Calhoun County 1
2 Table of ContentsPage 3. Introduction to Benefit Guide, General Disclaimers, & information needed to enroll Page 4. Carrier Contact InformationPage 5. Benefit Information, Eligibility, Waiting Period, Etc.Page 6. Making coverage changes and continuing your coveragePage 7. Who pays for your Coverage?Page 8-12. Medical InformationPage 13. Dental InformationPage 14-15. Vision InformationPage 16-18. Employer Paid Life/AD&D and Voluntary Worksite Benefits InformationPage 19-20. How to File a Claim with UNUMPage 21. Compliance Notices
Welcome to your Benefits Guide! We are delighted to provide you with this benefits guide, offering an overview of your employer's benefit program. As valued members of our team, your well-being and satisfaction are paramount to us. This guidebook aims to empower you with valuable information to make informed decisions about your benefits and ensure you get the most out of your employment package. About this Benefit Guidebook This Benefits Guidebook describes the highlights of your employer’s benefits program in non-technical language. Your specific rights to benefits under the plan are governed solely, and in every respect, by the official plan documents and not the information in this Guidebook. If there is any discrepancy between the description of the program elements as contained in this Benefits Guidebook and the official plan documents, the language in the official plan documents shall prevail as accurate. Please refer to the plan-specific documents published by each of the respective carriers for detailed plan information. Any and all elements of our benefits program may be modified in the future, at any time, to meet Internal Revenue Service Rules or otherwise as decided by us. Please note that while we strive to provide accurate information, the rates listed in this guide are subject to underwriting review and can change upon submission. If rates change, you will be notified. We hope you find this guide helpful in navigating your benefits and understanding the support available to you. Before you Enroll Please have the following information ready when enrolling. • Dependents Names • Birth Dates • Social Security Numbers • Address • Email • Phone Number 3
Contents & Contact Information Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources. Medical Contact: Blue Cross & Blue Shield of TX Policy # 032810 Phone: 972-766-6900 Website: www.bcbstx.com Telehealth Contact: MD Live *This is only available if you enrolled in the BCBS Medical Plan. Phone: 888-680-8646 Website: www.MDLIVE.com/bcbstx Dental Contact: Blue Cross & Blue Shield of TX Phone: 972-766-6900 Website: www.bcbstx.com Davis Vision Contact: Blue365 Phone: 888-897-9350 Website: www.davisvision.com Vision Contact: Dearborn National Phone: 800-348-4512 Website: www.dearbornnational.com/vision Whole Life, Term Life, Disability, Accident, Hospital, and Critical Illness Contact: UNUM Phone: 866-679-3054 Website: www.unum.com Emergency Transportation Contact: MASA Phone: 800-643-9023 Website: masaaccess.com/member 4
Benefit Information: Your benefits plan: We offer a variety of benefits allowing you the opportunity to customize a benefits package that meets your personal needs. You have the option to enroll in any or all of the benefit plans, each benefit is independent of the others, and you may choose any combination you like. In the following pages, you’ll learn more about the benefits offered. You’ll also see how choosing the right combination of benefits can help protect you and your family’s health and finances – and your family’s future. Choosing your benefits: You must actively choose any benefit that you pay for or share in the cost with. The premium for elected coverages are taken from your paycheck automatically. There are two ways that the money can be taken out, pre-tax or post –tax. Why do I pay for benefits with Pre-Tax money? There is a definite advantage to paying for some benefits with pre-tax money. Taking the money out before your taxes are calculated lowers the amount of your pay that is taxable. Therefore, you pay less in taxes. Which benefit premium are taken before tax? PRE-TAX: Medical, Dental, Vision, Critical Illness, & Accident POST-TAX: Life, & Disability Example Pre-Tax Post-Tax Gross Salary 50k 50k Health Premium 5k 5k Taxable Wages 45k 50k Income Tax on Wages 5,800 6,900 FICA Tax on Wage 3,433 3,825 Net Employee Pay $35,757 $34,275 Eligibility: You are considered an eligible employee if you are a regular full-time employee scheduled to work at least 30 hours each week. Waiting Period: Newly hired employees are eligible for benefits on the first of the month following 60 days of hire. *Restrictions apply to part-time employees. 5
Making Changes Generally, you can only change your benefit choices during the annual Benefits Enrollment Period. However, you can change your benefit choices during the year if you experience a life event change. Life event changes include but are not limited to: • Marriage • Divorce • Birth, adoption, or placement for adoption of an eligible child • Death of your spouse or covered child • Change in you or your spouse’s work status that results in the cancellation of your benefits • Becoming eligible for Medicare or Medicaid during the year If you have a life event change, you must notify Human Resources within 30 days of the change (for example, supply HR with your marriage or newborn's birth certificate). If you do not notify Human Resources within 30 days, you will have to wait until the next annual open enrollment period to make benefits changes unless you experience another life event change. Any changes you make to your benefit choices must be directly related to the life event change. When Coverage Ends Benefits end on the last day of the month following termination or when you cease to meet eligibility guidelines. Portability If you leave the company, some of your benefits are portable. This means you can take them with you if you leave, as long as you continue to pay the premiums yourself. The benefits that are portable include: • Voluntary Group Term Life • Universal Life / Whole Life • Accident Insurance • Critical Illness Continuing Your Coverage Under certain circumstances, you may continue your health care coverage when it would otherwise end. This is called COBRA. COBRA applies to these plans: • Medical • Dental • Vision You and/or your dependents are eligible to continue health care coverage if coverage is lost because: • Your employment ends for any reason other than “gross misconduct.” 6
• Your work hours are significantly reduced. • You die. • You become entitled to and enroll in Medicare prior to losing coverage. • You divorce or become legally separated from your spouse. • Your dependent loses dependent status. Who pays the cost for your coverage? Looking Ahead Now, let's delve into each benefit that constitutes your comprehensive benefits program. In the following pages, you'll discover more about the invaluable benefits your employer provides. You'll also understand how selecting the right combination of benefits can safeguard the health and well-being of you and your family. 7 Medical Employer SharedDental Employer SharedVision Employee PaidDavis Vision & 10k Basic Life Employer PaidShort & Long Term Disability Employee PaidAccident Employee PaidCritical Illness Employee PaidHospital Indemnity (NEW) Employee PaidEmergency Transportation Employee PaidWhole Life with Long Term Care Employee PaidVoluntary Term Life & AD&D Employee Paid
(Non-Grandfathered ACA Plan) BLUECHOICE NETWORK This is a general summary of your benefits. Please refer to your benefit booklet for additional details and a description of the plan requirements and benefit design. This plan does not cover all health care expenses. Upon receipt of your benefit booklet, carefully review the plan’s limitations and exclusions. Overall Payment Provisions In-NetworkBenefitsOut-of-Network Benefits Plan Year Deductibles Per-admission Deductible Deductible Applies to all Eligible Expenses except Inpatient Hospital Expenses (unless otherwise indicated) Plan Year Out-of-Pocket Maximum Deductibles are not applied to the Out-of-Pocket Maximum. Copayment Amounts will apply and will not be required after Out-of-Pocket Maximum has been satisfied. Your benefit booklet will provide more details. Copayment Amounts Required N/A-Refer to Medical/Surgical Expense section for benefits Physician office visit/consultation Refer to Medical/Surgical Expenses section for more information MDLIVE (Telemedicine) Urgent Care Outpatient Hospital Emergency Room/Treatment Room Refer to Emergency Room/Treatment Room section for more information Not Applicable 70% of Allowable Amount $150 Copayment Amount Maximum Lifetime Benefits Per Participant Unlimited Inpatient Hospital Expenses Inpatient Hospital Expenses All services must be preauthorized All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units 80% of Allowable Amount 60% of Allowable Amount Penalty for failure to preauthorize services None $250 Calhoun County8 BENEFIT HIGHLIGHTS PLAN 1400-NG$0$2,000 Individual /$6,000 Family$0$6,000 Individual /$18,000 Family$4,000 Individual / $7,200 FamilyNetwork Deductible &Out-of-Pocket Maximum will only apply toward Network Deductible &Out-of-Pocket Maximum$8,000 Individual / $24,000 FamilyOut-of-Network Deductible &Out-of Pocket Maximum do not apply toward Network Deductible& Out-of-Pocket Maximum$35 Copayment Amount $10 Copayment Amount $35/$45 Copayment Amount$150 Copayment AmountA Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationHCR Non-GF TAC Plan 1400 NG (4/03/20)
Medical/Surgical ExpensesIn-NetworkBenefitsOut-of-Network Benefits Medical / Surgical Expenses Services performed during the Physician’s office visit/consultation, including lab & x-ray (does not include Certain Diagnostic Procedures and surgical services) 70% of Allowable Amount after Plan Year Deductible Lab & x-ray in other outpatient facilities (excluding Certain Diagnostic Procedures) 70% of Allowable Amount after Plan Year Deductible Allergy Injections 70% of Allowable Amount after Plan Year Deductible Colonoscopy (All places of treatment and diagnoses) 70% of Allowable Amount after Plan Year Deductible Physician surgical services performed in any setting 60% of Allowable Amount after Plan Year Deductible Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, CT -Scan (with or without contrast), Ultrasound, MRI, Myelogram, PET Scan. 60% of Allowable Amount after Plan Year Deductible Home Infusion Therapy (Services must be preauthorized) 80% of Allowable Amount after Plan Year Deductible 60% of Allowable Amount after Plan Year Deductible Organ Transplants 80% of Allowable Amount after Plan Year Deductible 60% of Allowable Amount after Plan Year Deductible All other outpatient services and supplies 80% of Allowable Amount after Plan Year Deductible 60% of Allowable Amount after Plan Year Deductible In Vitro Fertilization Services Declined Extended Care ExpensesExtended Care Expenses All services must be preauthorized 70% of Allowable Amount after100% of Allowable Amount Plan Year Deductible Skilled Nursing Facility 25 day maximum each Plan Year* Home Health Care 60 visit maximum each Plan Year* Hospice Care Unlimited Special Provisions ExpensesSerious Mental Illness All services must be preauthorized Inpatient Services -Hospital services (facility) 60% of Allowable Amount80% of Allowable Amount-Physician services 80% of Allowable Amount after Plan Year Deductible 60% of Allowable Amount after Plan Year Deductible Outpatient Services -Services performed during Physician office visit/consultation(does not include psychological testing)70% of Allowable Amount after Plan Year Deductible -All outpatient services and psychological testing60% of Allowable Amount after Plan Year Deductible *Benefits used In-Network and Out-of-Network will apply toward satisfying any day, visit, Plan Year, Annual Maximum, series of treatments benefits indicatedYour Benefits 9100% of Allowable Amount after $35Copayment100% of Allowable Amount100% of Allowable Amount100% of Allowable Amount80% of Allowable Amount after Plan Year Deductible80% of Allowable Amount after Plan Year Deductible100% of Allowable Amount after $35Copayment80% of Allowable Amount after Plan Year DeductibleA Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationHCR Non-GF TAC Plan 1400 NG (4/03/20)
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationSpecial Provisions Expenses, cont. In-NetworkBenefitsOut-of-network Benefits Mental Health Care/Chemical Dependency All services must be preauthorized Inpatient Services -Hospital services (facility) 60% of Allowable Amount80% of Allowable Amount-Physician services80% of Allowable Amount after Plan Year Deductible 60% of Allowable Amount after Plan Year Deductible Plan Year Maximum 30 inpatient days/30 inpatient Physician visits each Plan Year* 30 inpatient days/30 inpatient Physician visits each Plan Year* Outpatient Services -Services performed during Physician office visit/consultation (does not include psychological testing) 70% of Allowable Amount after Plan Year Deductible -Emergency Room/Treatment Room60% of Allowable Amount after $150 Copayment Amount & Plan Year Deductible (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply) -Other Outpatient Services and psychological testing 60% of Allowable Amount after Plan Year Deductible Plan Year Maximum each Plan Year* Chemical Dependency Maximum (Inpatient treatment must be provided in a Chemical Dependency Treatment Center) Limited to three separate series of treatments for each covered individual per lifetime * Emergency Room/Treatment Room Accidental Injury & Emergency Care -Facility charges (outpatient Hospital emergency treatment room charges) 80% of Allowable Amount after $150 Copayment Amount (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply) -Physician charges 80% of Allowable Amount after Plan Year Deductible Non-Emergency Care -Facility charges (outpatient Hospital emergency treatment room charges) 80% of Allowable Amount after $150 Copayment Amount (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply) 60% of Allowable Amount after $150 Copayment Amount & Plan Year Deductible (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply) -Physician charges80% of Allowable Amount after Plan Year Deductible 60% of Allowable Amount after Plan Year Deductible Ground and Air Ambulance Services 80% of Allowable Amount after Plan Year Deductible *Benefits used In-Network and Out-of-Network will apply toward satisfying any day, visit, Plan Year, Annual Maximum, series of treatments benefits indicatedCalhoun County10 100% of Allowable Amount after $35 Copayment Amount80% of Allowable Amount after $150 Copayment Amount(Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply)80% of Allowable Amount after Plan Year Deductible30 outpatient visitsHCR Non-GF TAC Plan 1400 NG (4/03/20)
Special Provisions Expenses, cont. In-NetworkBenefitsOut-of-network Benefits Preventive Care Routine annual physical examinations, well-baby care exams, immunizations 6 years of age & over, vision exams, hearing exams, and any other preventive health services as determined by USPSTF 100% of Allowable Amount 70% of Allowable Amount after Plan Year Deductible Immunizations for Dependent children through the date of the child’s 6th birthday 100% of Allowable Amount 100% of Allowable Amount Speech and Hearing Services Services to restore loss of or correct an impaired speech or hearing function without hearing aids 80% of Allowable Amount after Plan Year Deductible 60% of Allowable Amount after Plan Year Deductible Physical Medicine Services Chiropractic Care-Office Services Airrosti Rehab Centers 60% of Allowable Amount after Plan Year Deductible Not Applicable Plan Year Maximum 35 visit maximum each Plan Year* All other Physical Medicine Services rendered by any other eligible Provider will be allowed on the same basis as any other sickness. *Benefits used In-Network and Out-of-Network will apply toward satisfying any day, visit, Plan Year, Annual Maximum, series of treatments benefits indicatedYour Benefits EMPLOYEE INFORMATION This is a general Summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions. MDLive (Telemedicine) is part of your benefit plan design. Access to an independently contracted board-certified doctor is available 24 hours a day, seven days a week to speak to immediately or schedule an appointment based on your availability. Please refer to your benefit booklet for other details. The following benefits apply to dependent coverage: Dependent children are covered to age 26. Automatic coverage for newborns for the first 31 days following birth. Infants not enrolled for coverage within the first 31 days after birth will not be eligiblefor coverage until the following open enrollment period or special enrollment event.Payments: Network providers agree to accept amounts negotiated with BCBSTX and are paid according to this BCBSTX-determined Allowable Amount. Covered individuals are responsible for any required Deductibles, Coinsurance Amounts, and Copayments. Plan benefits paid to Out-of-Network providers are based on the BCBSTX-determined Allowable Amount, except in the event of Emergency Care received in an outpatient hospital emergency treatment room within 48 hours of the incident. For all other services received by an Out-of-Network Provider, the covered individual will be responsible for charges in excess of the Allowable Amount in addition to any applicable Deductibles, Coinsurance Amounts, and Copayments. For cost savings information, refer to the section on ParPlan Providers and the definition of Allowable Amount in the benefit booklet. Replacement of Medical Coverage: In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the following provisions apply to each eligible participant who has health coverage under the employer’s plan immediately prior to the effective date of the health contract between the employer and BCBSTX (the contract date): Benefits for eligible expenses incurred for any service or supplies prior to the contract date, are not covered under the contract. Eligible expenses for services or supplies incurred on or after the effective date will be considered for benefits subject to all applicable contract provisions.11 80% of Allowable Amount after Plan Year Deductible$35 Copayment Amount
PRESCRIPTION DRUG PLAN OPTION 5B-NG $100 DEDUCTIBLE Prescription Drug Program Up to a 30-day Supply at Participating Navitus Health Solutions Network Retail Pharmacy Plan Year Deductible Tier 3 Drug Tier 2 Drug Tier 1 Drug $100 Individual / $300 Family $50 Copayment Amount $30 Copayment Amount Lesser of $10 Copayment Amount OR Actual Cost ATTENTION: Please note the following guidelines regarding your Prescription benefits: 1) Members electing to purchase brand name drugs when a generic is available will be required to pay the difference between the cost ofthe Generic drug and Brand Name drug, plus the Brand Name Copayment.2) Specialty and biotech medications are available only through mail order unless purchased and administered through the doctor’s office.Up to a 90-day supply at In-Network Retail or Mail Service Pharmacy Tier 3 Drug Tier 2 Drug Tier 1 Drug $100 Copayment Amount $60 Copayment Amount $20 Copayment Amount Note: Prescription Drug Benefits are provided by Navitus Health Solutions through a master contract with the Texas Association of Counties Health and Employee Benefits Pool. Prescription Drugs are not administered by Blue Cross and Blue Shield of Texas $73.84 $208.78$383.19$494.21$75512 Scan/Click QR Codeto view SBC
Dental Care Calhoun County offers a dental plan through BlueCross BlueShield of Texas. For more information, contact BCBS of TX directly at 972.766.6900 or visit them on the web at: bcbstx.com.BlueCare Dentist DentalBlue Dentist See a Non-Contracting Dentist• Your out-of-pocket cost will generallybe the least amount because BlueCareDentists have contracted to accept alower Allowable Amount as payment infull for Eligible Dental Expenses• You are not required to file claim forms• You are not balance billed for costsexceeding the BCBSTX AllowableAmount for BlueCare Dentists• Your out-of-pocket cost may be greaterbecause DentaBlue Dentists havecontracted to accept a higher AllowableAmount as payment in full for EligibleDental Expenses• You are not required to file claim forms• You are not balance billed for costsexceeding the BCBSTX AllowableAmount for DentalBlue Dentists• Your out-of-pocket cost may be greaterbecause Non-Contracting Dentists havecontracted to accept a higher AllowableAmount as payment in full for EligibleDental Expenses• You are not required to file claim forms• You are balance billed for costsexceeding the BCBSTX AllowableAmountCoverage General ProvisionsPolicy year Deductible (4th quarter carryover applies)Deductible credit from prior carrierPolicy year Maximum per Participant$50 Individual/$150 Family YES$1,500Preventive Services -Oral Examinations - 2 per policy yearProphylaxis - 2 cleanings per policy yearFlouride treatmentSealantsDental X-rays (subject to booklet provision)Labs and Tests100% BASIC Services - anesthesia, oral surgery, root canals, endodontics, periodontics, crowns**See summary for full listing80% MAJOR Services - Crowns, Inlays/Onlays Services Prosthodontics Services - bridges and dentures50% Miscellaneous Service Space MaintainersPalliative Care80% Orthodontia Not covered Each time you need dental care, you can choose from the following:Semi-Monthly (24 Pay Periods) DeductionsDental CoverageEmployee Only Employee & Child(ren) Employee & Spouse Family$1.66 $13.73 $16.14 $28.2113
Your Benefits Blue365 Vision Discount ProgramBlue Cross and Blue Shield of Texas (BCBSTX), a division of Health Care Service Corporation, is pleased to offer members a discount vision program through Davis Vision, Inc., a leading national provider of routine vision care programs. Save on eyeglasses and receive discounts on contact lenses, eye exams and accessories with Davis Vision. For more information, call Davis Vision at 888-897-9350 or visit davisvision.com, click Members and enter Client Code 2295 in the Open Enrollment section. If you enroll in voluntary vision, the Davis Vision is not an available benefit.SERVICE You PayComprehensive examination Contact lens examination 15% off or $5 off retail cost15% off or $10 off retail costSpectacle Lenses (Uncoated Plastic)3 Single vision Bifocal Trifocal Lenticular *Spectacle Lenses Options3 (Additional pricing- see full benefit summary for pricing)$35$55$65$110*Additional pricingFrames3Priced over $70 retail Priced over $70 retail$40 $40 plus 10% off the amount over $70Contact Lenses Conventional2 Disposable/Planned replacement220% off10% off1.) At Wal-Mart, members will receive comparable values on examination, spectacle lens and contact lens purchases. Members buying frames at Wal-Mart will receive a flat ten percent discount off of Wal-Mart’s price, rather than the discounts above. 2.) Discount will be applied to the provider’s usual and customary price for services. 3.) Special lens designs, materials, powers and frames may require additional cost. 4.)Pricing at some retail locations may vary The relationship between these vendors and Blue Cross and Blue Shield of Texas (BCBSTX) is that of independent contractors. Blue365 is a discount program available to BCBSTX members. Some of the services offered through Blue365 may be covered under your health plan. Please refer to your benefit booklet or call the customer service number on the back of your ID card for specific benefit information under your health plan. Use of Blue365 does not af-fect your premium, nor do costs of Blue365’s services or products count toward any maximums and/or plan deductibles. Discounts are only available through participating vendors.BCBSTX does not guarantee or make any claims or recommendations regarding the services or products offered under Blue365. You may want to consult with your physician prior to use of these services and products. Services and products are subject to availability by location. BCBSTX reserves the right to discontinue or change this discount program at any time without notice.The Davis Vision network consists of major national and regional retail locations, such as EyeMasters and Visionworks, as well as independent ophthalmologists and optometrists. For a list of Davis Vision providers near you just log in to Blue Access for MembersSM (BAM) at bcbstx.com. Click on the My Coverage tab at the top, and then the Blue365 Discount Program link. Mail order contact lensesDiscounts on disposable contact lenses through Davis Vision’s mail-order contact lens replacement program. For more information, contact Davis Vision at 888-897-9350 or visit davisvisioncontacts.com.Laser Vision Discounts on laser vision correction services for you and your eligible dependents through the TLC/TruVision network. To schedule an appointment, call TLC/TruVision directly at 866-484-2020. For more information, call Davis Vision at888-897-9350.How do I locate a Davis Vision provider?14
Voluntary Vision Vision Benefits should enhance your life, not complicate it. That's why Dearborn National Vision Care is working with EyeMed to bring you vision benefits that deliver more. Our vision benefit gives employees the freedom to choose at any in-network provider.Members can access their benefits, view their claims and request ID Cards from www.DearbornNational.com/Vision. Also benefits can be applied online at Glasses.com - providing access to huge selection of rams and lenses with 3-D virtual try on technology. Members can shop in their own homes.INDEPENDENT PR0VIDER NETWORK Exam with D ilation as Necessary Frequency: Examination Lenses or Contact Lenses Frame Exam Options: + Standard Contact Lens Fit and Follow Up: Frames: Any available frame at provider location Standard Plastic Lenses Single Vision BifocaJ Trifocal Lenticular Standard Progressive Lens Premium Progressive Lens Lens Options UV treatment T int (solid and gradient) Standard P lastic Scratch Coating Standard Polycarbonate -Adults Standard Polycarbonate -Kids under 1 9 Standard Anti-Reflective Coating Polarized Photocromatic/Transitions Plastic Premium Anti-reflective • · LESS(RAFTERS PEARLE 00 VISION. sears OPOCAI. @OPTICAL: EJoptical $10 Copay O nce every 12 months O nce every 12 months O nce every 24 months oeorborn i,.. Notional" eve Up to $40 for Standard ; 1 0 % off retail price for Premium $0 Copay; $130 Allowance, 20% off balance over $130 $25 Copay $25 Copay $25 Copay $25 Copay $75 Copay See table on page 2 $15 $15 $0 $40 $0 $45 20% off retail price $75 See Below Table Contact Lenses (Contact lens allowance indudes materials only) Conventional $0 Copay; $130 allowance, 15% off baJance over Disposable Medically Necessary Laser V ision Correction Lasik or PRK from U.S. Laser Network Additional Pairs Benefit: Progressive Price List* Standard Progressive : $75 Copay Premium Progressives as Follows: Tier 1 : $105 Copay T ier 2 : $95 Copay Tier 3: $120 Copay Tier 4 : $75 Copay, 80% of charge less $130 AUowance Other Add-ons P r;ce List: Photochromic (p lastic) : $75 Copay Polarized : 80% of Charge EMPLOYEE $3.10 $130 $0 Copay; $130 allowance. plus balance over $130 $0 Copay, Paid in full 1 5% off Retail Price or 5 % off P romotional Price Members also receive a 40% discount off complete pair eyeglass purchase and a 15% discount off conventional contact lenses once the funded benefit has been used. Anti-ReHective Coating Price List• Standard Anti-Reflective Coating : $45 Copay Premium Anti-Reflective Coatings as Follows: Tier 1 : $57 Copay Tier 2 : $68 Copay Tier 3 : 80% of Charge Semi-Monthly (24 Pay periods) Deductions Vision Coverage EMPLOYEE & SPOUSE $5.90 FAMILY$EMPLOYEE & CHILDREN $2.29 $4.59 $4.36 $6.7615
$10K Employer-Paid Life and AD&D Insurance Plan: To ensure that you have adequate coverage for your family's financial needs, Calhoun County provides $10,000 of basic life and AD&D coverage for all eligible employees enrolled in medical and/or dental coverage. Critical Illness Plan: A group critical illness plan helps prepare you for the added costs of battling a specific critical illness. The good news is that many people with a critical illness survive these life-threatening battles. Unfortunately, as the recovery process begins, people become aware of the medical bills that have piled up. Your recovery does not have to be spoiled by medical bills. With this plan, our goal is to help you and your family cope with and recover from the financial stress of surviving a critical illness. Click here to view Plan Summary Off Job Accident Expense Plan: An accident insurance plan provides benefits to help cover the costs associated with unexpected bills. When a Covered Accident occurs, the last thing on your mind are the charges that may be accumulating while you’re at the emergency room, including: Ambulance Ride Emergency Room Surgery and Anesthesia Stitches and Casts Wheelchairs and Crutches You hope they never happen, but at some point, you may take a trip to your local emergency room. If that time comes, wouldn’t it be nice to have an insurance plan that pays benefits? This group accident plan does just that. Click here to view Plan Summary 16
Hospital Indemnity Plan: Even a minor trip to the hospital can present you with unexpected expenses and medical bills. And though you may have major medical insurance, your plan may only pay a portion of what your entire stay entails. That’s how a group supplemental hospital indemnity insurance plan can help. It provides financial assistance to enhance your current coverage. You can avoid dipping into savings or having to borrow to cover out of pocket expenses health insurance was never intended to cover, such as transportation, meals, and help with childcare. Click here to view Plan Summary Short Term Disability: Your paycheck helps you maintain your current way of life. If you find yourself unable to earn income due to an “off the job” accident, serious illness, or maternity leave, a Group Short Term Disability will provide cash to help ease the financial stress. Click here to view Plan Summary Long Term Disability: Your paycheck helps you maintain your current way of life. If you find yourself unable to earn income due to an “off the job” accident, serious illness, or maternity leave, a Group Short Term Disability will provide cash to help ease the financial stress. Click here to view Plan Summary 17
Voluntary Term Life Plan: If your family depends on you financially, life insurance is an important topic you shouldn’t ignore. It can do more than replace a lost income – it can pay for final expenses, a mortgage, your child’s education, and more. Click here to view Plan Summary Whole Life with Long Term Care Plan: Whole life insurance with long-term care coverage offers lifelong financial protection and support for long-term care needs. This plan ensures your loved ones are financially secure after your passing and provides funds for necessary long-term care services, giving you peace of mind for the future. Click here to view Plan Summary Emergency Transportation: An emergency transportation plan covers the cost of air or ground ambulance services during medical emergencies. This plan ensures you receive immediate medical attention without the financial burden, providing peace of mind during unexpected crises. Click here to view Plan Summary 18
Unum | How to le a claimComplete one easy-to-use guided form, and we’ll check it for completeness before you submit—helping minimize delaysChoose direct deposit and get approved payments up to a week faster than checkLog in to view status 24/7 Opt in to receive updates and requests through email or text instead of snail mailUpload required documents any time—even using your phone’s camera! Access your policy documents and year-end tax forms The same tools in your online account areavailable in the app—giving you a flexible, efficientand transparent experience. You can:Experience the benets of ling and managing your claim onlineOnly your employer can electronically file, or check the status of a Term Life or Accidental Death & Dismemberment (AD&D) claim.Get the MyUnum for Members mobile app• Enjoy the convenience of your online account on-the-goby downloading from the applicable app store*• Easily submit photos of required documents directlyfrom the app• View benefits and file claims• Upload documents and add/update medical providers• Update your profile & communication preferences• View status and payment informationUse your MyUnum for Membersonline account for fastest results!When life gets complicated, we make it simple to access the benets you need. Don’t worry, we’ve got you. How to le a claim for Unum benetsUnhide the Client Name Layer.CM Dis, SH, LCalhoun Countylogin.unum.comRegister for an account at login.unum.com19
ClaimsCalloutThe mobile app makes the claims experience simple!The MyUnum for Members app makes submitting your claims convenient and quick, especially when you’re away from work.With just a few taps, you can check status and upload documents using your device’s camera.Download today from the applicable appstore to get the most convenient, efficient, and transparent claims experience!Approved for leave, but need to submit intermittent absences?Once approved, you will need to report and track intermittent absences throughout the duration of your leave. Always contact your supervisor or manager when you need time off, then log your absences to the approved leave appearing on your online account dashboard.The mobile app makes it simple!The MyUnum for Members app makes submitting intermittent absences convenient and quick, especially when you’re away from work.Filing a dental or vision claimElectronic submission is not available for dental and vision claims. Contact customer service at 888-400-9304, or download a claim form from unumdentalcare.com and unumvisioncare.com.You can mail, fax or email your claim form, along with the required documentation.Dental:Mail: Claims DepartmentP.O. Box 80139Baton Rouge, LA 70898-0139Fax: 855-400-9307Email: DentalClaims@Unum.comVisionMail: Claims DepartmentP.O. Box 14389Baton Rouge, LA 70898-4389Fax: 855-400-9307Email: VisionClaims@Unum.com Questions?Unable to le online?• STD, LTD: 888-673-9940• Supplemental Health: 800-635-5597• Term Life, AD&D: 800-445-0402• Experienced representatives are available to assist you8 a.m. to 8 p.m. ET, Monday through Friday• Note that additional required documents may berequested to complete the processFile by paper form• STD, LTD, Supplemental Health, Term Life, AD&D: Get claim forms at unum.com.• Send your form and required documents to the fax number or mailing address on the form• Once your claim or leave is received, please allow 24 - 48 hours for status to appear online.20
Important Compliance Documents To ensure you are fully informed about your health benefits and compliance requirements, please review the following important documents. These documents provide essential information on your rights, plan details, and responsibilities. You can access all the compliance documents by clicking the link below: Click here to Access Compliance Documents The documents included are: • HIPAA Notice for Non-Grandfathered Plans: Privacy rights and protections for non-grandfathered health plans. • Women's Health and Newborn Notices: Information about your rights and benefits related to women's health and newborn care. • CHIP Notice: Information about the Children’s Health Insurance Program and how it may affect your coverage. • Privacy Practices Notice: Details on how your health information is used and protected. • Health Insurance Marketplace Coverage: Information on options and coverage available through the Health Insurance Marketplace. • Emergency Evacuation Instructions: Instructions on what to do in the event of an emergency evacuation. • Spouse Eligibility Verification Form: Form required to verify the eligibility of a spouse for coverage. Make sure to review these documents carefully. If you have any questions or need further assistance, please contact HR. 21