductible Ho e er thisdeductible does not a ly to all ser ices

E am les of in net or ser ices not sub ectto deductible

■ dult re enti e isits ith PCP

■ ell child care and immuni ations ith PCP

■ B G isits and a tests

■ ammo rams

■ Prostate and colorectal screenin s

■ Routine renatal maternity ser ices

te l ill st t t se vicesour full benefits ill become a ailable once your

deductible if a licable is met as lon as you isitartici atin Care irst BlueChoice doctors and

facilities e endin on your articular lan youmay also ha e to ay a co ay or coinsurance henyou recei e care

eductible re uirements ary based on hetheryour co era e is an indi idual or family lan fmore than one erson is co ered under your lan

lease refer to your Certificate of Co era e fordetailed information on deductibles

te t- - c et iour out of oc et ma imum is the ma imum

amount you ill ay durin your benefit eriodny amount you ay to ard your deductible if

a licable and most co ays and or coinsuranceill count to ard your out of oc et ma imum

Should you reach your out of oc et ma imumCare irst ill then ay 1 ercent of the allo edbenefit for all co ered ser ices for the remainder ofthe benefit eriod

Please ee in mind that out of oc etre uirements also di er if your co era e is anindi idual or family lan etailed information onout of oc et ma imum amounts can be found inyour Certificate of Co era e

his is not a com lete list of all ser ices or a com rehensi e e lanation of your co era e lease chec your E idence of Co era e

BlueChoice HMO Open Access


Labs, X-rays or specialty imagingo et the most economical use out of your

laboratory benefits you must isit a abCorfacility for any laboratory ser ices Ser ices

erformed at a facility that isn t art of the abCornet or ill not be co ered under your lan

lso any lab or erformed in an out atienthos ital settin ill re uire a rior authori ationfrom your PCP

abCor has a ro imately locationsthrou hout aryland ashin ton C and

orthern ir inia o locate a abCor atientser ice center near you call B C RP

or isit labcorp.com

ia nostic ima in centers ha e e ui mentto roduce arious ty es of radiolo ic andelectroma netic ima es such as raysmammo rams C and PE scans and a

rofessional sta to inter ret the ima es f youneed rays or other s ecialty ima in ser ices youmust isit a artici atin freestandin non hos italdia nostic center such as d anced Radiolo y

t-o -area co erageut of area co era e is limited to emer ency or

ur ent care only Ho e er members and theirco ered de endents lannin to be out of theCare irst BlueChoice nc ser ice area for at least

consecuti e days may be able to ta e ad anta eof a s ecial ro ram ay rom Home Care

his ro ram allo s tem orary benefits throu hanother Blue Cross and Blue Shield a liated Ht ro ides co era e for routine ser ices and iserfect for e tended out of to n business or

tra el semesters at school or families li in a art

or more information on ay rom Home Carelease call ember Ser ices at the hone number

listed on your card

P ■ C


Away From Home CareYour HMO coverage goes with you

We’ve got you covered when you’re away from home for 90 consecutive days or more.Whether you’re out-of-town on extended business, traveling, or going to school out-of-state,you have access to routine and urgent care with our Away From Home Care program.

Coverage while you’re awayou re co ered hen you see a ro ider of an

a liated Blue Cross Blue Shield H Host Houtside of the Care irst BlueChoice nc ser icearea aryland ashin ton C and orthern

ir inia f you recei e care then you re considereda member of that Host H recei in the benefitsunder that lan So your co ays may be di erentthan hen you re in the Care irst BlueChoiceser ice area ou ll be res onsible for any co aysunder that lan

rolli g i way ro o e Careo ma e sure you and your co ered de endents

ha e on oin access to care

■ Call the ember Ser ice hone numberon your card and as for the ay romHome Care Coordinator

■ he coordinator ill let you no the nameof the Host H in the area If there are noparticipating affiliated HMOs in the area,the program will not be available to you.

■ he coordinator ill hel you choose arimary care hysician PCP and com lete

the a lication nce com leted thecoordinator ill send you the a lication tosi n and date

■ nce the a lication is returned e ill sendit to your Host H

■ he Host H ill send you a netem orary card hich ill identify yourPCP and information on ho to access yourbenefits hile usin ay rom Home Care

■ Sim ly call your Host H rimary carehysician for an a ointment hen you

need care

o a erwor or u ro once you are enrolled in the ro ram and recei e

care you don t ha e to com lete claim forms sothere is no a er or nd you re only res onsiblefor out of oc et e enses such as co aysdeductibles coinsurance and the cost of nonco ered ser ices

l ays remember to carry your cardto access ay rom Home Care

BRC 1P 1


Triple OptionOpen Access

Benefits of the Triple OptionOpen Access plan■ he ability to isit ro iders from either our

BlueChoice et or Care irst PP et orational PP et or or out of arearo iders

■ o PCP referral re uired to see a s ecialist

■ Recei e co era e for re enti e health careser ices at no cost

■ a e your health care benefits ith you—across the country and around the orld

o o r plan or sou ill be res onsible for the entire cost of your

medical care u to the amount of your deductiblefor ser ices here the deductible a lies nceyour deductible is satisfied your ri le tionco era e ill become a ailable to you

ith the ri le tion en ccess lan you canisit any ro ider of your choosin our out ofoc et costs are determined by ho you decide

to see

In-network benefits ro ide a hi her le el ofco era e meanin you ha e lo er out of oc etcosts Out-of-network benefits ro ide a lo erle el of co era e in e chan e for the freedom tosee care from any ro ider you choose

our in and out of net or benefits are or ani edinto three le els of co era e

Level 1: or your lo est and most redictable innet or out of oc et costs choose a BlueChoice

ro ider ou can isit any of the BlueChoicero iders ithin aryland ashin ton C

and orthern ir inia isit our online ro ider

Triple Option Open Access offers you the freedom to visit any provider you wish. You have theflexibility to choose from both in- and out-of-network providers with your out-of-pocket costsdetermined by your choice. There is no need to choose a primary care provider (PCP) or toobtain a referral before visiting a specialist.

directory at carefirst.com/doctor to locate innet or ro iders

Remember you ha e direct access to Care irstBlueChoice s ecialists ithout needin to obtain areferral from your PCP

Level 2: o recei e le el in net or benefits isita ro ider ho artici ates in either

■ he Care irst PP et or C andorthern ir inia or

■ he national BlueCard PP net or of o erdoctors and hos itals

o locate a PP ro ider isit carefirst.com/doctor

Level : his le el of co era e is out of net orand o ers you the most e ibility n e chan e fora lo er le el of co era e you ha e the freedom tosee care from any ro ider you choose

f you recei e ser ices from a ro ider ho doesnot artici ate in any of the net or s listed abo eyou may ha e to

■ Pay the ro ider s actual char e at the timeyou recei e care

■ ile a claim for reimbursement

■ Satisfy a hi her deductible and orcoinsurance amount

n eneral out of net or ro iders do not ha ean a reement ith Care irst to acce t the allo edbenefit as ayment in full for their ser ices

herefore if you recei e ser ices from a nonartici atin ro ider you may be balance billed

based on the ro ider s actual char e

Triple Option


Certain services under this level of coveragerequire you to meet a deductible. Check yourbenefits enrollment guide for details. Whenapplicable, you are responsible for the entire costof your medical care up to the amount of yourdeductible. Once your deductible is satisfied,your coverage will become available. Dependingon the service, you may have to pay a copay orcoinsurance when you receive care.

Laboratory serviceso receive the ma imum laboratory benefit from

your riple Option plan, you must use a abCorpfacility for any laboratory services. ab servicesat any other independent lab will be processedat evel or evel based on the laboratory snetwork status. lso, any lab work performed

in an outpatient hospital setting will require aprior authori ation.

abCorp has appro imately 1 locationsthroughout aryland, Washington, D.C. and

orthern irginia. o locate the abCorp patientservice center near you, call B CORP

6 or visit www.labcorp.com.

os ita a t ori ation network providers will obtain any necessary

admission authori ations for in area aryland,Washington, D.C. and orthern . ou will beresponsible for obtaining authori ation for servicesprovided by out of network and out of areaadmissions. Call toll free PRE H .

a esatie t os ita tay ai

rovi er tat se e t Leve

o tar e

o ee e t

are irst e rosse ie ays e ber ays

BlueChoice evel 1 1 , ,16 ,11 deductible

PPO evel 1 , ,1 ,1 deductible

Participating evel 1 , 1 , , 1 , deductible then B,

on participatingevel

1 , 1 , , 1 6, deductible then B, balance to charge

,6

ri ary are rovi er ce isit


o tar e

o ee e t


BlueChoice evel 1 1 6 1 O ce isit copay

PPO evel 1 O ce isit copay

Participating evel 1 Deductible applied


1 1 deductible plus balance tocharge

ater ity rovi er e ivery ar e


o tar e

o ee e t


BlueChoice evel 1 , 6 ,616 ,616 1 B Deductible was already met

PPO evel , 6 , 6 , 6 1 B Deductible was already met

Participating evel , 6 , ,616 Deductible was already metB


, 6 , ,616 , Deductible was met B di erence to charge

1,

Participating Provider— physician or other provider who has signed an agreement with Care irst BlueCross BlueShield to accept the llowedBenefit as payment in full.


Preferred Provider OrganizationA referral-free go anywhere health plan

Designed for today’s health conscious and busy families, the Preferred Provider Organization(PPO) plan offers one less thing to worry about during your busy day. Your PPO plan gives youthe freedom to visit any provider you wish—any time you wish. This means you can receivecare from the provider of your choice without ever needing to select a primary care provider(PCP) or obtaining a PCP referral for specialist care.

Benefits of PPO■ ccess to our net or of more than

doctors s ecialists and hos itals in arylandashin ton C and orthern ir inia

■ o rimary care ro ider re uired and noreferrals to see a s ecialist

■ a e your health care benefits ith you—across the country and around the orld

■ Recei e co era e for re enti e health careisits at no cost

■ oid balance billin hen you recei e carefrom a referred ro ider

■ En oy the freedom to isit ro iders outsideof the PP net or and still be co ered but

ith a hi her out of oc et cost

o o n o sn net o s o t of net o o e ehe amount of co era e your PP lan o ers

de ends on hether you see a ro ider in thePP net or referred ro ider ou ill al aysrecei e a hi her le el of benefits hen you isit a

referred ro ider Ho e er the choice is entirelyyours hat s the ad anta e of a PP lan

In-network benefits ro ide a hi her le el ofco era e his means you ha e lo er out of oc etcosts hen you choose a referred ro ider fyou are out of the Care irst BlueCross BlueShieldCare irst ser ice area you ha e the freedom to

select any ro ider that artici ates ith a BlueCross and Blue Shield PP lan across the countryand recei e benefits at the in net or le el

o referrals o PCPsCo era e e ery here

P

Preferred Provider Organization


Out-of-network benefits provide a lower levelof coverage in exchange for the freedom to seekcare from any provider you choose. If you receiveservices from a provider outside of the PPOnetwork (non-preferred provider), you may have to:

■ Pay the provider s actual charge at the timeyou receive care.

■ ile a claim for reimbursement.

■ Satisfy a higher deductible and orcoinsurance amount.

Hospital authorization/Utilization managementPreferred providers will obtain any necessaryadmission authori ations for in-area coveredservices. ou will be responsible for obtainingauthori ation for services provided by non-preferred providers and out-of-area admissions.Call toll-free 888-PRE- H ( - 88 ).

our ene tstep eet our e u ti leou will be responsible for the entire cost of your

medical care up to the amount of your deductiblefor services where the deductible applies. Onceyour deductible is satisfied, your PPO coverage willbecome available to you.

ollowing is a list of services for which thedeductible does O apply in-network:

■ Preventive care, including well child care,routine physical exam, routine gynecologicalexam and routine mammography

■ O ce isits for Illness

■ Physical, Speech and Occupational herapy

■ Chiropractic Care

■ O ce isits for ental Health and Substancebuse

PPO CORE members will have a di erentdeductible amount for in-network vs. out-of-network benefits. However, any amount applied toyour in-network deductible will also count towardsyour out-of-network deductible and vice versa.

If more than one person is covered under yourPPO plan, once the family deductible amount issatisfied, the plan will start to make payments for

everyone covered. eductible re uirements varybased on your coverage level (e.g. individual, family).

embers should refer to their Evidence of Coveragefor detailed deductible information.

tep our plan ill start to paor ser i esfter you satisfy your deductible, your PPO plan will

start to pay for covered services. he level of thosebenefits will depend on whether you see preferredor non-preferred providers.

tep our out o po et ma imumour out-of-pocket maximum is the maximum

amount you will pay during your benefit period.Should you reach your out-of-pocket maximum,Care irst will then pay 1 of the allowed benefitfor most covered services for the remainder of thebenefit period. ny amount you pay toward yourdeductible and most copays and or coinsurancewill count toward your out-of-pocket maximum.

ou will have a di erent out-of-pocket maximumfor in-network vs. out-of-network benefits.However, deductible amounts applied to yourin-network out-of-pocket maximum will alsocount toward your out-of-network out-of-pocketmaximum and vice versa.

If more than one person is covered under yourPPO plan, once the total out-of-pocket maximumis satisfied, no copays or coinsurance amounts willbe re uired for anyone covered under your plan.Out-of-pocket maximum re uirements vary basedon your coverage level (e.g. individual, family) as wellas the specific PPO plan selected. embers shouldrefer to their Certificate or Evidence of Coverage fordetailed out-of-pocket maximum information.

ut o area o erageou have the freedom to take your health care

benefits with you—across the country and aroundthe world. BlueCard PPO, a program from the BlueCross and Blue Shield ssociation, allows you toreceive the same health care benefits when receivingcare from a BlueCard preferred provider whileliving or traveling outside of the Care irst servicearea ( aryland, ashington, .C. and orthern

irginia). he BlueCard program includes morethan ,1 hospitals and , other health careproviders nationally.


BlueCard & Global CoreWherever you go, your health care coverage goes with you

With your Blue Cross and Blue Shield member ID card, you have access to doctors andhospitals almost anywhere. BlueCard gives you the peace of mind that you’ll always havethe care you need when you’re away from home, from coast to coast. And with Blue CrossBlueÿShield Global Core (Global Core) you have access to care outside of the U.S.

our membershi i es you a orld of choices ore than of alldoctors and hos itals throu hout the S contract ith Blue Crossand Blue Shield lans hether you need care here in the nitedStates or abroad you ll ha e access to health care in more than

countries

hen you re outside of the Care irst BlueCross BlueShield andCare irst BlueChoice nc ser ice area aryland ashin ton

C and orthern ir inia you ll ha e access to the local BlueCross Blue Shield Plan and their ne otiated rates ith doctors andhos itals in that area ou shouldn t ha e to ay any amount abo ethese ne otiated rates lso you shouldn t ha e to com lete a claimform or ay u front for your health care ser ices e ce t for thoseout of oc et e enses li e non co ered ser ices deductiblesco ayments and coinsurance that you d ay any ay

Within the U.S.l ays carry your current member card for easy reference

and access to ser ice

o find names and addresses of nearby doctorsand hos itals isit the ational octor and Hos italinder at www.bcbs.com or call BlueCard ccess at

B E

Call ember Ser ices for re certification or riorauthori ation if necessary Refer to the hone number onyour card because it s di erent from the BlueCard ccessnumber listed in Ste

hen you arri e at the artici atin doctor s o ce or hos italsim ly resent your card

fter you recei e care you shouldn t ha e to com lete anyclaim forms or ha e to ay u front for medical ser ices otherthan the usual out of oc et e enses Care irst ill send youa com lete e lanation of benefits

s al ays o directly tothe nearest hos ital inan emer ency

BlueCard & Global Core


Around the worldi e your ass ort you should al ays carry your

card hen you tra el or li e outside the S heBlueCard orld ide ro ram ro ides medicalassistance ser ices and access to doctors hos italsand other health care rofessionals around the

orld ollo the same rocess as if you ere inthe S ith the follo in e ce tions

■ t hos itals in the Global Core et or youshouldn t ha e to ay u front for in atientcare in most cases ou re res onsible forthe usual out of oc et e enses nd thehos ital should submit your claim

■ t hos itals outside the Global Coreet or you ay the doctor or hos ital for

in atient care out atient hos ital care andother medical ser ices hen com lete aninternational claim form and send it to theGlobal Core Ser ice Center he claim form isa ailable online at bcbs.globalcore.com

■ o find a BlueCard ro ider outside of theS isit bcbs.com select Find a Doctor

or Hospital.embers of aryland Small Grou Reform SGR rou s ha e

access to emer ency co era e only outside of the S

ed l t n e whenout de theCall 00 0 B E 2 toll free or 02 hours a day days a ee for information ondoctors hos itals other health care rofessionalsor to recei e medical assistance ser ices medicalassistance coordinator in con unction ith amedical rofessional ill ma e an a ointment

ith a doctor or arran e hos itali ationif necessary

isit bcbs.com to find ro iders ithinthe S and around the orld

BRC 2 0 P

BlueCard & Global Core


Your pharmacy benefit program is now administered by CVS Caremark. This program is basedon the CareFirst Formulary 2, that encourages the use of Generic drugs and certain Branddrugs. You pay a different copay depending on whether you choose a Generic drug, a Branddrug on the Preferred Drug List, or a Non-preferred Brand drug. Always remember to talk toyour doctor about using Preferred drugs that can save you money. You and your doctor shouldcheck your Preferred Drug List before you receive a prescription.

CareFirst Prescription Drug ProgramFor BlueChoice HMO, Triple Option and PPO Plans

Retail programhe retail ro ram ro ides a day or less su ly

of medication hen urchased at a artici atinretail harmacy Present your rescri tion druidentification card at any artici atin harmacyand ay the a ro riate co ayment for yourmedication aintenance medication hen

urchased at a artici atin harmacy is dis ensedu to a day su ly for one co ay for ri le

tion and PP C RE Plan members and t oco ays for H Plan members

ail or er er i epre riptio program

our mail order rescri tion dru ro ram isadministered by C S Caremar he ail rderSer ice Prescri tion Pro ram is a s ecial addedfeature to your Care irst Plan or those hore ularly ta e one or more ty es of maintenancemedication this ser ice ro ides a con enientine ensi e ay for you to order thesemedications and ha e them deli ered at home

or ri le tion you can order u to a daysu ly of maintenance medication for timesthe co ayment or PP C RE youcan order u to a day su ly of maintenancemedication for times the re uired co ayment

or H you can order a daysu ly of maintenance medication for times theco ayment he co ayment cannot bereimbursed throu h your edical Benefits Plan

edications are deli ered to your home osta eaid ia PS or irst Class S ail

f you ha e any uestions re ardin thisrescri tion ser ice call the Care irst

Pharmacy Ser ices toll free tele hone numberonday throu h riday a m m and

Saturday a m m at

CareFirst Prescription Drug Program


Refill guidelinesRefills ill not be authori ed on any rescri tionsuntil 2 or less of the ori inal uantity isremainin in your ossession has been used

i n su lSince your ro ram has a nation ide net or inmost cases there are se eral area artici atin

harmacies a ailable hen on acation ou mayobtain a ritten rescri tion from the hysician

rior to lea in and obtain a list of harmacies inthe area in hich you ill be tra elin

■ f you are tra elin out of the countryfor less than one month call Care irstPharmacy Ser ices at 2 torecei e authori ation for an additional shortterm su ly

■ or additional uantities reater than onemonth lease contact Care irst emberSer ices usin the number on your card

Please call no less than days in ad ance of yourde arture date to re uest the additional su ly

n i i ingf a harmacy is non artici atin you ill be

re uired to ay the full cost of the rescri tionat the time of urchase Claims for these

rescri tions should be submitted on thea ro riate claim form

C S Caremar claim forms are a ailable onthe Care irst ebsite at carefirst.com or youcan contact Care irst Pharmacy Ser ices at

2

ene i d ug e l ess enedi ll ne ess

hen members cannot ta e the Genericmedication due to medical reasons themember s hysician ould be re uired tosu ly medical ustification for rescribinthe Brand medication

2 he member s hysician must initiate there uest rocess by com letin the C S BrandE em tion orm a ailable on Share ointBenelo ic and hc s or

Re uests ill be for arded directly to C SCaremar Re uests ill be re ie ed andturned around ithin 2 business days hensubmitted durin business hours

nce the a eal is recei ed and a ro alis i en by C S Caremar the rescribin

hysician and the harmacy are ro idednotification of the a eal and the harmacy

ill be re uested to re rocess the claim

he a ro al of a Brand medication ill bealid for 2 months from the ori inal fill date

of the medication


S P

Rx Choice Pharmacy NetworkWith the Rx Choice network, you can purchase your prescription medications from any of59,000 in-network pharmacies located around the corner and across the country.

The Rx Choice network contains 59,000pharmacies nationwide.

Please note: your co era e onlyro ides benefits for harmaciesithin the net or f you choose to

use an out of net or harmacy yourrescri tions ill not be co ered

R Choice i es you access to both inde endentand national harmacies includin

■ C S

■ almart

■ ar et

■ Safe ay

■ ro er

■ Rite id

Finding and using in-networkpharmacies

f your harmacy is already in the net oryou don t ha e to do anythin

f your current harmacy is not in theR Choice net or and you ant to transferan e istin rescri tion to a net or

harmacy sim ly ta e your currentmedication label to the ne harmacy andthey ill handle the rest

o chec to see if your harmacy is in thenet or

hen your benefits are e ecti e lo in tocco nt at a e st o a o nt

Go to r and harmac Reso rces andselect ind a harmac

r call Care irst Pharmacy Ser ices at


SUM2379-1P (9/18)_C ■ All Access (Mandatory)

Maintenance Choice All AccessFill your maintenance drug prescriptions withMaintenance Choice All Access

Maintenance Choice All Access o ers you o tions and sa in s hen fillin your maintenance medicationsMaintenance medications are used to treat chronic lon -term conditions such as hi h blood ressure ordiabetes and are ta en on a re ular recurrin basis ith Maintenance Choice All Access maintenancemedication must be urchased at a C S harmacy or throu h C S Mail Ser ice Please see chart on a e 2and 3 -37 for s ecific lan co ay amounts

With CVS Caremark Mail Service, you can:■ En oy con enient home deli ery ser ice

■ Refill your rescri tions online by honeor email

■ Chec account balances and ma e aymentsthrou h an automated hone system

■ Si n u to recei e email notifications oforder status

■ Access a harmacist by hone 24 hours a day

t a CVS harmacy retail location, youÿcan:■ Access the C S Pharmacy net or

■ al ith a harmacist face-to-face

■ Pic u your medications at a timecon enient to you or

■ Choose a deli ery o tion for your maintenanceand short-term medications as ell as otherselect health care items

ne to t o-day deli ery to any addressithin miles of a C S Pharmacy (includin

C S Pharmacy in ar et stores) at noadditional cost

n-demand deli ery for 7 to recei e yourorder ithin four hours

you oul like heno re ister for C S Mail Ser ice Please let us know.

ou can do so uic ly and easily Choose the o tion that or s best for you■ nline Go to a e st. o a ount to lo in or re ister for My Account

Under the Co era e tab select rug and harmacy esources and selecte uest a ew Mail rder rescription

■ By hone Call the Pharmacy hone number on the bac of your membercard ur Customer Care re resentati es can al you throu h the rocess

o find a C S Pharmacyretail location

Go to a e st. o a ount to lo in or re ister for My Account Clicrug and harmacy esources and select Find a harmacy to find a location

con enient for you

ithin a 1 mile radius of a C S Pharmacy for on-demand deli ery orders must be laced at least four hours before the harmacy closes

or more information call the Pharmacy number on the bac of your member card


CareFirst Drug Program Summary of BenefitsFormulary 2

Plan FeatureBlueChoiceHMO Open

AccessTriple Option PPO CORE Description

Deductible one one one our benefit does not ha e adeductible

Prescription DrugOut-of-PocketMaximum

ndi idualamily

ndi idualamily

ndi idualamily

our benefit does not ha e a familydeductible ma imum

Preventive Drugsu to a day su ly not sub ect to

deductiblenot sub ect todeductible

not sub ect todeductible

re enti e dru is a rescribedmedication or item on Care irst sPre enti e ru ist

Oral Chemotherapy &Diabetic Suppliesu to a day su ly

iabetic su lies include needleslancets test stri s and alcohol s abs

Generic Drugs(Tier 1)u to a day su ly

Generic dru s are co ered at this co ayle el

Preferred BrandDrugs (Tier 2)u to a day su ly

ll referred brand dru s are co eredat this co ay le el

Non-Preferred BrandDrugs (Tier 3)u to a day su ly

ll non referred brand dru s on thisco ay le el are not on the Preferred

ru ist iscuss usin alternati esith your hysician or harmacist

Maintenance Copaysu to a day su ly

aintenance medication must beurchased at a C S harmacy or

throu h ail Ser ice for a daysu ly

Retail C S onlyGenericPreferred

on referredail rderGenericPreferred

on referredPrior Authorization Some rescri tion dru s re uire Prior uthori ation Prior uthori ation is a tool used

to ensure that you ill achie e the ma imum clinical benefit from the use of s ecifictar eted dru s our hysician or harmacist must call to be in the riorauthori ation rocess or the most u to date rior authori ation list isit the rescri tiondru ebsite at carefirst.com/rxgroup

Mandatory GenericSubstitution

f you choose a on referred Brand dru ier instead of its Generic e ui alent you illay the hi hest co ay lus the di erence in cost bet een the on referred Brand dru

and the Generic f a Generic ersion is not a ailable you ill only ay the co ay


Prescription Drug ProgramA total prescription for health

Prescription drugs are an integral part of high-quality health care. The prescription benefitsyour employer is offering give you an affordable and convenient way to make the bestdecisions when it comes to your prescriptions.

Your prescription benefitss a Care irst BlueCross BlueShield or Care irst

BlueChoice nc Care irst member you ll ha eaccess to

■ nation ide net or of more than 6artici atin harmacies

■ early co ered dru s

■ ail Ser ice Pharmacy a con enient and fasto tion to refill your rescri tions throu hhome deli ery

■ Coordinated medical and harmacyro rams to hel im ro e your o erall health

and reduce costs

eepin ou in or eo ether ith our harmacy benefit mana er C S

Caremar e ee you informed about yourrescri tion dru co era e and ro ide you itheriodic u dates about your lan throu h tar eted

mailin s and hone calls a e the call and orre ie your mailed notices to learn about lo ercost dru alternati es ossible safety concernsdru tier chan es and more

n ine too s n resourceso et the most from your rescri tion drulan you need to stay informed ur easy to use

interacti e tools and resources are a ailable 2isit carefirst.com/rxgroup to see if a dru is

co ered find a harmacy learn ho dru s interactith each other and et more information about

medications ou can access e en more toolsand resources once you re a member throu h

Acco nt by selectin r an har aceso rces under ic in s

C S Caremar is an inde endent com any that ro ides harmacy benefit mana ement ser ices to Care irst members

Prescription Drug Program


Understanding your formulary—Formulary 2formulary is a list of co ered rescri tion dru s ur dru list is re ie ed and a ro ed by an inde endent

national committee com rised of hysicians harmacists and other health care rofessionals ho ma e surethe dru s on the formulary are safe and clinically e ecti e he rescri tion dru s found on the Care irstormulary dru list are di ided into tiers hese tiers include ero dollar cost share enerics referred brand

and non referred brand dru s our cost share is determined by the tier the dru falls into

rug tier es ri tion

ier rugs ■ Pre enti e dru s e statins as irin folic acid uoride iron su lementssmo in cessation roducts and a ro ed contrace ti es for omenare a ailable at a ero dollar cost share if rescribed under certain medicalcriteria by your doctor

ier eneri rugs ■ Generic dru s are the same as brand name dru s in dosa e form safetystren th route of administration uality erformance characteristics andintended use

■ Generic dru s enerally cost less than brand name dru s

ier 2 referred randrugs

■ Preferred brand dru s are brand name medications that do not ha e aeneric e ui alent

■ hey are chosen for their cost e ecti eness to alternati es■ our cost share ill be more than eneric dru s but less than non referred

brand dru s■ f a eneric dru becomes a ailable the referred brand dru ill be mo ed

to the non referred brand tier

ier on referredrand rugs

■ on referred brand dru s often ha e a eneric or referred brand druo tion here your cost share ill be lo er

ote f the cost of your dru is less than your co ay or coinsurance you only ay the cost of the dru nce you meet your deductible ifa licable to your lan you may ay a di erent co ay or coinsurance for dru s de endin on the dru tier Some dru s may not be co eredbased on your lan here is an e ce tion rocess if you need an e cluded dru to be co ered for medical necessity reasons Chec yourbenefit summary or enrollment materials for s ecific lan information nce you are a member you can ie s ecific cost share information inMy Account.

referred rug istCare irst s Preferred ru ist includes eneric and

referred brand dru s selected for their ualitye ecti eness and safety by the C S Caremarnational Pharmacy and hera eutics P&committee By usin the Care irst Preferred ruist you can or ith your doctor or harmacist

to ma e safe and cost e ecti e decisions to bettermana e your health care and out of oc et costs

on referred dru s aren t included on thePreferred ru ist they are still co ered but atthe hi hest cost share lso some dru s on thePreferred ru ist may not be co ered basedon your lan o see your full formulary o tocarefirst.com/rxgroup



Prescription guidelinesSome medications are only intended to beused in limited uantities others re uire thatyour doctor obtain rior authori ation throu hCare irst before they can be filled hese dru

uidelines are indicated on the formulary found atcarefirst.com/rxgroup

■ ua t t m ts ha e been laced on theuse of selected dru s for uality or safetyreasons imits may be laced on the amountof the dru co ered er rescri tion or for adefined eriod of time

■ r or aut or at o is re uired before you fillrescri tions for certain dru s our doctor

must obtain a ro al from Care irst beforethese dru s are co ered

■ tep t erap as s that you try lo er coste ually e ecti e dru s that treat the samemedical condition before tryin a hi hercost alternati e Prior to ettin the hi hercost alternati e your doctor must recei ea ro al from Care irst

s to s eHere are some ays to hel you sa e on your rescri tion dru costs

■ se ge er c rugs— eneric dru s can cost u to 8 ercent less than their brand namecounter arts ade ith the same acti e in redients as their brand name counter arts enerics arealso e ui alent in dosa e safety stren th uality erformance and intended use

■ se rugs o t e re erre rug st—the Preferred ru ist identifies eneric and referredbrand dru s that may sa e you money

■ se ma te a ce me cat o s—maintenance medications are dru s you ta e re ularly foron oin conditions such as diabetes hi h blood ressure or asthma aintenance medicationmust be urchased at a C S harmacy or throu h ail Ser ice for a day su ly

■ se ma or er—by usin our ail Ser ice Pharmacy you et the added con enience of ha in yourrescri tions deli ered ri ht to your home

o s to llet il p r ciesith access to more than harmacies across

the country you can isit carefirst.com/rxgroup anduse our Find a Pharmacy tool to locate a con enient

artici atin harmacy Be sure to ta e yourrescri tion and member card ith you hen

fillin rescri tions

il er ice P r cail Ser ice Pharmacy is a con enient ay to fill

your rescri tions es ecially for refillin dru sta en fre uently ou can re ister three ays—online throu h y cc n by hone or by mail

nce you re ister for ail Ser ice Pharmacy you llbe able to

■ Refill rescri tions online by hone orby email

■ Choose your deli ery location

■ Consult ith harmacists by hone 2

■ Schedule automatic refills

■ Recei e email notification of order status

■ Choose from multi le ayment o tions



S P C

he ro ram or s ith your doctor to ensure thatyou are not only ta in the best dru s to mana eyour conditions but you are also able to ta e yourdru s as rescribed

Medication Therapy Management Programa in medications as rescribed not only hel s

im ro e your health but can also reduce yourhealth care costs Care irst s edication hera y

ana ement ro ram is desi ned to hel you etthe best results from your dru thera y

e re ie harmacy claims for o ortunities to

■ Sa e you money

■ Su ort com liance ith medications

■ m ro e your care

■ Ensure safe use of hi h ris medications

hen o ortunities are identified rud isories ill be communicated to either you

and or your doctor re ardin your dru thera yhrou h our Pharmacy d isor ro ram you may

also ha e the o ortunity to s ea one to one itha harmacist ho can ans er uestions and helyou mana e your rescri tion dru s

are management programo ether ith C S Caremar our harmacy benefit

mana er e o er care mana ement ro ramsand tools desi ned to im ro e your health hilelo erin your o erall health care costs

pecia ty Pharmacy oordination Programhe S ecialty Pharmacy Coordination Pro ramro ides ersonali ed care for our members ith

certain chronic conditions li e rheumatoid arthritisor cancer re uirin the use of s ecialty dru sor certain chronic conditions you ill recei e

enhanced one on one su ort ith a re isterednurse and dedicated clinical team ho illcoordinate care ith your doctor

he ro ram ro ides

■ hour harmacist assistance

■ n ection trainin coordination

■ Educational materials for yours ecific condition

■ ru interaction monitorin and re ie

■ ru s mailed to your home or o ceor a ailable for ic u at any C Sretail harmacy

■ Refill reminders

omprehen i e Medication e iehen you are ta in multi le dru s to treat a

medical condition it can be o er helmin heCom rehensi e edication Re ie ro ram canconnect you ith a C S Caremar harmacist

ho ill re ie your dru s and tal to your doctorabout dosa es duration and any other ertinentissues he harmacist ill or ith your doctorto e aluate o ortunities to

■ dentify ossible dru interactions

■ m ro e dru adherence

■ Reduce a s in care

■ Eliminate du lications in dru thera y

Should you ha e any uestions aboutyour rescri tion benefits leasecontact Care irst Pharmacy Ser ices at


BlueVisionA plan for healthy eyes, healthy lives

Professional vision services including routine eye examinations, eyeglasses and contact lensesoffered by CareFirst BlueChoice, through the Davis Vision, Inc. national network of providers.

How the plan worksHow do I find a provider?

o find a ro ider o to carefirst.com and utili e the in arovi er feature or call a is ision at 800-783-5602 for a list of

net or ro iders closest to you Be sure to as your ro ider ifhe or she artici ates ith the a is ision net or before yourecei e care

How do I re eive are ro a network provider?Sim ly call your ro ider and schedule an a ointment dentifyyourself as a Care irst BlueChoice member and ro ide the doctor

ith your identification number as ell as your date of birthhen o to the ro ider to recei e your ser ice here are no claim

forms to file

an I et onta ts and e e lasses in the sa eenefit period?ith Blue ision the benefit co ers one air of eye lasses or a

su ly of contact lenses er benefit eriod at a discounted rice

ail order repla e ent onta t lensesa s s o o tacts.com o ers members the e ibility to sho

for re lacement contact lenses online after benefits are s enthis ebsite o ers a ide array of contact lenses easy con enienturchasin online and uic shi in direct to your door

eed more informationisit carefirst.com or call00 3 0

s of some ro iders in aryland and ir inia may no lon er ro ide these discounts

BRC 0 P C ■ month 0 co ay ■ Blue ision ■ tion

BlueVision


BRC P ■ month co ay ■ Blue ision ■ tion

BlueVision u o Bene sIn-network You Pay

EYE EXAMINATIONSRoutine Eye E amination ithdilation er benefit eriodFRAMESPriced u to retailPriced abo e retail lus of the amount

o erSPECTACLE LENSESSin le isionBifocal

rifocalenticular

LENS OPTIONS (add to spectacle lens prices above)Standard Pro ressi e ensesPremium Pro ressi e enses

arilu etcltra Pro ressi e enses

di italPolari ed ensesHi h nde ensesGlass ensesPolycarbonate ensesBlended in isible bifocalsntermediate ision enses

Photochromic ensesScratch Resistant CoatinStandard nti Re ecti e RCoatin

ltra iolet CoatinSolid intGradient intPlastic Photosensiti e ensesCONTACT LENSESContact ens E aluation andittin

of retail rice

Con entional of retail riceis osable Planned

Re lacementof retail rice

a is isionContacts comail rder Contact ens

Re lacement nline

iscounted rices

LASER VISION CORRECTION to o allo ed amount or o any

ad ertised s ecial

month benefit eriodt certain retail locations members recei e com arable alue

throu h their e eryday lo rice on e amination frame and contactlens urchaseCare irst BlueChoice does not under rite lenses frames and contactlenses in this ro ram his ortion of the Plan is not an insurance

roduct s of some ro iders in aryland and ir inia mayno lon er ro ide these discounts S ecial lens desi ns materials o ers and frames may re uireadditional cost Some ro iders ha e at fees that are e ui alent to these discounts

Ehe follo in ser ices are e cluded from co era e

ia nostic ser ices e ce t as listed in hat s Co ered under the E idenceof Co era e

edical care or sur ery Co ered ser ices related to medical conditions ofthe eye may be co ered under the E idence of Co era ePrescri tion dru s obtained and self administered by the ember forout atient use unless the rescri tion dru is s ecifically co ered under theE idence of Co era e or a rider or endorsement urchased by your Grouand attached to the E idence of Co era eSer ices or su lies not s ecifically a ro ed by the ision Care esi nee

here re uired in hat s Co ered under the E idence of Co era ertho tics ision trainin and lo ision aids

Glasses sun lasses or contact lensesision Care ser ices for cosmetic use

Ser ices obtained from on Contractin Pro idersor BlueChoice t ut Plus members ision Care benefits are not a ailable

under the ut of et or E idence of Co era eE clusions a ly to the Routine Eye E amination ortion of your isionco era e iscounts on materials such as lasses and contacts may still a lyBenefits issued under olicy form numbers BC P S R CBC P S R BC P S R


Medical Benefits OptionsE ecti e for lan year uly 2 une 3 2 2

B llo ed Benefithis chart contains hi hli hts only and is sub ect to chan e he s ecific terms of co era e e clusions and limitations are contained in the

Summary Plan escri tion the Grou Benefit Guide or the Grou Ser ice reement B— llo ed Benefit P— era e holesale Price

The Benefits BlueChoice HMO OpenAccessBlueChoice Providers

Triple Option CareFirst BlueCross BlueShield Preferred ProviderOrganization CORE

Level 1BlueChoice Providers

Level 2BlueCross BlueShield

PPO Providers

Level 3Participating and

Non-participating Providers

In-networkBlueCross BlueShield

PPO Providers

Out-of-networkParticipating and


T B T T ndi idual 3 amily a re ateeductible a lies to all ser ices unless

other ise noted does not a ly to R benefits

ndi idual amily a re ateeductible a lies to all ser ices unless


ndi idualamily a re ateeductible a lies to all

ser ices unless other isenoted does not a ly toR benefits

2 ndi idual amilya re ate eductible a liesto all ser ices unless other isenoted does not a ly to Rbenefits

ndi idual 3 amilya re ate eductible a liesto all ser ices unless other isenoted does not a ly to Rbenefits

3 ndi idual amilya re ate eductible a liesto all ser ices unless other isenoted does not a ly to Rbenefits

T T ndi idual 3 2 amilyinte rated ith R out of oc et ma imum

2 ndi idual 2 amilycombined in and out of net or

2 ndi idual 2 amilycombined in and out of net or

2 ndi idual amilycombined in and out of net or

T nlimited nlimited nlimited

T

Hos ital Room Semi Pri ate B B B B B B

S illed ursin acility B limited to days contract year B B B B B

n atient Rehabilitation B limited to days contract year B B B B B

ut atient Sur ery B B B B B B

Emer ency Care Emer ency Room— co ay ai ed ifadmitted

r ent Care Center— 3 co ay

Emer ency Room— co ay ai ed ifadmitted

r ent Care Center— 2 co ay

Emer ency Room—co ay ai ed if

admitted r ent CareCenter— 2 co ay

Emer ency Room— co ayai ed if admitted r ent

Care Center— B

Emer ency Room—co ay no deductible—

ai ed if admitted r entCare Center— 2 co ay nodeductible

Emer ency Room—co ay no deductible— ai edif admitted r ent CareCenter— B

Sur eon B B B B B B

ssistant Sur eon B B B Paid as e el 2 B Paid as in net or

nesthesiolo ist B B B Paid as e el 2 B Paid as in net or

n Hos ital edical B B B B B B

ce isits PCP 2 S ecialist co ay PCP 2 S ecialist co ay 2 PCP 2 S ecialistco ay

B 2 PCP 2 S ecialist co ayno deductible

B

ut atient acility B B B B B B

ut atient Physician PCP 2 S ecialist co ay PCP 2 S ecialist co ay 3 co ay B 3 co ay B

ia nostic rays B B B n atient—Paid as e el 2 ce & ut atient— B

B B in atient Bo ce

Radiation hera y 2 S ecialist co ay B B B B B

Chemothera y 2 S ecialist co ay B B B B B

aboratory ests B abCor only B abCor only B n atient—Paid as e el 2 ce & ut atient— B

B B in atient Bo ce

ller y estin PCP 2 S ecialist co ay B B B B B

ller y reatment n ections PCP 2 S ecialist co ay B B B B B

Medical Benefi ts Options


The Benefi ts BlueChoice HMO OpenAccessBlueChoice Providers




PPO Providers




PPO Providers



T B T T ndi idual amily a re ateeductible a lies to all ser ices unless


ndi idual amily a re ateeductible a lies to all ser ices unless


ndi idualamily a re ateeductible a lies to all

ser ices unless other isenoted does not a ly toR benefits

ndi idual amilya re ate eductible a liesto all ser ices unless other isenoted does not a ly to Rbenefits



T T ndi idual amilyinte rated ith R out of oc et ma imum

ndi idual amilycombined in and out of net or



T nlimited nlimited nlimited

T

Hos ital Room Semi Pri ate B B B B B B

S illed ursin acility B limited to days contract year B B B B B

n atient Rehabilitation B limited to days contract year B B B B B

ut atient Sur ery B B B B B B

Emer ency Care Emer ency Room— co ay ai ed ifadmitted

r ent Care Center— co ay

Emer ency Room— co ay ai ed ifadmitted

r ent Care Center— co ay

Emer ency Room—co ay ai ed if

admitted r ent CareCenter— co ay

Emer ency Room— co ayai ed if admitted r ent

Care Center— B

Emer ency Room—co ay no deductible—

ai ed if admitted r entCare Center— co ay nodeductible

Emer ency Room—co ay no deductible— ai edif admitted r ent CareCenter— B

Sur eon B B B B B B

ssistant Sur eon B B B Paid as e el B Paid as in net or

nesthesiolo ist B B B Paid as e el B Paid as in net or

n Hos ital edical B B B B B B

ce isits PCP S ecialist co ay PCP S ecialist co ay PCP S ecialistco ay

B PCP S ecialist co ayno deductible

B


ut atient Physician PCP S ecialist co ay PCP S ecialist co ay co ay B co ay B

ia nostic rays B B B n atient—Paid as e el ce & ut atient— B

B B in atient Bo ce

Radiation hera y S ecialist co ay B B B B B

Chemothera y S ecialist co ay B B B B B

aboratory ests B abCor only B abCor only B n atient—Paid as e el ce & ut atient— B

B B in atient Bo ce

ller y estin PCP S ecialist co ay B B B B B

ller y reatment n ections PCP S ecialist co ay B B B B B

Precertification re uired or enalties may a lyerni ht stays for obser ation are not considered an in atient admission







PPO Providers




PPO Providers



T

Physical S eech andccu ational hera y

combined isits

S ecialist co ay isit ma imum ercondition er contract year combined iths eech and occu ational thera y

S ecialist co ay isit ma imum ercontract year combined ith s eech andoccu ational thera y

S ecialist o ce3 P acility 3 P

Professional isitma imum er contractyear occu ationals eech combined in andout of net or

B isit ma imum ercontract year occu ationals eech combined in and outof net or

S ecialist o ce co ay 3P acility 3 P Professional

no deductible isitma imum er contract yearoccu ational s eech combined

in and out of net or


Chiro ractic Care S inalani ulation

S ecialist co ay isit ma imum ercondition er contract year

S ecialist co ay S ecialist co ay B S ecialist co ay B

cu uncture ot co ered S ecialist co ay S ecialist co ay B S ecialist co ay B

T

ell Child Care mmuni ation B no deductible B no deductible B no deductible B B no deductible B

Routine Physical E am B no deductible B no deductible B no deductible B B no deductible B

Breast Cancer ScreeninRoutine ammo ra hy

B no deductible B no deductible B no deductible B no deductible B no deductible B no deductible

Prostate Cancer Screenin B no deductible B no deductible B no deductible B no deductible B no deductible B no deductible

Routine Gynecolo ical E amone er contract year

B no deductible B no deductible B no deductible B B no deductible B

Eye E ams co ay er annual isit no referrala is ision ro ider no deductible

co ay er annual isit no referrala is ision ro ider no deductible


o Benefit o Benefit

Eye Glasses enses Contactenses

iscounts a ailable See a es 3 3 iscounts a ailable See a es 3 3 iscounts a ailable See a es 3 3 o Benefit o Benefit

urable edical E ui ment B B B B B B

Home Health Care isits B B B B B B

Hos ice B B B B B B

aternity Care Pre Posteli ery

B B B B B B

ursery Careust be enrolled ithin 3

days

B B B B B B

nfertility Ser ices Pre a ro al re uired rtificialnsemination— B of char es limited

to attem ts er li e birth n itroertili ation— B of char es limited to 3

attem ts er li e birth not to e ceed a ma imumlifetime limit of

Pre a ro al re uired rtificialnsemination— B of char es limited

to attem ts er li e birth n itroertili ation— B of char es limited to 3


rtificialnsemination— Bre a ro al re uired

limited to attem tser li e birth n itroertili ation— Bre a ro al re uired

limited to 3 attem ts erli e birth not to e ceed ama imum lifetime limit of

rtificial nsemination— Bre a ro al re uired limited

to attem ts er li e birthn itro ertili ation— Bre a ro al re uired limited

to 3 attem ts er li e birth notto e ceed a ma imum lifetimelimit of







a band Benefits B B B B B B

Sur ical reatment for orbidbesity Gastric By ass &

Gastric Slee e

ot Co ered ot Co ered ot Co ered ot Co ered ot Co ered ot Co ered





Precertification re uired or enalties may a lyandatory eneric substitution—see the Care irst ru Pro ram section on a e





PPO Providers




PPO Providers



T

Physical S eech andccu ational hera y

combined isits

S ecialist co ay isit ma imum ercondition er contract year combined iths eech and occu ational thera y

S ecialist co ay isit ma imum ercontract year combined ith s eech andoccu ational thera y

S ecialist o ceP acility P

Professional isitma imum er contractyear occu ationals eech combined in andout of net or


S ecialist o ce co ayP acility P Professional

no deductible isitma imum er contract yearoccu ational s eech combined

in and out of net or


Chiro ractic Care S inalani ulation

S ecialist co ay isit ma imum ercondition er contract year

S ecialist co ay S ecialist co ay B S ecialist co ay B

cu uncture ot co ered S ecialist co ay S ecialist co ay B S ecialist co ay B

T

ell Child Care mmuni ation B no deductible B no deductible B no deductible B B no deductible B

Routine Physical E am B no deductible B no deductible B no deductible B B no deductible B

Breast Cancer ScreeninRoutine ammo ra hy

B no deductible B no deductible B no deductible B no deductible B no deductible B no deductible

Prostate Cancer Screenin B no deductible B no deductible B no deductible B no deductible B no deductible B no deductible

Routine Gynecolo ical E amone er contract year

B no deductible B no deductible B no deductible B B no deductible B

Eye E ams co ay er annual isit no referrala is ision ro ider no deductible



o Benefit o Benefit

Eye Glasses enses Contactenses

iscounts a ailable See a es iscounts a ailable See a es iscounts a ailable See a es o Benefit o Benefit

urable edical E ui ment B B B B B B

Home Health Care isits B B B B B B

Hos ice B B B B B B

aternity Care Pre Posteli ery

B B B B B B

ursery Careust be enrolled ithin

days

B B B B B B

nfertility Ser ices Pre a ro al re uired rtificialnsemination— B of char es limited

to attem ts er li e birth n itroertili ation— B of char es limited to


Pre a ro al re uired rtificialnsemination— B of char es limited

to attem ts er li e birth n itroertili ation— B of char es limited to


rtificialnsemination— Bre a ro al re uired

limited to attem tser li e birth n itroertili ation— Bre a ro al re uired

limited to attem ts erli e birth not to e ceed ama imum lifetime limit of



to attem ts er li e birth notto e ceed a ma imum lifetimelimit of







a band Benefits B B B B B B

Sur ical reatment for orbidbesity Gastric By ass &

Gastric Slee e

ot Co ered ot Co ered ot Co ered ot Co ered ot Co ered ot Co ered







PPO Providers




PPO Providers



T

mbulance hen edicallyecessary surface airri ate and ublic

B B B Paid as e el B Paid as in net or

Hearin E am co ay co ay co ay B co ay B

Hearin ids one er hearinim aired ear e ery 36 months

B B B B B no deductible B

T TB T B

n atient Care B B B B B B


ce isits co ay co ay co ay B co ay no deductible B

T

Prescri tion ru ut ofPoc et a

6 6 ndi idual 3 amily inte ratedith medical out of oc et ma imum

ndi idual amily ndi idual amily ndi idual amily

Retail Prescri tion ru co ay Generic dru ier co ay Preferred Brand ier co ay on referred Brand ier 3

aintenance dru s day su ly times retailco ay at C S only

co ay Generic dru ier co ay Preferred Brand ier co ay on referred Brand ier 3

co ay Generic dru ier3 co ay Preferred Brand ier

co ay on referred Brand ier 3aintenance medication u to day

su ly times retail at C S only co ay Generic dru ier

3 co ay Preferred Brand ier co ay on referred Brand ier 3

co ay Generic dru ier3 co ay Preferred Brand ier co ay on referred Brand ier 3

aintenance medication u to day su ly timesretail at C S only



aintenance medication u to day su ly times retail atC S only


ail rder ru C S Caremar ail rder times retail co ayu to day su ly

co ay Generic dru ier co ay Preferred Brand ier co ay on referred Brand ier 3

C S Caremar ail rder Prescri tionPro ram for maintenance medicationtimes co ay to day su ly

co ay Generic dru ier3 co ay Preferred Brand ier

co ay on referred Brand ier 3

C S Caremar ail rder Prescri tion Pro ram formaintenance medication times co ay to day

su ly co ay Generic dru ier

3 co ay Preferred Brand ier co ay on referred Brand ier 3

C S Caremar ail rder Prescri tion Pro ram formaintenance medication times co ay to day su ly


ral Contrace ti es B B B B

iabetic su lies B B B B









PPO Providers




PPO Providers



T

mbulance hen edicallyecessary surface airri ate and ublic

B B B Paid as e el B Paid as in net or

Hearin E am co ay co ay co ay B co ay B

Hearin ids one er hearinim aired ear e ery months

B B B B B no deductible B

T TB T B

n atient Care B B B B B B


ce isits co ay co ay co ay B co ay no deductible B

T

Prescri tion ru ut ofPoc et a

ndi idual amily inte ratedith medical out of oc et ma imum

ndi idual amily ndi idual amily ndi idual amily

Retail Prescri tion ru co ay Generic dru ier co ay Preferred Brand ier co ay on referred Brand ier

aintenance dru s day su ly times retailco ay at C S only

co ay Generic dru ier co ay Preferred Brand ier co ay on referred Brand ier


aintenance medication u to daysu ly times retail at C S only


co ay Generic dru ier co ay Preferred Brand ier

co ay on referred Brand ieraintenance medication u to day su ly times

retail at C S only co ay Generic dru ier

co ay Preferred Brand ier co ay on referred Brand ier


co ay on referred Brand ieraintenance medication u to day su ly times retail at

C S only co ay Generic dru ier


ail rder ru C S Caremar ail rder times retail co ayu to day su ly


C S Caremar ail rder Prescri tionPro ram for maintenance medicationtimes co ay to day su ly


C S Caremar ail rder Prescri tion Pro ram formaintenance medication times co ay to day

su ly co ay Generic dru ier


C S Caremar ail rder Prescri tion Pro ram formaintenance medication times co ay to day su ly


co ay on referred Brand ier

ral Contrace ti es B B B B

iabetic su lies B B B B

Precertification re uired or enalties may a lyandatory eneric substitution—see the Care irst ru Pro ram section on a e


CST1310-1P (9/17)

Patient-Centered Medical HomeSupporting the relationship between you and your doctor

hether you re tryin to et healthy or stay healthy you need the bestcare That s hy Care irst1 created the Patient-Centered edical Home(PC H) ro ram to focus on the relationshi bet een you and your

rimary care ro ider (PCP)

The ro ram is desi ned to ro ide your PCP ith a more com leteie of your health needs our PCP ill be able to use information

to better mana e and coordinate your care ith all your health carero iders includin s ecialists labs harmacies and others to ensure

you et access to and recei e the most a ro riate care in the mosta ordable settin s

Extra care for certain health conditionsf you ha e certain health conditions your PC H PCP ill artnerith a care coordinator a re istered nurse to

■ Create a care lan based on your health needs ith s ecificfollo u acti ities

■ Re ie your medications and ossible dru interactions

■ Chec in ith you to ma e sure you re follo in yourtreatment lan

■ ssist you in obtainin ser ices and e ui ment necessary tomana e your health condition(s)

is i ortant too r health

By visiting your PCP for routinevisits, you build a relationship,and your PCP will get to knowyou and your medical history.

If you have an urgent healthissue, having a PCP who knowsyour history often makes iteasier and faster to get the careyou need.

Even if you are young andhealthy, or don’t visit the doctoroften, choosing a PCP is key tomaintaining good health.

PCPs lay a hu e role in ee in you healthy for the lon run f you don t already ha e arelationshi ith a doctor you can be in researchin one today

■ To find a PC H PCPloo for the PC H lo o

hen searchin forrimary care ro iders

in our Pro ider irectoryor lo in to y ccountand clic Select hange

under uic in s

1 ll references to Care irst refer to Care irst BlueCross BlueShield and Care irst BlueChoice nc collecti ely


You know that CareFirst BlueCross BlueShield (CareFirst) provides your health benefits andprocesses claims, but that’s not all we do. We’re there for you at every step of care—and everystage, even when life throws you a curveball.

hether you are faced ith an une ected medicalemer ency mana in a chronic condition li ediabetes or loo in for hel ith a health oal suchas losin ei ht e o er one on one coachin andsu ort ro rams ou may recei e a letteror ostcard in the mail or a call from a nursehealth coach or harmacy technician e laininthe ro rams and in itin you to artici ate

hese ro rams are confidential and art of yourmedical benefit hey can also lay a hu e rolein hel in you throu h an illness or ee in youhealthy nce you decide to artici ate you canchoose ho in ol ed you ant to be e encoura eyou to connect ith the Care irst team so you canta e ad anta e of this ersonal su ort

Take the Call

PharmacyHealth &Wellness

BehavioralHealth

om leare

oor ination

carefirst.com/takethecall

Take the Call


Here are a few examples of when we may contact you about these programs.Visit carefirst.com/takethecall to learn more.

Program name Overview Why it’s important Communication

Health & Wellness Personal coachingsupport to helpyou achie e yourhealth goals

Health coaching can help you managestress eat healthier uit smokinglose weight and much more

etter or phone callfrom a Sharecarecoach

le a enat n

Support for a arietyof critical healthconcerns or chronicconditions

Connecting you with a nurse whoworks closely with your primarycare pro ider PCP to helpyou understand your doctor srecommendations medicationsand treatment plans

ntroduction by yourPCP or a phone callfrom a are r carecoor a or r e

H s talans t n

a e

Supporting transitionfrom hospital tohome

Help plan for your reco ery afteryou lea e the hospital answer your

uestions and based on your needsconnect you to additional ser ices

nsite isit orphone call froma are r r e

ha a s anagingmedications forspecific conditions

nderstanding your condition andstaying on track with appropriatemedications is crucial to successfullymanaging your health

etter or a phone callfrom a S are ar

har ac ec a

ehens ee at n

e e

anaging multiplemedications

alking to a pharmacist whounderstands your medication historycan help identify any possible sidee ects or harmful interactions

Phone call from a Sare ar har ac

e altha a

nat n

anaging specialtymedications forchronic conditions

Connecting with a nurse whospeciali es in your conditionpro ides additional support soyou can adhere to your treatmentplan for better health

etter or phone callfrom a S are ar

ec a r e

eha al Healthan stan e

se s e

Support for mentalhealth and/oraddiction issues

Confidential one on one supportto help schedule appointmentsexplain treatment optionscollaborate with doctors andidentify additional resources

Phone call from aare r eha ora

hea h carecoor a or

his wellness program is administered by Sharecare nc. an independent company that pro ides health impro ement management ser icesto Care irst members. Sharecare nc. does not pro ide Care irst BlueCross BlueShield products or ser ices and is solely responsible for thehealth impro ement management ser ices it pro ides.CVS Caremark is an independent company that pro ides pharmacy benefit management ser ices to Care irst members. CVS Caremark doesnot pro ide Care irst BlueCross BlueShield products or ser ices and is solely responsible for the pharmacy benefit management ser icesit pro ides.

S 4 0 P /


Choosing the right setting for your care—from allergies to X-rays—is key to getting the besttreatment with the lowest out-of-pocket costs. It’s important to understand your options soyou can make the best decision when you or your family members need care.*

Know Before You GoYour money, your health, your decision

Primary care provider (PCP)Establishin a relationshi ith a rimary care ro ider is the best

ay to recei e consistent uality care E ce t for emer enciesyour PCP should be your first call hen you re uire medicalattention our PCP may be able to ro ide ad ice o er the honeor fit you in for a isit ri ht a ay

ir e p ree o r r e advice i eCall anytime to s ea ith a re istered nurse ursescan ro ide you ith medical ad ice and recommend the mosta ro riate care

Care ir ideo i iSee a doctor ithout an a ointment ou can consult itha board certified doctor on your smart hone tablet or com uter

octors can treat a number of common health issues li e u andin eye isit carefirst.com/needcare for more information

Co ve ie ce care ce er (re ai ea c i ic )hese are ty ically located inside a harmacy or retail storeli e C S inuteClinic or al reens Healthcare Clinic and o er

accessible care ith e tended hours isit a con enience carecenter for hel ith minor concerns li e cold sym toms andear infections

r e care ce err ent care centers such as Patient irst or E ressCare ha e

a doctor on sta and are another o tion hen you need care onee ends or after hours

mer e cy room ( )n emer ency room ro ides treatment for acute illnesses and

trauma ou should call or o strai ht to the ER if you ha e alife threatenin in ury illness or emer ency Prior authori ation isnot needed for emer ency room ser ices

or more information isitcarefirst.com/needcare.

he medical ro iders mentioned in this document are inde endent ro iders ma in their o n medical determinations and are notem loyed by Care irst Care irst does not direct the action of artici atin ro iders or ro ide medical ad ice

Know Before You Go


PLEASE READ: The information provided in this document regarding various care options is meant to be helpful when you are seeking care andis not intended as medical advice. Only a medical provider can offer medical advice. The choice of provider or place to seek medical treatmentbelongs entirely to you.

When you need carehen your PCP isn t available being familiar with your options will help you locate the most

appropriate and cost effective medical care. The chart below shows how costs vary for your healthplans depending on where you choose to get care.

ue ho ceen

cce

r eon

oren ne or a e y o a a e

ideo isit Level 2■ Cough cold and u■ Pink eye■ Ear infection

ConvenienceCare e.g.C S inuteClinic

Level 2■ Cough cold and u■ Pink eye■ Ear infection

rgent Caree.g. Patient irst

or E pressCare

Level2 2

■ Sprains■ Cut re uiring stitches■ inor burns

Emergency Room Level■ Chest pain■ Di culty breathing■ Abdominal pain

o de er ne your ec c ene and a oc a ed co■ Log in to My Account at carefirst.com/myaccount

■ Check your Evidence of Coverage or benefit summary

■ Ask your benefit administrator or

■ Call ember Services at the telephone number on the back ofyour member D card

or more information and fre uently asked uestionsvisit carefirst.com/nee care.

you no t at ere youc oose to et a or raysan sur ca roce ures can

a e a m act on youra et y ca y ser ceser orme n a os ta cost

more t an non os tasett n s e a or ance

a o o y or am u atorysur ery centers.

S P C


My AccountOnline access to your health care information

My Account makes it easier than ever to understand and manage personalized informationabout your health plan and benefits. Set up an account today! Go to carefirst.com/myaccount to create a username and password.

s ie e on a smart hone

s ie e on a com uter

Home■ uic ly ie lan information includin e ecti e

date co ays deductible out of oc et status andrecent claims acti ity

■ ana e your ersonal rofile details includinass ord username and email or choose to recei e

materials electronically

■ Send a secure messa e ia the essa e enter

■ Chec lerts for im ortant notifications

My Account e

o e e■ ccess your lan information— lus see ho is co ered

■ date your other health insurance information if a licable

■ ie order or rint member cards

■ Re ie the status of your health e ense account HS or S

■ rder and refill rescri tions

■ ie rescri tion dru claims

en ormat on nc u e on

your mem er care nee e to set u

your account.

■ s t carefirst.com/myaccount

■ e ect Register Now

■ reate your usernamean ass or

nly if o ered by your lan

My Account


Claims■ Chec your claims acti ity status and history

■ Re ie your E lanation of Benefits E Bs

■ rac your remainin deductible andout of oc et total

■ Submit out of net or claims

■ Re ie your year end claims summary

m s■ oo u lan forms and documentation

■ o nload Vitality your annual memberresource uide

As viewed on a smartphone.

As viewed on a computer.

s■ ind in net or ro iders and facilities

nation ide includin s ecialists ur entcare centers and labs

■ Select or chan e your rimary carero ider PCP

■ ocate nearby harmacies

al■ ccess health and ellness discounts

throu h Blue

ls■ ccess the reatment Cost Estimator

to calculate costs for ser icesand rocedures

■ se the dru ricin tool to determinerescri tion costs

l■ ind ans ers to many fre uently

as ed uestions

■ Send a secure messa e or locateim ortant hone numbers

nly if o ered by your lannly a ailable hen usin a com uterhe doctors accessed ia this ebsite are inde endent ro iders ma in their o n medical determinations and are not em loyed by

Care irst Care irst does not direct the action of artici atin ro iders or ro ide medical ad ice

BRC 4 P


Find a Doctor, Hospital or Urgent Carecarefirst.com/doctor

hether you need a doctor nurse ractitioner or health carefacility carefirst.com/doctor can hel you find hat you re loo infor based on your s ecific needs

ou can search and filter results by

■ Pro ider name

■ Pro ider s ecialty

■ istance

■ i code

■ Gender

■ cce tin ne atients

■ an ua e

■ Grou a liations

■ City and state

It’s easy to find the most up-to-date information on health care providers and facilitieswho participate with CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.(collectively CareFirst).

o e erso a edormat o o c doctors

are o r et or o toMy Account o o r com terta et or smart o e a d c cFind a Doctor rom t e octorsta or t e c s.

C P


Health & WellnessPutting the power of health in your hands

Improving your health just got easier! CareFirst BlueCross BlueShield (CareFirst) has partneredwith Sharecare, Inc.* to bring you a new, highly personalized wellness program. Catering toyour unique health and wellness goals, our program offers motivating digital resources—accessible anytime—to help you live a healthier life.

Ready to take charge of your health?ant to find out if your healthy habits are truly

ma in an im act a e the Real e healthassessment n ust a fe minutes Real e illhel you determine the hysical a e of your bodyersus your calendar a e ou ll disco er the lifestyle

beha iors hel in you stay youn er or ma in youa e faster and recei e insi htful recommendationsbased on your results

clu e featureur ellness ro ram is full of tailored resources

and tools that re ect your o n references andinterests ou et

■ Recei einsi hts content and ser ices

■ Connect your earable de ices tomonitor daily habits li e slee ste s nutritionand more

■ Ha in trouble stayin moti atedoin a challen e to ma e achie in your healthoals more entertainin

■ ccess your im ortant healthdata li e biometric information accine historylab results and medications all in one lace

ownload the o ile app toa ess wellness tools and resour eswhene er and where er you want

Sharecare nc is an inde endent com any that ro ides health im ro ement mana ement ser ices to Care irst members

Health & Wellness


Specialized programshe follo in ro rams can hel you focus on

s ecific ellness oals

eal coac i gou may recei e a call or email in itin you toartici ate in health coachin Coaches are

re istered nurses and trained rofessionals horo ide one on one su ort to hel you reach

your ellness oals f you are contacted eencoura e you to ta e ad anta e of this oluntaryand confidential ro ram that can hel you achie eyour best ossible health

eig ma ageme programf you are a e or older ha e a body mass indeB of or reater and are loo in to loseei ht our ei ht mana ement ro ram o ers aersonali ed solution for lon term ei ht loss

o acco cessa io programuittin smo in and other forms of tobacco

can lo er your ris for many serious conditionsfrom heart disease and stro e to lun cancer ur

ro ram s e ert uidance su ort and ealth oftools ma e uittin easier than you mi ht thin

i a cial ell ei g programearn ho to ta e small ste s to ard bi

im ro ements in your financial situation hetheryou ant to sto li in aychec to aychec etout of debt or send a child to colle e our financial

ell bein ro ram can hel

ddi io al o eri gs■ Wellness discount program—

Si n u for Blue atcarefirst.com/wellnessdiscounts torecei e s ecial o ers from to nationaland local retailers on fitness ear ymmembershi s healthy eatin o tionsand more

■ Vitality maga ine—Read our memberma a ine hich includes im ortant laninformation at carefirst.com/ italit

■ ealt education— ie ourhealth library for more health and

ell bein information atcarefirst.com/li ing ealt

o et started isit carefirst.com/s arecare ou ll need to enter yourCare irst account username and ass ord and com lete the one timere istration ith Sharecare to lin your Care irst account information

his ill hel ersonali e your e erience

S P ■ ellness Self nsured


Mental Health SupportWell-being for mind and body

Living your best life involves good physical and mental health. Emotional well-being isimportant at every stage in life, from adolescence through adulthood.

t s common to face some form of mental healthchallen e durin your life Care irst BlueCrossBlueShield and Care irst BlueChoice nc Care irstare here to hel ur irstCare team includess ecially trained ser ice re resentati es re isterednurses clinical social or ers and licensedbeha ioral health s ecialists ho based on yourindi idual needs ill

■ Hel you find the ri ht mental healthro ider s and schedule a ointments

■ Connect you ith a care coordinator ho illor ith your doctor to create a tailored

action lan

■ ind su ort rou s and resources to helyou stay on trac

hen mental health di culties arise for you or alo ed one remember you are not alone Hel isa ailable and feelin better is ossible

Care irst members ha e access to s eciali edser ices and ro rams for de ression an ietydru or alcohol de endence eatin disorders andother mental health conditions

irstCare is a ser ice mar of Care irst BlueCross BlueShield

f yo are in ri iel i a ailable

a - -

f you or someone close to you needs su ort or hel ma in an a ointmentcall our irstCare team at 8 4 onday riday 8 a m m E r formore information isit carefirst.com/mentalhealth.

S P


Copyright © 2017 Delta Dental. All rights reserved.HL_PPO_MD #103600 (rev. 1/17)

o an still visit any li ensed dentist t yo r o t o po et osts ay e higher i yo hoose a non PPO dentist. et or dentists are paid ontra ted ees.

o are responsi le or any appli a le ded ti les oins ran e a o nts over plan a i s and harges or non overed servi es.

e re o end veri ying e ore ea h appoint ent that yo r dentist is a PPO dentist.

Applies only to pro ed res overed nder yo r plan. yo egan treat ent prior to yo r e e tive date o overage yo or yo r prior arrier is responsi le orany osts. ro p and state spe i i e eptions ay apply. nrollees rrently ndergoing a tive orthodonti treat ent ay e eligi le to ontin e treat ent nderDelta Dental PPO. evie yo r viden e o Coverage ary Plan Des ription or ro p Dental ervi e Contra t or spe i i details a o t yo r plan.

LEGAL NOTICES: A ess ederal and state legal noti es related to yo r plan at deltadentalins. o /a o t/legal/inde enrollee.ht l.

S Oisit a dentist in the PPO net or to a i i e yo r

savings.1 hese dentists have agreed to red edees and yo on t get harged ore than yo r

e pe ted share o the ill.2 ind a PPO dentist at.3

Set in or ation a o t yo r plan anyti e any herey signing p or an Online ervi es a o nt at

. his ree servi e availa le on eyo r overage i s in lets yo he ene ts andeligi ility in or ation nd a net or dentist and ore.

C Io don t need a Delta Dental D ard hen yo visit

the dentist. st provide yo r na e irth date andenrollee D or so ial se rity n er. yo r a ily

e ers are overed nder yo r plan they ill needyo r in or ation. Pre er to ta e a paper or ele troniD ard ith yo i ply sign in to Online ervi eshere yo an vie or print yo r ard ith the li o

a tton.

C yo re overed nder t o plans as yo r dental o e

to in l de in or ation a o t oth plans ith yo r laiand e ll handle the rest.

Did yo start on a dental treat ent plan e oreyo r PPO overage i ed in enerally lti stagepro ed res are only overed nder yo r rrent plani treat ent egan a ter yo r plan s e e tive date ooverage. o an nd this date y logging in to Onlineervi es.

Nisit

ave ith aPPO dentist

O NON O

Keep SmilingDelta Dental PPO M

Delta Dental


Eligibility Primary enrollee, spouse and eligible dependent children to the end o themonth dependent turns age

tiblelta ental PP dentists

per person per amily each plan yearon elta ental PP dentists

per person per amily each plan yeareductibles ai ed oriagnostic Pre enti e P

and rthodonticses

i , per person each plan year

P counts to ard ma imum o

iti g i asic ene itsone

a or ene itsone

Prosthodonticsone

rthodonticsone

imitations or aiting periods may apply or some bene its some ser ices may be e cluded rom your planeimbursement is based on elta ental ma imum contract allo ances and not necessarily each dentist s

submitted eeseimbursement is based on PP contracted ees or PP dentists, PP contracted ees or Premier dentists

and PP contracted ees or non elta ental dentists

elta ental o Pennsyl aniane elta ri eechanicsburg, P

t i l iP o

echanicsburg, P

lt t lihis bene it in ormation is not intended or designed to replace or ser e as the plan s idence o o erage orummary Plan escription you ha e speci ic uestions regarding the bene its, limitations or e clusions or your

plan, please consult your company s bene its representati ePP P e

l it ig lig t ar ord ounty Public choolsPP omprehensi e

iti

lt t lti t

lt t lti t

i g ti ti iams, cleanings, rays and

sealantsgi l l tti iillings, denture repair relining,

stainless steel cro ns, bridges,bridge recementation repair andposterior composite restorations

E ti root canalso ered nder asic er icesi ti gum treatmento ered nder asic er icesl g yo ered nder asic er ices

iro ns, inlays, onlays and cast

restorationst tienturesl to ered only as an alternati e

to a i ed bridget ti it

ependent children to age

t ti i i etime i etime

Delta Dental


Eligibility Primary enrollee, spouse and eligible dependent children to the end o themonth dependent turns age

tibl per person per amily each plan year

eductibles ai ed oriagnostic Pre enti e P

es

i , per person each plan yearP counts to ard ma imum o

iti g i asic ene itsone

a or ene itsone

Prosthodonticsone

imitations or aiting periods may apply or some bene its some ser ices may be e cluded rom your planeimbursement is based on elta ental ma imum contract allo ances and not necessarily each dentist s

submitted eeseimbursement is based on PP contracted ees or PP dentists, Premier contracted ees or Premier

dentists and Premier contracted ees or non elta ental dentists

elta ental o Pennsyl aniane elta ri eechanicsburg, P

t i l iP o

echanicsburg, P

lt t lihis bene it in ormation is not intended or designed to replace or ser e as the plan s idence o o erage orummary Plan escription you ha e speci ic uestions regarding the bene its, limitations or e clusions or your

plan, please consult your company s bene its representati e

PP P e

l it ig lig t ar ord ounty Public choolsPP lus Premier tandard

iti

lt t lti t

lt t lti t

i g ti tiiams, cleanings, rays and

sealantsi iillings, stainless steel cro ns and

posterior composite restorations

E ti root canals

l g y

i ti gum treatment

iro ns, inlays, onlays and cast

restorations

t tiridges and dentures


StayConnected

Want information about your dentalplan? Take advantage of our web andmobile resources to:

• check your eligibility

• look up coverage details

• check claims

• find a network dentist

• improve your oral wellness

• and more

W et er you re on a computer tablet or smartp oneyou can access all t e information you need at your

ngertips

isit deltadentalins com

ccess t e mobile optimi ed site

se t e ree elta ental app

We keep you smilingdeltadentalins com enrollees


Copyright © 2018 Delta Dental. All rights reserved.EF30 #111840C (rev. 3/18)

Delta Dental re ier and Delta Dental are nder ritten y Delta Dental ns ran e Co pany in A DC F A A and and y not or pro tdental servi e o panies in these states CA Delta Dental o Cali ornia A D Delta Dental o ennsylvania Delta Dental o e or DE Delta Dental oDela are Delta Dental o est irginia. n e as Delta Dental ns ran e Co pany provides a dental provider organi ation (D ) plan.

hese enterprise o panies are e ers or a liates o e ers o the Delta Dental lans Asso iation a net or o 3 Delta Dental o panies that togetherprovide dental overage to illion people in the . . he e site deltadentalins. o is the ho e o the Delta Dental o panies listed a ove. For other DeltaDental o panies visit the Delta Dental lans Asso iation e site at deltadental. o .

Go mobile

1 Applies to Delta Dental and Delta Dental re ier enrollees only.

1. Enter el e li omon yo r s artphone s

ro ser.2. Cli the i i obile

i e tton.

e ei e i

ie o ele o i

e e iblem im m

1. pen the o e orGoo le l .

2. ear h or ele l.

3. Do nload the reeapp titled el e l

y Delta Dental lansAsso iation.

e e

Ge o e im e

i e i

e l im

e e i e

Ge e

oo o be e i eli ibili

e m i l ime o b o mi e

oo o be e i eli ibili

e l im

1. Enter el e li om e olleeon yo r o p ter s ro ser.

2. ro se the eat res listed elo .yo haven t already done so

register or nline ervi es.Already got an a o nt og in

e e

li e e i e (register or log in)ee ene its and eligi ility in ohe lai s vie or print an D ard

i e i

e l l o G i e

mile ell e i e


Save with PPO.Visit a dentist in the PPO1

network to maximize yoursavings.2 These dentists have agreedto reduced fees, and you won’t getcharged more than your expectedshare of the bill.3 Find a PPO dentistat e ta e ta i . .

If you can’t find a PPO dentist, DeltaDental Premier® dentists offer the nextbest opportunity to save. Unlike non–Delta Dental dentists, they have agreedto set fees, and you won’t get chargedmore than your expected share of thebill. What’s more, they’re part of thelargest dentist network in the country.4

ewly coveredVisit e ta e ta i . we e

Delta Dental PPO

In Texas, Delta Dental Insurance ompany offers a Dental Provider Organization DPO plan.

ou can still visit any licensed dentist, but your out of pocket costs may be higher if you choose a non PPOdentist. PPO dentists won’t bill you for any amount over their PPO fees.

ou are responsible for any applicable deductibles, coinsurance, amounts over plan maximums and chargesfor non covered services.

et inder Dental etwork Trend eport, eptember 2 1 . Delta Dental Premier is the largest dentistnetwork nationwide, based on total uni ue dentists.

See eve tive a e.egular exams and cleanings are

available at low or no cost. Theseservices help catch problems before theyre uire costly and extensive treatment.

Set a i e a t.

et information about your plananytime, anywhere by signing up

for an Online ervices account. vailableonce your coverage kicks in, this free servicelets you nd a network dentist, view orprint your ID card and more. The one timeregistration process takes only a minute.

a e e .

eceive an email when a newdental bene ts statement is

available online. ave time, reduce clutterand preserve environmental resources Toenroll, log in to Online ervices and updateyour settings.

1 2

3

ways to make the most ofyour dental plan

We keep you smiling®deltadentalins.com enrollees


Copyright © 2017 Delta Dental. All rights reserved.EF17_PPO-PRE #104066C (rev. 3/17)

Try mobile.isit el e li . om on yo r

s artphone to a ess o ile-opti i ed Online ervi es on the goin l ding a help l dentist lo ator tool. Ordo nload the Delta Dental app availa lethro gh the App tore or oogle Play toa ess yo r plan in or ation and try o tthe handy tooth r sh ti er.

oor i e be e .Are yo overed nder a se onddental plan As yo r dentist to

in l de in or ation a o t oth plans ithyo r lai and e ll handle the rest.

li e i eFor i and easy online assistan e go to el e li . om o sele t the Delta Dentalo pany and hoose the appli a le sto er servi e or .

Tele o e i eDelta Dental o Cali orniaCali ornia hool Distri t E ployeesDelta Dental o Dela are Delta Dental o the Distri t o Col ia Delta Dental o e or DeltaDental o Pennsylvania (and aryland) Delta Dental o est irginiaDelta Dental ns ran e Co pany (Ala a a Florida eorgia o isiana ississippi ontana evadae as tah)

T l o yo r e i .Fro pregnan y to dia etesoverall health an a e t yo r

dental health. tart ea h visit ith a ihat a o t any iss es.

y i orme .et oral health tools and tips

at o r ile ay ellness site(my mile y. om). Don t orget tos s ri e to Grin! o r ree dental ellnesse- aga ine.

o im le e io se o r a to ated phone syste availa le 24/7. o an he yo r overage levelsre aining a i and ore. st all one o the sto er servi e n ers listed a ove and ollo the pro pts.

Delta Dental Pre ier and Delta Dental PPO are nder ritten y Delta Dental ns ran e Co pany in A DC F A A and and y not- or-pro it dental servi e o panies in these states CA Delta Dental o Cali ornia PA D Delta Dental o Pennsylvania Delta Dental o e or n . DE DeltaDental o Dela are n . Delta Dental o est irginia n .

O r Delta Dental enterprise in l des these o panies in these states Delta Dental o Cali ornia CA Delta Dental o the Distri t o Col ia DC Delta Dental oPennsylvania PA D Delta Dental o est irginia n . Delta Dental o Dela are n . DE Delta Dental o e or n . Delta Dental ns ran eCo pany A DC F A A and .

T A ess ederal and state legal noti es related to yo r plan deltadentalins. o /a o t/legal/inde -enrollee.ht l.

ro p- and state-spe i i e eptions ay apply. Please revie yo r plan oo let or details a o t oordination o ene its in l ding r les or deter ining pri aryand se ondary overage.

5

6

7

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Flexible Spending Account (FSA) HighlightsWhat is a Flexible Spending Account?

le ible S endin ccount S ermits you toay for certain health care and or de endent care

e enses ith re ta dollars Because you ill notay any federal state or social security ta es on

income laced into the lan you can otentiallysa e for e ery you elect to defer

Who is eligible?ll acti e benefit eli ible em loyees or in for

Harford County Public Schools are eli ible toartici ate in the le ible S endin ccounts

o t pes o FSAs a ailable to ouealth ca e spending accountou may set aside u to annually in a

Health Care S endin ccount to ay for ualifiedmedical rescri tion dru co ayments certaino er the counter C su lies dental and isioncare e enses he health care e enses maybe for you your s ouse or your de endents aslon as you claim them as de endents on yourta return or throu h the ta year in hich theyturn 6

ependent ca e spending accounthe e endent Care ccount hel s you ay the

cost of day care for your de endents so you andyour s ouse can or Eli ible de endents for thisaccount must be claimed as de endents on yourfederal ta return and either be

■ nder a e or

■ entally or hysically unable to care forhim herself re ardless of a e this may be as ouse or older relati e

f you are sin le or are married and filin a ointta return you may contribute u to 5each contract year f you are married and filina se arate ta return you may contribute u to

5 er year

o FSAs o■ urin o en enrollment or hen you first

become eli ible you decide ho much youant to contribute from your ay to a Sou can establish a S for your health

care e enses and or for your de endentcare e enses ote that health care S sand de endent care S s are t o se arateaccounts and not interchan eable

■ hen you enroll you authori e yourem loyer to deduct a certain ortion ofyour earnin s each ay eriod before ta es

our contributions are set aside in your Sthrou hout the year ia ayroll deduction

■ hen you ha e an eli ible e ense you canuse your B Benefits Card or ay the cost ufront and be reimbursed from your accountRemember you do not ay ta es on themoney reimbursed to you from your le ibleS endin ccount

■ ou can contribute u to 5 a year to thede endent care S or 5 a year if youare married but file a se arate ta returnfrom your s ouse ou can contribute u to

a year to the health care S

■ f you ha e money left in your account at theend of the lan year it cannot be returnedto you nor carried o er to the ne t lan yearor strate ies on usin your account balance

see Plannin our Election

Flexible Spending Account (FSA) Highlights


Important Flexible SpendingAccounts informationRS re ulations im ose a use it or lose it rule that

re uires you to forfeit any money not used by theend of the Plan ear HCPS can neither refundmoney to you nor carry it for ard from one Plan

ear to the ne t

ou must re enroll in S s each Plan ear e enif you ee the amount of your contributionsthe same

ou may artici ate in one or both of the le ibleS endin ccounts but the Health Care and

e endent Care s endin accounts are se arateoney cannot be transferred from one account to

the other

ou may choose either the re ta ad anta e ofthe de endent care s endin account or claima ta credit on your federal income return butyou may not do both Consult your ta ad isor todetermine hether the S or the ta credit i esyou the reater ta ad anta e

e hires or enrollments due to a ualified lifee ent oinin the lan after the be innin of thePlan ear should determine ho many ayrolldeductions for benefits remain before decidinu on the amount to set aside in S s Payrolldeductions are ta en from ays for monthem loyees and ays for month em loyeesuly or Se tember une

o exible spending accounts ill sa e ou monehen you elect to artici ate in a S you ill ha e a s ecific amount of dollars deducted from

your ross earnin s before ta each ay eriod By contributin re ta dollars you ill lo er yourta able income and increase your s endable income n fact by artici atin you are actually usindollars you ould ha e aid in ta es to hel ay for your medical and or de endent care costs Beloare some e am les of ho much can sa e on your e eryday e enses

Sample ealt care expenses our costit out a FSA

our costit a FSA

our estimatedout of poc etsa ings

PP octor Co ay

H octor Co ay

PP Generic Retail R Co ay

H on referred Brand R Co ay

er the Counter Pain Relie er

onthly iabetic Su lies

onthly rthodontic Payment

Eye lasses

aser Eye Sur ery

Sample dependent care expenses

aycare for child under a e

Before fter School Care

Summer Cam

isabled Elder dult aycare

ssumin ederal a Brac et



Planning your electionHere are ust a fe strate ies you can use to besure that you are ma in e ery enny count inyour S

Plan a ea en enrollingBase your contribution on your antici atede enses for the lan year hich are not co eredby other insurance or benefit lans

oo ac to la t yearne ay to estimate those e enses is to loo bac

at the health care and de endent care e enseyou aid out of your o n oc et durin the astyear his can be the startin oint for your annualcontribution ad usted of course for any ast orfuture e traordinary e enses

oo out i e your ealt lanany health care lans o er some but not full

co era e for certain e enses such as laser eyesur ery orthodontia o er the counter Cmedicines etc

aluate your o e ar acyStart by thro in a ay all e ired o er the counter

C medications hen the ne t time your isityour health care ro ider as for a rescri tion forthe C medications you use on a re ular basis

hese may include aller y medications antacidscold medications ain relie ers Bandaids acebanda es contact lens solutions and other Citems non medication can be reimbursed ithouta rescri tion

e con er ati eny unused funds cannot carry for ard to the ne tlan year and are forfeitedm ortant E ecti e for all urchases made after anuary

all o er the counter C dru s and medicines ill re uire arescri tion for reimbursement

nrolling in t e lana e your election durin o en enrollment

or hen you first become eli ible

■ etermine your election amount s by usinthe S or sheet

■ Elect u to the lan ma imums

■ Remember you do not ha e to artici ate inthe health lan to be eli ible for the S

■ nnual election s ill be deducted e uallyre ta o er the course of your lan year

e it carPartici atin in a S ith B Benefits Card hasmany ad anta es oo at hat the card can dofor you

■ Eliminates the need of fillin out claims formsand aitin for a reimbursement chec

■ ost transactions ill not re uiresu ortin documentation

■ B Benefits ill notify you by email hensubstantiation is re uired and ill also

ro ide you ith a monthly statement ofunsubstantiated claims

■ f you choose not to use the card or if yourro ider does not acce t asterCard

you can ay out of oc et and submitfor reimbursement

oo ho the ad anta es really add u t s timefor to be in sa in money and sim lifyinyour e enses

grace erioou ha e an e tended months time frame

until 5 to incur e enses and ha e thema lied to ards your accountE enses incurred durin the Grace Period uly

throu h Se tember 5 and a ro ed forreimbursement ill be aid first from a ailableamounts that ere remainin at the end of the

recedin Plan ear and then from any amountsthat are a ailable to reimburse e enses incurreddurin the current Plan ear t is im ortant to eethe e tension in mind hen you determine yourne S contributions his added feature ill helto irtually eliminate the use it or lose it clauseassociated ith le ible S endin ccounts

mounts remainin in your account at the end ofthe Plan ear that are not a lied to ay e ensessubmitted on or before the ctober 8th deadline

ill be forfeited Claim forms are a ailable atwww.flex-admin.com



The FBA Benefits Cardhe B Benefits Card o ers the con enience ofayin for your eli ible e enses directly at theoint of sale t or s li e any other credit card

Since the card lets you ay for eli ible healthcare e enses directly from your health careS it means no more ayin cash for ser ices

u front t also eliminates the aitin eriod forreimbursement chec s and the hassle of fillinout claims forms he B Benefits Card can beused at authori ed health care ro iders here

asterCard is acce ted f you lan to use yourB Benefits Card to ay for daycare e enseslease chec ith your daycare ro ider to see if

they are e ui ed to acce t asterCard

Since the S lan is a re ta benefit the nternalRe enue Ser ice RS re uires that all urchasesbe substantiated herefore you may be re uiredto submit co ies of your recei ts to the lanadministrator to com ly ith the uidelines

ro ided by the RS

or the health care S the limit on your card isyour annual elected contribution amount or thede endent care S the limit on your card is your

ayroll deduction less your reimbursedf a ser ice ro ider does not acce t the card you

can al ays submit a claim for reimbursement BBenefits ill either mail a reimbursement chec toyour home address or issue a direct de osit intothe ban account that you ha e ro ided oreinformation about the B Benefits Cardis a ailable at www.flex-admin.com

e red re rd ee nSa e all your recei ts in a con enient locationsince all urchases made ith your B BenefitsCard must be erified he lan administrator isre uired to substantiate all transactions that donot match an e act co ayment associated ithyour em loyer s health lan his system ill alsobe hel ful hen re arin your ta es

T eF A

a Ann aC ntr t n a es e enses

Health CareE eduction

amounts must bein hole dollarincrements

■ orthodontia■ co ayments■ deductibles■ acu uncture■ chiro ractic care■ hearin aids and batteries

■ eye lasses■ smo in cessation e enses■ S eye sur ery■ Prescri tion dru co ayments■ certain C su lies

e endentCare E eduction

amounts must bein hole dollarincrements

■ licensed day care facility child oradult

■ re school or nursery schoolnot inder arten

■ before and after schoolro rams

■ care in someone else s home■ house ee er ho erforms

de endent care duties■ day care ro ided by a non

de endent relati e o er the a eof

he nternal Re enue Ser ice RS determines hich e enses are eli ible and hich are ineli ible or a detailed list of e am leslease refer to hfsbenefits comor orthodontia reimbursement send a co y of your orthodontia a reement orthodontic contract alon ith your com leted claim

form hen treatment be ins he orthodontic a reement must statehe be innin date of ser icehe a ro imate len th of ser iceotal cost of ser ice

Record fee

nitial fee do n ayment Subse uent monthly fees

otal insurance co era e if a licable

he fee for orthodontic records is eli ible for reimbursement on the date the rays hotos and casts are ta en Pro erdocumentation is a statement of ser ices rendered from orthodontist he initial fee do n ayment is eli ible for reimbursementon the date of the first treatment ain ro er documentation is a statement of ser ices rendered from orthodontist

Subse uent monthly fees are eli ible for reimbursement as monthly orthodontic ad ustments occur Pro er documentation is astatement of ser ices rendered a recei t from orthodontist sho in date of ayment orthodontic clearly noted on recei t or a co yof ayment stub from orthodontic ayment boo let S ecial ayment schedules hich do not coincide ith dates of ser ice such asfull ayment at bandin ill be aid in e ual installments o er the eriod of ser ice rthodontics is an on oin treatment and the RS

rohibits re ayment of these ser ices



Your FSA administratorPlease contact le ible Benefit dministrators nc

ith any uestions re ardin your S lan he e di ision

is a ailable onday riday 0 a m m E

Flexible Benefit Administrators, Inc.509 Viking Drive, Suite FVirginia Beach, VA 23450

Phone 00ebsite ddress www.flex-admin.com

ll forms are a ailable on HCPS SharePoint atHumanResources/benefits or the B ebsite

n in a ount a ssou also ha e access to your account balance

and claim information f you are a first time useryou ill need to o to the e ser lin to set u

your account ou must ha e an email addresson your account to roceed ith the onlineaccount creation Please follo the ste s belo foraccount creation

■ Go to htt s // ba.wealthcare ortal.com

■ Clic on Register

■ Em loyee is your SS ithout dashes

■ Enter your mail

■ Em loyer is B HCPS or benefits cardnumber

■ Clic on it

f you need assistance in settin u your accountlease contact B Benefits and a re resentati eill assist you



FSA frequently asked questionsen is t e lan year for FSA

he lan S is uly to une

an arti i ate in t e FSA lans if anot enrolled in y e loyer s ealt lan

es s lon as you meet the benefit eli ibilityre uirements you can artici ate in either S

an use t e edi al are FSA to ay fory s ouse s dedu ti les or o ay ents if

t ey aren t o ered y y rou edi allan

es Ho e er health care remiums deductedfrom your s ouse s aychec and remiums forindi idual health olicies are not eli ible

o e er ay ta es on t e oney ut intoeit er a ount

o ith the e ce tion of e ersey andPennsyl ania e endent Care S state tayou do not ay ta on money ta en out ofthese accounts

an an e t e a ount of oney setaside in y a ount s durin t e lan year

s a eneral rule no he RS ho e er does alloyou to ma e chan es hen a ualifyin e ent occurssuch as marria e di orce or ainin or losin as ouse or de endent

at a ens if ter inate e loy entdurin t e lan year

ou ill ha e a eriod after your terminationdate chec your SP to submit e enses incurred

hile you ere an acti e em loyee lso youmay ha e the o tion to continue contributinto your Health Care S usin after ta dollarsthrou h C BR

o at a e ay use t e e endent areFSA for e enses in urred for y ild

ou may submit e enses incurred for yourde endent child on or before his her th birthday

Are e enses for efore after s oolro ra s onsidered eli i le e enses

es but you must se arate the cost of such carefrom the cost of the school

en o lete y ersonal ta return doa e to re ort anyt in re ardin y FSAes hen you artici ate in a e endent Care

S you ill need to com lete and file RS ormnstead of com letin Part and Part you

should com lete Part and of the form oaction is re uired for the edical Care S

at a ens if y e enses are lo ert an anti i ated

he RS sti ulates that you must forfeit anyfunds remainin in your account at the end of the

lan year Ho e er you are i en a race eriodof an additional days to submit recei ts forser ices incurred durin the lan year or race

eriod Please re ie section titled Planninour Election

o an o tain y a ount alan einfor ation

ou can contact our B Benefits Customer Caredurin normal business hours or you can ieyour account information online hours a daydays a ee at https://fba.wealthcareportal.com

ou may ie detailed information such asyour account balance claim status and checinformation ou can also access this informationia the free B Benefits mobile a or elect to

recei e this information ia te t notifications

o do re ei e a rei urse ent for ylai s

ll claims recei ed in the o ce of le ible Benefitdministrators nc ill be rocessed ithin oneee Please allo business days for rocessin

of your submitted claims once they ha e beenrecei ed Reimbursement chec s ill be sentdirectly to your home address Reimbursementsmade throu h irect e osit are a ailable inyour ban account ithin business days after

rocessin l ays erify ith your ban that fundsare a ailable before ma in ithdra als

o do su it a lain order to file a claim for an e ense that you

did not urchase usin your B Benefits Cardor to res ond to a documentation re uest fora card urchase you ill need to com lete andsi ri a coordinatin form Please isit our ebsitewww.flex-admin.com to access the form s younee Each form contains instruction on ho tosubmit your claim for reimbursement


A group life and accidental death and dismemberment insurance program is available toall benefit eligible employees of Harford County Public Schools through MetLife InsuranceCompany as a financial resource to protect their families.

Basic Life Insurance and Accidental Death andDismemberment (AD&D) Insurance

Basic ife and & insurance allo s an em loyeeto urchase a benefit e ual to one times theirannual earnin s rounded u to the nearest

minimum of u to a ma imum of& ro ides financial rotection for

you and your family a ainst e enses associatedith accidental death or in ury reduced benefit

is ayable should you become dismembered as aresult of an accident

Supplemental Life InsuranceSu lemental ife nsurance allo s you to

urchase an additional amount of life insuranceon yourself e ual to 6 your salary minimum

6 u to a ma imum of combinedith Basic ife

epen ent Life Insurancee endent ife nsurance allo s you to urchase

co era e for your s ouse or child ren ou mayurchase a at co era e amount for your s ouse

of 2 ou may urchase a at co era eamount for your child or children u to a e 26 of

—no health uestions are re uired oumust be enrolled in Su lemental ife to enrollyour de endents

Dependent Flat Monthly RateS ouse

Child ren

our s ouse and eli ible child ren must not be confined toa hos ital on the enrollment date or at home for any medicalreason or be recei in or entitled to recei e disability income forany medical reason on the date co era e is scheduled to becomee ecti e

nsurance for a e endent Child may be continued ast the a elimit if the child is inca able of self sustainin em loyment becauseof a mental or hysical handica as defined by la Proof of suchhandica must be sent to et ife ithin days after the date theChild attains the a e limit and at reasonable inter als after suchdate

he o pleted o t e et ned to Met e no late than neo a a la le at http h p enelo o nde Fo

Basic Life Insurance and Accidental Death and Dismemberment (AD&D) Insurance


Eligibilityou ill be eli ible for co era e on the first day of

the month follo in your date of hire

f you do not enroll ithin days after becomineli ible and are enrollin in more than ofco era e the follo in limitations ill a ly to alater enrollment

ou and your s ouse must submit Statementof Health S H and

ou may not enroll until an nnual enEnrollment Period

f you a ly for co era e durin an nnual enEnrollment Period the co era e ill start the laterof the date et ife a ro es your Statementof Health or uly st follo in the nnualEnrollment Period

t ghe Board ays ercent of the cost of Basicife and & insurance he em loyee is

res onsible for of the cost of Su lementaland e endent co era e he current monthly costof Basic ife & & is cents er thousanddollars of co era e Su lemental rates are erthousand dollars of co era e based on your a esee chart belo for e act rate e endent rates area at monthly rate

Age Rate

i li gGrief counselin ser ices are o ered ith yourbasic life insurance co era e hether it s helco in ith a loss or a ma or life chan e the

rofessional counselors and ser ices e o erthrou h ife or s S nc are ready to su ortyou and your family to mo e for ard —at noe tra cost

e t a t — a in sure yourecei e rofessional and confidential su ortdurin life s di cult times is our riority

a t a e e e —Sometimesyou ust need a little uidance ife or so ers self hel resources online to hel youthrou h the rie in rocess i in the le elof su ort you need at your o n ace

e a a ta e e e — hrou hri ate sessions counselors can hel you

your lo ed ones and your beneficiaries ithcustomi in funeral arran ements

ill tHa in a ill is one of the most im ortant thin syou can do for your family a in sure your illis u to date can hel ensure that your assets aredistributed the ay you ant

s an added benefit ith your et ife Basic ifelan you ha e access to et ife s online illre aration ser ices to create a ill li in ill

or assi n a o er of attorney in a secure eben ironment his ser ice is ro ided by an outsideendor Smart e al orms nc and as created

e clusi ely for et ife to be an easy to useebsite a ailable to you hours a day days aee isit illsCenter com to et started

e a a g a e e ta g at at a e ea e t e a e ge a t e t at

e a t e a e te a e at tt t e

Grief Counselin and uneral ssistance ser ices are ro ided throu h an a reement ith ife or s S nc ife or s is not an a liate ofet ife and the ser ices ife or s ro ides are se arate and a art from the insurance ro ided by et ife ife or s has a nation ide

net or of o er counselors Counselors ha e masters or doctoral de rees and are licensed rofessionals he Grief Counselinro ram does not ro ide su ort for issues such as domestic issues arentin issues or marital relationshi issues other than a finali ed

di orce his ro ram is a ailable to insureds their de endents and beneficiaries ho ha e recei ed a serious medical dia nosis or su ereda loss E ents that may result in a loss are not co ered under this ro ram unless and until such loss has occurred Ser ices are not a ailablein all urisdictions and are sub ect to re ulatory a ro al ot a ailable on all olicy forms

illsCenter com is a document ser ice ro ided by Smart e al orms nc an a liate of E o Grou td Smart e al orms nc and is nota liated ith et ife he illsCenter com ser ice is se arate and a art from any insurance or ser ice ro ided by et ife he illsCentercom ser ice does not ro ide access to an attorney does not ro ide le al ad ice and may not be suitable for your s ecific needs Pleaseconsult ith your financial le al and ta ad isors for ad ice ith res ect to such matters illsCenter com is a ailable to anyone re ardless ofa liation ith et ife

Basic Life Insurance and Accidental Death and Dismemberment (AD&D) Insurance


Discounts on funeral services through the largestnetwork of funeral homes and cemetery providerswith compassionate experts that guide youthrough the pre-planning process.

In-person will preparation serviceswith a professional attorney

s an added benefit when you enroll in et ife sSupplemental erm ife plan you have access topersonal ill Preparation services o ered by Hyattegal Plans—at no additional cost to you ou

and your spouse can access professional attorneysto help you prepare or update a will living will orassign a power of attorney. Choose to meet in-person or by phone with a participating attorney.ees are fully covered and there are no claim forms

to file

ithout a will your final wishes may not beacknowledged and assets may be distributedaccording to state law. ith ill Preparationservices you have access to professional resourcesto help ensure your final wishes are clear.

hese services o ered through Hyatt egalPlans fully covers attorney fees by a participatingplan attorney to settle an estate. ou areeligible for this service if you are enrolled in

et ife s Supplemental erm ife. Some coveredservices are

■ nlimited in-person or telephoneconsultations with an attorney to discussmatters or general uestions relating toprobating an estate.

■ Preparation of estate documents andprofessional court representation at courtproceedings available to help properlydistribute probated assets from the estate.

■ Preparation of correspondence needed totransfer non-probate assets as well as anyassociated tax filings.

et starte to ay. Contact Hyatt egal Plans at - - -64

and a Client Service Representative will

sk for your Company name Groupumber and the last 4 digits of your Social

Security or Employee D number

o ocate a participating plan attorney inyour area

Provide you with a case number to give tothe attorney of your choice

nswer any uestions you have

. hen call the o ce of your chosen attorneyto make an appointment at a time that worksbest for you.

ncluded with Supplemental ife nsurance. ill Preparation Services are o ered by Hyatt egal Plans nc. a et ife company Clevelandhio. n certain states legal services benefits are provided through insurance coverage underwritten by etropolitan Property and Casualty

nsurance Company and liates arwick Rhode sland. ax Planning and preparation of iving rusts are not covered by the ill PreparationService.ncluded with Supplemental ife nsurance. et ife Estate Resolution Services are o ered by Hyatt egal Plans nc. a et ife company

Cleveland hio. n certain states legal services benefits are provided through insurance coverage underwritten by etropolitan Propertyand Casualty nsurance Company and liates arwick Rhode sland. Certain services are not covered by Estate Resolution Servicesincluding matters in which there is a con ict of interest between the executor and any beneficiary or heir and the estate any disputes withthe group policyholder et ife and or any of its a liates any disputes involving statutory benefits will contests or litigation outside probatecourt appeals court costs filing fees recording fees transcripts witness fees expenses to a third party udgments or fines and frivolous orunethical matters.


Harford County Public Schools is pleased to offer an Employee Assistance Program (EAP) forall employees, and their family members or significant others that reside in their immediatehousehold. KEPRO will provide these confidential services.

Employee Assistance Program

EAPSometimes ersonal and family roblems can ha ea direct im act on ersonal ell bein and or

erformance Gettin timely rofessional hel canresult in a healthier more roducti e indi idual

e reco ni e the alue in assistin em loyees andtheir de endents to find the best ossible hel in atimely manner

HCPS ro ides an E P hich is administered byEPR e encoura e em loyees their co ered

eli ible family members or other members of theirimmediate household to ta e ad anta e of thisim ortant benefit hen needed

EAPn E P ro ides the o ortunity to tal

confidentially ith a mental health rofessionalabout a ide ran e of ersonal matters such as

■ amily or relationshi roblems

■ Parentin di culties

■ or related roblems

■ inancial issues

■ Child and eldercare issues

■ Substance abuse and alcohol misuse

■ Grief and loss

■ Emotional and hysical abuse

■ n iety and stress

■ Emotional mental health concerns

■ Con enience Ser ices

■ e al Ser ices

Currently this benefit is not a ailable to HCE or HCESC eli iblemembers

EAPhe E P may ro ide u to ei ht isits er

issue er year ith a local licensed mental healthcounselor at no cost to you hese sessions are toassist you ith roblem identification short termcounselin or refer you for assistance based ontheir assessment of your s ecific situation andtreatment needs to ei ht isits are a ailableto you for each ty e of situation for hichyou may ant to see assistance f additionalser ices outside the E P are recommended theE P rofessionals ro ide and hel facilitate thereferral to the a ro riate health care ro ideror community resource ee in mind that thefinancial res onsibility for additional ser icesoutside the E P is yours ho e er your medicalinsurance may co er art of these costs odetermine co era e for beha ioral health ser icesand co ered ro iders lease chec ith yourhealth care lan

Employee Assistance Program

■ Harford County Public Schools—Benefits Enrollment & Reference Guide66 ■ Harford County Public Schools—Benefits Enrollment & Reference Guide66

HCPS em loyees and their family members alsoha e access to thousands of la yers certified

ublic accountants certified financial lannersand insurance s ecialists n E P counselor illassess your needs and arran e a no costminute consultation for you ith an attorney orfinancial consultant f a member elects to retain theattorney they ill recei e a reduction of the

rofessional s customary fee

full ran e of or life su ort resources area ailable to HCPS em loyees and their familymembers Child and Elder Care ser ices includechild and elder care referrals hich are researchedto your references and ro ider site a ailabilityEm loyees and members of their family ha econsultation educational materials and referralsa ailable to address issues in ol in a de endent orelder care e endent care s ecialists ro ide casemana ement educational material consultationsand referrals on many child adult elder careissues Referrals include but are not limited to

renatal care ado tion summer cam s bac ucare lon term care o tions su ort ser icesmeals trans ortation res ite care day care andrecreational acti ities

Con enience ser ices allo you to roducti ely focusyour time and attention by lettin the E P researchinformation for you Con enience ser ices includeconsultation and referrals for household sho insuch as home re airs et sitters cleanin ser icesand other day to day needs n addition referralscan be made for dinin entertainment and tra elre uests Please note that the E P ill locate theresources ho e er the em loyee or family memberis res onsible for the cost of the oods ser ices

Who may use the EAP?ll em loyees and their de endents or si nificant

others in their immediate household

What a out o e t a ty?he decision to ta e ad anta e of this ser ice is

yours ll con ersations remain confidential E ce tas re uired by la EPR ill not disclose toanyone that you ha e in uired about benefits areconsiderin treatment or are recei in treatmentf you are referred to the E P due to attendance

or disci linary issues the referral ill be no n toHCPS ith your ermission but the details of yourisits ill remain confidential bet een you and

your counselor

What oes the EAP ost?here is no cost to em loyees and eli ible

members of their household to access and usethe E P he initial assessment and short termcounselin are free or many eo le the one toei ht isits er issue er year may be su cientor others additional ser ices and treatment may

be needed our E P counselor ill or ith youto determine if further treatment is necessary

dditional treatment is sub ect to the ro isionsof the health care lan in hich you are enrolledt is the artici ant s res onsibility to erify

co era e hene er a referral for treatment isrecommended

o o ma e a a o tme t?or more information about the E P or to arran e

an a ointment lease call 1-866-795-5701

nformation and assistance is also a ailable iathe internet at www.EAPHelpLink.com ust enterHCPS as your Com any Code

E P counselors are a ailable hours daysa ee

he E P is an im ortant resource to hel youbetter mana e your ersonal or and familysituations t s easy to use does not cost youanythin and it can ma e a di erence


Harford County Public Schools offers you several ways to begin saving money through payrolldeductions. We offer our employees both U.S. Savings Bonds and Tax Sheltered Annuities(403(b) and 457 (b) Plans.)

Savings & Retirement Benefits

U.S. Savings BondsSa in s Bonds are a ailable to all em loyeesthrou h a ayroll distribution to the S

e artment of the reasury he reasury irectro ram is a con enient and secure eb based

system hich allo s you to urchase mana e andredeem electronic a erless sa in s bonds at

or or from home reasury irect is not limited toust S Sa in s Bonds Em loyees may urchasethe follo in reasury mar etable securities billsnotes bonds and PS or more information oto www.treasurydirect.gov dditionally for steby ste instructions on ho to o en an account

ith the S e artment of the reasury o to theHCPS SharePoint HR Benefits eb site hc sshareand clic on “Treasury Direct Directions”

n d B n nsion anid you no that the a era e erson needs

to re lace to of his final income inorder to a ord retirement id you no thatre ardless of your years of ser ice the efinedBenefit Pension Plan ill not ro ideof your final income herefore it is im ortant to

artici ate in the b and b a eferrednnuity Plans described belo hen it comes

to retirement lannin it s ne er too soon tostart our retirement income ill come frommore than one source Ho e er the rinci alsources of income hen you retire are ersonalsa in s Social Security and your ension fromone of the systems in hich Harford County PublicSchools artici ates t is im ortant to understand

hich retirement lan you are eli ible for hoto enroll and the benefits your lan ill ro ideat retirement

i i n an aigi o

e endin on your ob classification and the dateyou ere em loyed you may be eli ible for one oft o retirement ro rams listed belo

ary a d tate eac ers oyeesetire e t yste

igi i ityrovisio

ust ha e enrolled rior to as aublic school educator administrator or

clerical em loyee

esti grovisio

utomatic membershi afterfor eli ible em loyees as defined by

aryland C R re ulations StatePersonnel and Pensions rticle

ary a d tate eac er s oyeese sio yste

igi i ityrovisio

ested allo ance is ayable at a eafter accruin years of creditableser ice

esti grovisio

ested allo ance is ayable at a e for members of the Reformed

Contributory Pension Benefit afteraccruin yrs of eli ible ser ice andat a e for all other members afteraccruin years of eli ible ser ice

in o n inan ia andi n ans

ou may sa e for retirement and reduce yourcurrent ta es by artici atin in b and bretirement lans Sections b and b of thenternal Re enue Code authori e a ta deferred

retirement sa in s ro ram for em loyees ofublic schools he account shelters your money

from ta es in t o ays

■ Pre ta in estin — n estments are madethrou h the con enience of automatic ayrolldeductions before federal and state ta esare calculated on your income C ta isalso ithheld and this lo ers your currentta able income



■ a deferred com oundin — our contributions andin estment earnin s accumulate ta free hile in your

b account ou ay ta es only hen you ithdrathe money

our sa in s in these accounts are enerally not a ailable untila e unless you ha e a financial hardshi as defined bythe RS f you meet the hardshi re uirements you may be ableto borro or ithdra money from your account before

ote n early ithdra al enalty from the b lan illa ly to em loyees se aratin from ser ice before a e

istributions from a b lan are not sub ect to theearly ithdra al enalty

Roth 403(b) contributions — What are they?s a art of the b lan you can ma e after ta Roth b

contributions Roth b contribution allo s you to ma eafter ta contributions on a re ular basis hen Roth bcontributions are ithdra n in estment earnin s may be tafree and your contributions are al ays ta free hich mayresult in reduced income ta es durin retirement

f you ould li e more information call incoln inancial at8 Press to s ea to a re resentati e or theinance ce at 88

Retiree insurance bene tsour retiree insurance benefits are ro ided by Harford County

Public Schools re ardless of the retirement lan from hichyou are recei in your ension Please note that the insurancebenefits and the Board s contribution ercenta es as sho n onthe follo in a e are sub ect to chan e in the future de endinu on the Board and its fundin authorities

hile you may be ested in your ension lan your ability toartici ate in the retirement insurance lans of HCPS may be

limited n order to be eli ible to artici ate in retiree benefitsno or in the future you must be enrolled for the benefit riorto your retirement date retire in ood standin and be in torecei e a monthly ension directly follo in at least years ofcontinuous ser ice to HCPS immediately recedin retirement

n em loyee ho does not ualify to recei e a ension or hoelects to defer ension benefits or has not com leted the last

years of continuous ser ice ith HCPS is ineli ible for futureartici ation in the Board s benefit lans

ey oints 403(b) an 4 (b)Retire ent ans■ ll Em loyees are eli ible to

artici ate in the b andb lans

■ here is no aitin eriodto be in sa in in a lan

ou may enroll or disenrollat anytime

■ Partici ation isoluntary Harford County

Public Schools does not matchyour contributions

■ eductions are ta en from6 aychec s er contract

year for month em loyeesand from aychec s ercontract year for monthem loyees ou decide hoto in est your contributionsand ho much of your salaryto in est

■ RS re ulations ermit youto set aside u tofor contract year nadditional contribution canbe made if you are a eor older by the end of thecontract year Contact youra ro ed endor to assist youin determinin your ersonalannual ma imum

■ fter you ha e obtained thea e of or older the RS

ermits you to contribute anadditional 6 er year

■ Harford County Public Schoolso ers one com any incolninancial to ro ide you the

b and b Plans



Enrolling in your retiree insurancePrior to retirement you must submit a letter ofretirement to the Su erintendent ith a co yto your su er isor Human Resources Benefits

ill be notified of your retirement from theSu erintendent and ill send you a letter and thea ro riate retirement forms ith instructions tocontact a retirement coordinator to schedule yourretirement conference

ou must be enrolled in benefits at the time of yourretirement to elect retiree benefits s of uly

em loyees ho retire any date other thanuly of each year ill ha e a one time o ortunity

to chan e their health insurance benefit lan afterretirement n order to ta e ad anta e of this onetime o ortunity the em loyee must indicate theirdesire to artici ate in the ne t o en enrollmentfollo in their retirement date hen meetin

ith the Harford County Public Schools HCPSretirement coordinator before they retire f theem loyee does not select this o tion they ill notbe able to chan e lans durin the ne t scheduledo en enrollment Harford County Public Schoolsretirees may not enroll in a health dental or lifeinsurance lan follo in their retirement dateEm loyees ho elect to discontinue co era e ator after retirement may not elect co era e at alater date

ealt insurancehe cost of your health insurance is aid by you

and Harford County Public Schools or em loyeeshired rior to uly the Board contributes

ercent of the total cost of your healthdental or life insurance Em loyees hired afteruly recei e benefits based on a tiered

structure Ser ice of thirty years or more recei ethe full Board contribution retirees ithyears recei e t o thirds of Board contribution and

years of ser ice recei e one third of Boardcontribution nly continuous ser ice time iththe Harford County Public Schools a lies

Health insurance remiums are deducted froma retiree s monthly ension chec ormallyretirements occur at the end of a school year andten month em loyees ha e already aid remiums

for co era e throu h u ust herefore if a tenmonth em loyee retires on uly the first healthinsurance remium deduction ill be ta en fromthe Se tember retirement chec S ecial handlinis re uired for retirin indi iduals and or theirs ouses ho are edicare eli ible

he same lans a ailable to acti e em loyees area ailable to retiree s ho are ineli ible for edicare

on reachin eli ibility for edicare usually ata e or earlier if eli ible due to disability retiree sand or their s ouses must enroll in MedicareParts A & B in order to continue artici ation in theBoard s health insurance lans and ill be enrolledin a edicare Su lemental health lan hichcoordinates ith edicare Please note that each ofthe medical lans o ered by Harford County PublicSchools includes co era e for rescri tion dru sf you elect a edicare lan you ill lose yourrescri tion co era e ith Harford County Public

Schools and cannot re elect co era e at a later date

ental co erageental co era e may be continued into retirementhe cost of the lan if elected ill be deducted

from your ension chec

i e insuranceife nsurance may be continued into retirement

Premiums are deducted from your ension checon retirement a retiree s life insurance co era e

starts at he amount of insurance reducesby uly each year until it is at hichis here it remains

at is re ita le o erages of anuary edicare beneficiaries ha e

the o ortunity to recei e subsidi ed rescri tiondru co era e throu h the ne edicare Part

ro ram Beneficiaries ho choose not to si n uat the first o ortunity may ha e to ay more ifthey ait to enter the ro ram later after the o enenrollment eriod

Beneficiaries ho ha e other sources of druco era e—throu h a current or former em loyeror union for e am le—may stay in that lan andchoose not to enroll in the edicare dru lan f



their other coverage is at least as good as the newMedicare drug benefit and therefore considered“creditable coverage”, then the beneficiary cancontinue to get the high quality care they have nowas well as avoid higher payments if they sign up forthe Medicare drug benefit.

Under Section 423.56(a) of the final regulation,coverage is creditable if the actuarial value of thecoverage equals or exceeds the actuarial valueof standard prescription drug coverage underMedicare Part D, as demonstrated through theuse of generally accepted actuarial principles andin accordance with CMS actuarial guidelines. Ingeneral, the actuarial equivalence test measures

whether the expected amount of paid claims underthe entity’s prescription drug coverage is at least asmuch as the expected amount of paid claims underthe standard Part D benefit.

Required disclosures toMedicareÿbeneficiariesHarford County Public Schools must provide anotice of creditable prescription drug coverage toMedicare beneficiaries who are covered by, or whoapply for, prescription drug coverage under any ofthe Harford County Public Schools plans.

lans Retiree enefits dditional etails

on Medicare ( 65)

■ Care irst BlueCrossBlueShield PPC RE P US

■ BlueChoice HM■ riple ption

Medicare Eligible

■ Care irst BlueCrossBlueShield MedicareSupplemental Plan

■ BlueChoice HM

HCPS contributes toward health care premiums for employeeswith 0 or more years of service who are approved forretirement from the Maryland State Retirement and PensionSystems. Board contributions are

Years ofConsecutive

Service to HCPS Hired Prior to 7/1/06 Hired After 7/1/06

0 yrs. ull Boardcontribution

3 Board contribution

20 2 yrs. ull Boardcontribution

2 3 Board contribution

30 yrs. & up ull Boardcontribution

ull Boardcontribution

Upon eligibility for Medicare (usually at age 65 or if eligible dueto disability), retiree’s and or their Medicare eligible dependentsare required to convert to coverage which supplementsMedicare.

Continuation ofInsurance fterRetirement —Deducted monthlyfrom pension incombination withdental and life.

Delta Dental Insurance Retirees may elect to continue to participate in the Delta dentalplans o ered to active employees. or contribution, see chart inmedical row above.

Deducted monthlyfrom pension incombination withhealth insurance.

ife Insurance Retirees pay 0 of the cost of life insurance. he 20,000 basicterm life insurance will continue with a reduction of 2,000 eachuly until the coverage is at 0,000. or contribution, see

chart in medical row above.

Deducted monthlyfrom pension incombination withhealth insurance.

Surviving Spouse’sBenefit

Upon retiree’s death, if the spouse has been covered under aHCPS health care or dental plan, he or she will have the option tocontinue coverage. If elected coverage will continue without anyBoard contribution. or contribution, see chart in medical rowabove.

Billed monthly byHCPS or deductedfrom monthlypension benefitchec if applicable.

5 for BlueChoice HM , 0 for PP C RE, and 5 for riple ption plan members. Part time HCE and HCESC members receive 50 ofboard contribution.


Frequently Asked QuestionsWhat are my Open Enrollment Options?■ Enroll in a medical dental and or e ible

s endin lan

■ Chan e from one medical and or dental lanto another

■ dd or delete a de endent

■ Cancel enrollment of your life medical and ordental insurance lan

■ ly for life insurance Basic— salarySu lemental— salary ou mustcom lete an E idence of nsurability for

nder ritin and be a ro ed by the ifensurance Com any before co era e can

become e ecti e

■ ly for e endent ife must be enrolled inSu lemental to a ly

When an enroll online?Be innin ay st he site ill be o en from

ay st throu h ay nd at m

o ha e to o online to enroll or ene ts?ES f you do not currently artici ate and ish to

elect benefits for the lan year you musto online to enroll

Will et a ne ene ts ar ?ll artici ants to the lan ill be issued a debit

card ebit cards are for three years Cards ill bemailed to your home address

as enrolle in the le i le pen ino nt this year ill nee to enroll

or the ne t plan year online?YES. ou must enroll for S each lan year ourbenefit election will not carry o er into the ne t

lan year

f you are currently artici atin in a le ibleS endin ccount your benefits ill end on une

o artici ate in S for the lanyear you must o online durin o en enrollmentto enroll If you do nothing, you will not be able tocontribute to the Flexible Spending Accounts for2019–20.

ant to han e or enroll in i e ins ran eo ha e to enroll online?

f you are currently enrolled in BasicSu lemental and ish to enroll in Basic only youmust ai e the Su lemental co era e f you arecurrently enrolled in Basic ife and ant to addthe Su lemental ife or if you ha e no co era eand ish to a ly for life insurance you must rintout a Statement of Health lication com leteand mail he completed S form must beprinted, signed and returned to the addressat the top of the form no later than une 1 ,2019. et ife nsurance ill not acce t any forms

ostmar ed after une ou ill be notifiedby et ife if you are a ro ed declined or ifadditional information is needed nce the Benefits

ce recei es confirmation from et ife of youra ro al the benefit ill be chan ed accordin ly

reali e that ma e a mista e henenrolle an orre t my error?

es ou may lo bac on at any time durin theen Enrollment eriod throu h ay nd and

ma e your chan es

as interr pte an hen ame a toontin e enrollin the system time o t an

or ha to stop part ay thro h the sessionWhat sho l o?

ou ill ha e to lo on a ain he system illremember hat you sa ed so you do not ha e tore enter the information

Will e a le to lo a on an he myele tions a ter Open Enrollment?

es sin the same ass ord you created youmay lo bac on at any time and re ie yourelections or lan information Ho e er you illnot be able to ma e chan es after ay nd

Frequently Asked Questions


Who is an eligible dependent?Refer to the Benefits and Eli ibility section of thisboo let on a es

NOTE: If you and your spouse are both employees ofHCPS you can each enroll as an individual or one ofyou can elect Employee/Spouse or Family coverage. Ifyou elect coverage separately, you cannot cover eachother as dependents and your eligible dependentchildren may only be covered by one of you.

an hange ele tions d ing the ea ?RS re ulations re uire you to ee your elections

throu h une 2 2 unless you ha e a ualifiedife E ent Chan es must be re uested ithin

days of the ualified ife E ent

What is a ali ed i e ent?■ Birth or ado tion of a child

■ eath

■ arria e or di orce

■ ermination of em loyment orcommencement of em loyment

■ Co ered de endent ceasin to be an eli iblede endent

■ S ouse s loss of benefits

■ Court ordered custody

o be considered a ualified life e ent the e entmust result in the em loyee or de endent aininor losin eli ibility for benefits nly the co era ecate ory can be chan ed not the lan choice

When an add a spo se hild o ne bo n toins an e o e age? his is s all not

an open en oll ent e entou ha e days from date of birth ado tion or

marria e to add the de endent to your healthdental lans Co era e ill ta e e ect retroacti elyto the date of birth date of ado tion or marria ef you miss this day eriod the ne t o ortunity

to add the child or s ouse ould be durin theo en enrollment eriod held annually ou illneed to ro ide a de endent erification formand documentation birth certificate marria ecertificate ado tion a er or

a en olled in a edi al o ental planand do to lea es the net o anhange ele tion?o his is not considered a ualified life chan e

When do dependents lose eligibilito o e age?

Refer to the Benefits and Eli ibility section ofthis boo let ou must notify the Benefits ceas soon as you no that your de endent illno lon er meet the eli ibility re uirements forco era e ou should notify the Benefits cein ad ance so the de endent can be remo edfrom co era e at the a ro riate time hereare no refunds of bi ee ly deductions deducteddurin the eriod of ineli ibility Remember

hen co era e ends for a de endent he or shemay choose to continue co era e under C BRfor a ma imum of months as lon as youha e notified the Benefits ce of your re uestto continue co era e ithin days of the lossof eli ibility

en oll o bene ts online hen doeso e age sta t?

Benefits ill become e ecti e uly 2 foranyone ho elects co era e durin our o enenrollment eriod or all ne hires the benefitsare e ecti e the first of the month follo in yourdate of hire cards ill be mailed to your homeaddress

When does o e age end i esign?f your em loyment ends follo in the close of

the school year and you are a month em loyeeyour benefits terminate as of u ust f yourem loyment ends durin the school year or youare a 2 month em loyee benefits terminateon the last day of the month in hich you are onacti e ay status

When does o e age end o dependentssho ld die?End of the month in hich the death occurred

our sur i in s ouse de endent ill ha ethe o tion of continuin co era e on HarfordCounty Public Schools lan throu h C BR but isres onsible for ayin 2 of the remium for uto months


Once you become covered under a group health plan (the Plan) you have COBRA rights. Thissummary contains important information about your right to COBRA continuation coverage,which is a temporary extension of coverage under the Plan. The right to COBRA continuationcoverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Actof 1985 (COBRA). COBRA continuation coverage can become available to you when you wouldotherwise lose your group health coverage. It can also become available to other membersof your family who are covered under the Plan when they would otherwise lose their grouphealth coverage.

COBRAContinuation Coverage Rights Under COBRA

What is COBRA continuationcoverage?C BR continuation co era e is a continuationof Plan co era e hen co era e ouldother ise end because of a life e ent no nas a ualifyin e ent fter a ualifyin e entC BR continuation co era e must be o ered toeach erson ho is a ualified beneficiary ouyour s ouse and your de endent children couldbecome ualified beneficiaries if co era e underthe Plan is lost because of the ualifyin e ent

nder the Plan ualified beneficiaries ho electC BR continuation co era e must ay for C BRcontinuation co era e he cost is the monthly

remium e ui alent to the full cost of co era elus an administrati e char e of

f you are an em loyee you ill become a ualifiedbeneficiary if you lose your co era e under thePlan because either one of the follo in ualifyine ents ha ens

■ our hours of em loyment are reduced or

■ our em loyment ends for any reason otherthan your ross misconduct

f you are the s ouse of an em loyee you illbecome a ualified beneficiary if you lose yourco era e under the Plan because any of thefollo in ualifyin e ents ha ens

■ our s ouse dies

■ our s ouse s hours of em loymentare reduced

■ our s ouse s em loyment ends forany reason other than his or her rossmisconduct

■ ou become di orced from your s ouse

■ our de endent children ill becomeualified beneficiaries if they lose co era e

under the Plan because any of the follo inualifyin e ents ha ens

he arent em loyee dies

he arent em loyee s hours ofem loyment are reduced

he arent em loyee s em loymentends for any reason other than his or her

ross misconduct

he arents become di orced or

he child sto s bein eli ible for co era eunder the lan as a de endent child

When is COBRA coverage avai a e?he Plan ill o er C BR continuation co era e

to ualified beneficiaries only after the Benefits ce has been notified that a ualifyin e ent has

occurred hen the ualifyin e ent is the end ofem loyment or reduction of hours of em loymentor the death of the em loyee the Benefits ce

ill be notified of the ualifyin e ent

COBRA


How is COBRA coverage provided?nce the Benefits ce recei es notice that aualifyin e ent has occurred C BR continuation

co era e ill be o ered to each of the ualifiedbeneficiaries Each ualified beneficiary ill ha ean inde endent ri ht to elect C BR continuationco era e Co ered em loyees may elect C BRcontinuation co era e on behalf of their s ousesand arents may elect C BR continuationco era e on behalf of their children

C BR continuation co era e is a tem orarycontinuation of co era e hen the ualifyine ent is the death of the em loyee your di orce ora de endent child s losin eli ibility as a de endentchild C BR continuation co era e lasts foru to a total of months hen the ualifyine ent is the end of em loyment or reduction ofthe em loyee s hours of em loyment C BRcontinuation co era e enerally lasts for only uto a total of months here are t o ays in

hich this month eriod of C BR continuationco era e can be e tended

isa i i e e sio o o period oco i a io coveragef you or anyone in your family co ered under

the Plan is determined by the Social Securitydministration to be disabled and you notify the

Benefits ce in a timely fashion you and yourentire family may be entitled to recei e u to anadditional months of C BR continuationco era e for a total ma imum of months hedisability ould ha e to ha e started at sometime before the th day of C BR continuationco era e and must last at least until the end of the

month eriod of continuation co era e oumust ro ide ritten notice to he Benefits ce

South Hic ory e Bel ir 4

eco d a i i g eve e e sio oo period o co i a io coverage

f your family e eriences another ualifyin e enthile recei in months of C BR continuation

co era e the s ouse and de endent children inyour family can et u to additional months ofC BR continuation co era e for a ma imum of

months if notice of the second ualifyin e entis ro erly i en to the Plan his e tension maybe a ailable to the s ouse and any de endent

children recei in continuation co era e if theem loyee or former em loyee dies or etsdi orced or if the de endent child sto s beineli ible under the Plan as a de endent child butonly if the e ent ould ha e caused the s ouse orde endent child to lose co era e under the Planhad the first ualifyin e ent not occurred

o ave es io suestions concernin your Plan or your C BR

continuation co era e ri hts should be addressedto the Benefits ce or C BR rates lease isitthe benefits ebsite

eep o r p a i or ed oaddress c a gesn order to rotect your family s ri hts you shouldee the Benefits ce informed of any chan es

in the addresses of family members ou shouldalso ee a co y for your records of any noticesyou send to the Benefits ce


Health Insurance PortabilityAccountability Act (HIPAA)The Health Insurance Portability and Accountability Act (HIPAA)places limitations on a group health plan’s ability to impose pre-existing condition exclusions, provides special enrollment rightsfor certain individuals, and prohibits discrimination in grouphealth plans based on health status.

We are electronically transmitting data to the vendors foreligibility purposes. The vendors and HCPS are in compliancewith the HIPAA requirements. No personally identifiableinformation may be released to a third party.

Special enrollment rightsf you are declinin enrollment for yourself or your de endentsincludin your s ouse because of other health insurance co era e

you may in the future be able to enroll yourself or your de endents inthis lan ro ided that you re uest enrollment ithin days afteryour other co era e ends n addition if you ha e a ne de endent asa result of marria e birth ado tion or lacement for ado tion youmay be able to enroll yourself and your de endents ro ided that youre uest enrollment ithin days after the marria e birth ado tion or

lacement for ado tionf you your s ouse or eli ible de endent child loses co era e under edicaid or a State

Children s Health nsurance Pro ram S CH P or becomes eli ible for state ro ided remiumassistance the a ected indi idual s has days from the date of the e ent to elect co era e inthe HCPS Healthcare lans Contact HR Benefits ce for more information

or more informationabout your ri htsincludin C BRthe Health nsurancePortability and

ccountability ctH P and other

la s a ectin rouhealth lans contactthe nearest Re ionalor istrict ce ofthe S e artmentof abor s Em loyeeBenefits Security

dministration EBSin your area or isitthe EBS ebsite at

dol o ebsa


The Family Medical Leave Act (FMLA) was passed by Congress to protect eligible employeeswho cannot attend work for reasons related to birth, adoption, and/or serious healthconditions involving the employee or the need to care for a spouse, child or parent with aserious health condition.

Family and Medical Leave Act (FMLA)

Eli ibility for lea e is also based u on len thof time em loyed and number of hours or ed

ithin the month eriod immediately beforedate lea e is to be in n eli ible em loyee canta e u to or ee s in a month eriod

Eli ibility ill be determined by the Benefits ceu on notification and or submission of re uireddocuments School system em loyees ho are inneed of lea e for one of the reasons notedabo e must com lete an electronic lea ere uest and ro ide medical certification or otherdocumentation based u on the reason for thelea e re uest he re uest should be submitted

days in ad ance for any foreseeable needfor lea e

n accordance ith the la may be rantedfor the follo in reasons

■ he birth of a child and in order to care forthat child

■ he lacement of a child ith an em loyeefor ado tion or foster care

■ he care of a s ouse arent or child ith aserious health condition as defined by the

re ulations

■ he serious health condition of the em loyee

Military Family Leavehe also ro ides certain military family

lea e entitlement ou may ta e lea efor s ecified reasons related to certain militaryde loyment dditionally you may ta e u to 6

ee s of lea e in a sin le month eriod tocare for a co ered ser ice member ith a seriousin ury or illness

■ ilitary Care i ers ea e

■ ualifyin E i ency ea e

he electronic lea e re uest and re uireddocuments can be found on SharePoint oradditional information contact the Benefits ceat 7

Harford County Public Schools ill maintain rouhealth insurance co era e on the same termsand conditions as if the em loyee continued to

or urther information concernin benefits andlea e can be obtained by callin the Benefits

ce or isitin the HCPS SharePoint ebsiteat https://hcps365.sharepoint.com/sites/humanresources/benefits

rom a non HCPS com uter the electronic lea ere uest form can be accessed ia my.hcps.org oin ith your HCPS username and ass ord selectHCPS FMLA eb lin and continue throu h the

rocess of submittin your re uest


Privacy Notice

Harford County Public Schools the Board isre uired under the edical Pri acy Rules of theHealth nsurance Portability and ccountability

ct H P to ro ide all of its em loyees andretirees artici atin in its self funded healthcare lans ith this PR C CE hichconcerns ersonal rotected health informationyou ha e ro ided to the Board as a condition ofyour em loyment

n ro idin health insurance benefits to you theBoard collects the follo in ty es of ersonalinformation information you ro ide to uson an a lication or enrollment form in order toobtain insurance includin your name addresstele hone number date of birth and SocialSecurity number remium ayments theBoard ays on your behalf the fact that youare currently or ha e been one of our em loyees

information you ha e i en to us from any ofyour hysicians or other health care ro iders

information related to your health carestatus includin dia nosis and claims aymentinformation and other information about youthat is necessary for us to ha e in order to ro ideyou ith health insurance

e may disclose this information to our third artyendors the endors ithout rior authori ation

as ermitted by la e do not disclose anyersonal information about either our current

em loyees or former em loyees to anyone e ce tas ermitted by la e may from time to timedisclose ersonal information about you ithout

rior authori ation as ermitted by la to theendors to erform ser ices or functions on our

behalf f e ma e such a disclosure e ill do soonly if e ha e a contract in lace that rohibits the

endors from disclosin or usin the informationfor any ur ose other than the ur ose of thedisclosure e ce t as ermitted by la e restrict

access to your ersonal information to thoseem loyees of the Board ho need to no thatinformation in order to ro ide ser ices to you

e maintain hysical electronic and roceduralsafe uards that com ly ith H P re ulationsto uard your ersonal information Em loyees

ho ha e access to your ersonal informationare re uired to abide by the follo in standards

to safe uard and secure confidential ersonalinformation as re uired by la to limit thecollection and use of any artici ants informationto the minimum necessary and to ermit onlytrained authori ed em loyees to ha e accessto your ersonal information Em loyees hoiolate the olicy ill be sub ect to our established

disci linary olicy n addition the Board illro ide all of our artici ants at least annuallyith any u dates to this olicy ro ide

information about you to the endors only inaccordance ith the la re uire the endorsto enter into a contract that rohibits disclosure orthe use of your ersonal information other thanto carry out the ur ose of the disclosure e ce tas ermitted by la not share your ersonalinformation for ur oses other than allo edby la allo artici ants the o ortunity tocorrect ersonal information that they belie e isnot accurate

our ri acy is a hi h riority for Harford County Public Schools and it ill be treated iththe hi hest de ree of confidentiality

New Health Insurance Marketplace Coverage Options and Your Health Coverage Sample Form


N

:

New Health Insurance Marketplace Coverage Options and Your Health Coverage Sample Form


P

3. Employer name 4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number

7. City 8. State 9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address

Harford County Public SchoolsSouth Hic ory nu

l ir

n fits ffic

n fits hc s or

ular ull ti loy sPart ti loy s or in or hours r or or


Definitions

Allowed Benefithe criteria Care irst BlueCross BlueShield uses

to determine ayments to your hysician t isbased u on the Resource Based Relati e alue

nit System his system ta es factors intoconsideration or alue amount of s ill timee ort re uired for ser ice ractice e ense costof o erhead e enses and the liability mal racticee ense for co ered ser ices

d dent fi t on e edentification or membershi card for medicalharmacy co era e he card identifies the

em loyee ty es of elected co era e ty e ofmembershi and the e ecti e date of co era e

o n n ecost sharin re uirement under your Care irst

BlueCross BlueShield olicy hich re uiresyou to assume a ercenta e of the costs ofco ered ser ices

oCost sharin in hich you ay a at amount erser ice nli e coinsurance the amount does notary as a ercenta e of the cost of the ser ice

ed t lemount of e ense you must incur before

Care irst BlueCross BlueShield or elta ental illassume any liability for all or art of the remainincost of co ered ser ices

l l tState of fulfillin re uirements for co era e

n netwo o dereferred ro ider ithin a Preferred

Pro ider r ani ation

ed l e enhe sudden and une ected onset of a serious

illness or condition hich re uires necessaryimmediate medical care

on t t n o dehysician or other ro ider ho has not si ned

an a reement ith the Care irst BlueCrossBlueShield lan to acce t the llo ed Benefit as

ayment in full

t o netwo o dero ider that is not art of the PP net or

t o o ethe deductible co ayment lus any coinsurance

amount that the subscriber ays once this hasbeen met the olicy ill normally ay at 00 ofthe llo ed Benefit for most co ered ser ices

t t n o dendi idual hysicians hos itals and rofessional

health care ro iders ho ha e a contract ithCare irst BlueCross BlueShield and or Care irstBlueChoice nc to ro ide ser ices to its membersat a discounted rate and to be aid directly forco ered ser ices

ed l nd ent l l n ehe Plan ear is t el e months uly une 0

A l n eS Plan ear is t el e months uly une 0

o e on l o onenthat ortion of a char e for ray or laboratory

ser ices erformed in a hos ital hich is allocatedto a hysician as his rofessional fee

o den indi idual or institution that ro ides

medical care

hese definitions ha e been de elo edto hel you become familiar ith someof the terms in this manual


Employers that offer health insurance benefits finance those benefits in one of two ways: Theypurchase health insurance from an insurance company (fully-insured plans), or they providehealth benefits directly to employees (self-insured plans). Typically, these plans differ by whoassumes the insurance risk, plan characteristics, and employer size.

Fully-Insured vs. Self-InsuredWhat is the difference?

If an employer-sponsored plan is fully-insured:he insurance com any is ultimately res onsible

for the health care costs and the em loyer aysremiums n a fully insured lan the em loyerays a er em loyee remium to someone else

an insurance com any to ta e on the ris thatthey ill ay out more in benefits than they collectfrom you in remiums he insurer collects the

remiums and ays the health care claims basedon your olicy benefits he co ered ersons areres onsible to ay any deductible amounts orco ayments re uired for co ered ser ices underthe olicy

If an employer-sponsored plan is self-insured:he em loyer assume the financial ris and acts

as its o n insurer and is ultimately res onsiblefor the health care costs and ays for all of thosecosts lus administration fees Self insured lansoften contract ith an insurance com any orother third arty to administer the lan but theem loyer bears the ris associated ith o erinhealth benefits

Harford County Public Schools (HCPS) self-insuresall medical and dental plans offered

his means e assume the ris for e ery dollarof health care e ense our em loyees andtheir families incur e use the dollars collectedthrou h your ayroll contributions and HCPS scontributions to ay em loyees claims and theadministration costs of the lans n addition ealso share in costs ith em loyees at the ointof care throu h the lan s benefit features ecoinsurance and co ayments ur third artyadministrators are Care irst and elta ental

Self insurin our medical and dental lans benefitsHCPS and our em loyees in many ays

■ ur bene t dollars o to ard bene tsBuilt into the cost of any insurance olicy isthe insurer s rofit hen e self insure eeliminate the middleman—the insurer—andits built in rofit hou h third arty insurersadminister our lans they do so on a feefor ser ice basis they ta e no financial risfor ayin our claims nd since HCPS is notma in a rofit by ro idin health insuranceco era e to you e ery dollar of your and HCPS scontributions are used to ay claims and theadministrati e e enses for our lans

■ e ha e more e ibility hen e self insureour lans HCPS and not an insurance com anydecides ho our lans or his ro ides us

ith more e ibility in desi nin our lans edecidin on co ayment and coinsurance le elsto fit the needs of our em loyees he insurancecarrier is res onsible for ne otiatin rates ith innet or ro iders and the rocessin of claims

■ e ha e more control Self insured lansare sub ect to federal re ulations hile fullyinsured lans are re ulated by the state in

hich the lan o erates his e em ts HCPSfrom ro idin for state mandated benefits inour lans hich can be costly and from ayinstate mandated ta es on health care remiumsan additional e ense for the lans

E en thou h HCPS lans are self funded HCPSdoes not assume of the ris for catastro hicclaims Rather e urchase hat is no n as Stooss insurance to rotect a ainst lar e indi idual

claims as ell as total claims hich e ceed thee ected le el for our rou of co ered ersons

he total cost of a self funded lan is the fi edcosts lus the claims e ense less any stoloss reimbursements


Notice of Nondiscrimination andAvailability of Language Assistance Services(UPDATED 7/12/18)

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalizationand Medical Services, Inc., CareFirst BlueChoice, Inc.,The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbiaand Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. InVirginia, CareFirst MedPlus and CareFirst Diversified Benefits are the businessnames of First Care, Inc. of Maryland (used inVA by: First Care, Inc.). ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

Care irst BlueCross BlueShield Care irst BlueChoice nc Care irst Di ersified Benefits and all of theircor orate a liates (Care irst) com ly ith a licable federal ci il ri hts la s and do not discriminate on thebasis of race color national ori in a e disability or se Care irst does not e clude eo le or treat themdi erently because of race color national ori in a e disability or se

Care irst

■ Pro ides free aid and ser ices to eo le ith disabilities to communicate e ecti ely ith us such asualified si n lan ua e inter retersritten information in other formats (lar e rint audio accessible electronic formats other formats)

■ Pro ides free lan ua e ser ices to eo le hose rimary lan ua e is not En lish such asualified inter reters

nformation ritten in other lan ua es

If you need these services, please call 855-258-6518.

f you belie e Care irst has failed to ro ide these ser ices or discriminated in another ay on the basisof race color national ori in a e disability or se you can file a rie ance ith our Care irst Ci il Ri htsCoordinator by mail fa or email f you need hel filin a rie ance our Care irst Ci il Ri hts Coordinator isa ailable to hel you

To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinatoras indicated below. Please do not send payments, claims issues, or other documentation to this office.

Civil Rights Coordinator, Corporate Office of Civil Rightsailin Address P Bo 88

Baltimore aryland 2122

Email Address [email protected]

Tele hone umber 1 28 782a umber 1 2 11

ou can also file a ci il ri hts com laint ith the U S De artment of Health and Human Ser icesce for Ci il Ri hts electronically throu h the ce for Ci il Ri hts Com laint ortal a ailable at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or hone at

U S De artment of Health and Human Ser ices2 nde endence A enue SRoom HHH Buildin

ashin ton D C 2 2 18 8 1 1 8 7 7 7 (TDD)

Com laint forms are a ailable at http://www.hhs.gov/ocr/office/file/index.html


Foreign Language Assistance



CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalizationand Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association.® Registered trademark of the Blue Cross and Blue Shield Association.

Health benefits administered by:

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