Post on 03-Aug-2020
2017 BenefitsSCANA Corporation
Effective January 1, 2017
This guide serves as the Summary of Material Modifications describing the changes made to the SCANA Corporation Health and Welfare Plan. This guide should be kept with a copy of the applicable summary plan description that was provided to you and which can be found on The Edge. The details of these plans are contained in the official plan documents. The plans are subject to and governed by applicable federal laws and regulations, principally those administered by the Internal Revenue Service and the Department of Labor. SCANA reserves the right at will to change or terminate any of the benefits offered by the Plan, or the Plan itself, as allowed by applicable law. For details on benefits, you are encouraged to view the benefits summaries on the open enrollment website found on The Edge.
Your regular health plan benefits generally will not cover these services. You are responsible for any costs of these services your benefit plan does not cover … but they may help you take charge of your health and save money.
Check out the discounts on items such as:
• Hearing screenings
• Hearing aids
• Cosmetic surgery
• Cosmetic dentistry
• Hair restoration
• Eye care
• Eyewear
• Lasik services
• Weight loss programs
• Allergy relief products
• Companion Global Healthcare
• Companion Global Dental
Are there alternative health services you
find helpful — or want to try?
You also can find discounts on:
• Acupuncture
• Massage therapy
• Chiropractic services
• Fitness centers
• Diet and supplement advisers
For details on discounts:
1. Go to www.SouthCarolinaBlues.com.
2. Select Member Perks, then choose a category.
Besides the health benefits outlined in this booklet, you
have access to discounts on a variety of products and
services to enhance your quality of life. Think of them as
special perks just for being Blue.
Discounts for you — just for being Blue
1
Make the most of your benefits Continuing to offer valuable benefits that are affordable and competitive isn’t
easy. That’s especially true when increasing health care costs and compliance
with health care reform laws are challenging all of us on a personal and
business level. But it’s the right thing to do, and it makes me proud that our
collective team works hard to make the adjustments needed to maintain a
competitive plan for our self-insured company.
How about you? What adjustments have you made – daily, monthly, annually –
to ensure you’re taking full advantage of what your benefits premium buys you? Are you:
• Scheduling your recommended 100%-covered preventive care and screenings, especially an
annual physical?
• Choosing generic medications when available – even getting FREE preventive generic medications,
if applicable, through the SCANA Pharmacy?
• Maximizing the wellness resources SCANA and BlueCross BlueShield make available to help you
achieve or maintain your best health?
• Shopping around for quality care at the best price and choosing in-network providers to get the
lowest rate?
• Investing in a health savings account and funding it now, even if you don’t need it, as a way to save
for health care costs in your retirement? SCANA even provides you seed money to help you get started.
Don’t leave anything on the table. Make the most of the benefits available to you. Enclosed is information
to help you do that.
After reviewing the details contained here, if you have any questions, be sure and call the Employee
Resource Center at 803-217-4444.
Stay well,
Kevin Marsh
SCANA Chairman & Chief Executive Officer
Your Benefits. Your Choice.
2
3Your Benefits. Your Choice.
How to Enroll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
What you need to know now . . . . . . . . . . . . . . . . 5Overview of SCANA Choice plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Prescription Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Dental Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Vision Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
HSA and FSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Find the Right Doctor, Choose the Right Plan . . . . . . . . . . . . . . . . . . . . . 17
Life, Accident and Disability Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Employee Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Required Notices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Summary of Benefits and Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Spousal Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Dependent Change Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Life Insurance Beneficiary Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Caremark Mail Service Order Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Enrollment Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Contents
4 Your Benefits. Your Choice.
Use this guide to review your benefit options and determine the coverage you want to
elect. Then log on to PeopleSoft to enroll using your checklist from page 51.
How to enroll online for your 2017 benefits1. Access The Edge from a work computer or home (only if you have an Entrust token). If you need to reset your network
password, call the IST Help Desk at 803-217-7655 and select option 1.
a. From a work computer, click on The Edge and select either the 2017 Benefits Open Enrollment promotion image at thetop of the page or the PeopleSoft (HR) link.
b. From a home computer, go to www.remote.scana.com and log in with your user ID, password and Entrust token. On theJuniper home page, select The Edge and then follow the directions above for accessing online enrollment.
2. Log in to PeopleSoft using your user ID and your network password.
a. If you selected the 2017 Benefits Open Enrollment promotion image, you will be redirected to the online enrollment page.
b. If you selected the PeopleSoft (HR) link, click on the Benefits Enrollment link under Announcements.
3. Make your benefit elections.
4. Certify that you will be eligible in 2017 to make contributions to your HSA. If you fail to do so, you will NOT receive seed money.
5. If you don’t have an existing health savings account (HSA), complete the HSA authorization form to begin the process ofopening your account.
6. Establish pretax payroll deductions for HSA or FSA. (You can have a dependent care FSA and HSA, but you cannot have ahealth care FSA and HSA.)
7. Review your dependent/beneficiary information for accuracy. If you need to make a change, contact theEmployee Resource Center (803-217-4444) and provide the required documentation.(See pages 45-47 for forms.)
8. If you plan to cover your spouse, certify that he/she does not have access to employer-sponsored group medicalcoverage elsewhere. If you fail to certify, your spouse will NOT be covered in 2017.
9. Review your selections.
10. Press “Submit” to complete your transaction.
11. Print your summary of benefit elections. (Note: Printing from home is not available.)
12. You can make changes to your elections until 11:59 p.m. Friday, October 21, 2016.
13. Following the close of open enrollment, all employees will be directed to their individual summary of elections in PeopleSoftto serve as their confirmation statement.
5Your Benefits. Your Choice.
What you need to know nowThere are many resources available to help you make decisions about your 2017 benefits.
Refer to the resources on the inside back cover of this book.
Overview of benefits changes, effective January 1, 2017• There will be a slight increase in medical plan premiums, ranging from $.59-$3.72 per pay period, depending on level of
coverage. See page 7 for details.
• Preventive Generic Medications continue to be free at the SCANA Pharmacy; will be subject to deductible and 30% coinsuranceat retail or mail order.
• A printed confirmation of benefit elections will not be mailed to employees. Following the close of online benefits openenrollment, employees will be directed to their individual summary of elections within PeopleSoft where they will be encouragedto verify their elections and print the summary for their records. Any necessary corrections can also be made at that time.
• Employees who transition to Long-Term Disability on Jan. 1, 2017 and after will continue receiving medical coverage underthe active Choice Plan for up to 24 months. If they remain disabled after that period, they will need to find individual coverageelsewhere, since SCANA will no longer offer LTD medical coverage.
If you have questions about any of these changes, contact the Employee Resource Center at 803-217-4444.
Your Benefits. Your Choice.6
The SCANA Choice plan is a consumer-driven health plan featuring affordable premiums.
In this plan, your medical and prescription costs combine to satisfy the deductible and
out-of-pocket maximum.
As a participant in the SCANA Choice plan, you may be eligible to open a health savings account through HSA Bank to contribute pretax dollars through payroll deduction*. SCANA also contributes seed money – $400 for individual coverage and $800 for any level of family coverage – into your HSA account. The account is yours to use for paying medical expenses as they occur or to save for future needs, like medical expenses in retirement. You may even use the account to pay qualified medical expenses for your spouse who may be covered under another plan, as long as your spouse doesn’t have a health care flexible spending account (FSA).
Prescription coverage is included when you elect medical coverage through SCANA, and preventive services are provided at 100 percent coverage when an in-network provider is used.
* Individuals enrolled in TRICARE or Medicare, or who have received VA medical benefits in the previous 90 days, are not eligibleto make HSA contributions or receive seed money from SCANA.
2017 SCANA Choice Plan In Network Out of Network
Preventive Care 100% Coverage Deductible and coinsurance apply
Deductible $1,500 Individual $3,000 Family
$3,000 Individual $6,000 Family
HSA Seed Money $400 individual/$800 family
Medical care – Inpatient, Outpatient 20% after deductible 40% after deductible
Emergency/Urgent Care/Ambulance 20% after deductible
Annual Out-of-Pocket MaximumDeductible & Coinsurance
$3,000 Individual $6,000 Family Includes Rx
$6,000 Individual $12,000 Family Includes Rx
Overview of SCANA Choice plan
New BlueCross ID cards will be issued by early 2017 for all participants. You may use existing cards until the new ones arrive, but discard them once you receive the new cards in order to have accurate information.
Your Benefits. Your Choice. 7
• For spouses who both work at SCANA and choose familycoverage, a taxable payroll credit will apply to the employeewho waives health care coverage.
• In-network providers are required to precertify all hospitaladmissions, outpatient surgical procedures and someradiological imaging. In-network providers incur a penalty fornon-emergency services that are not precertified.
• If you use an out-of-network provider, precertification is yourresponsibility, and you are responsible for paying the penaltyif you fail to precertify. See Summary of Benefits and Coveragefor more details.
• You may request additional BlueCross ID cards online atwww.SouthCarolinaBlues.com or by calling Member Servicestoll free at 877-705-5428.
• If your spouse has medical coverage through Medicare,TRICARE, VA, a trade or professional association, or anindividually purchased plan, you may cover him/her onSCANA’s plan.
Things to note
Understanding Choice Plan Deductibles and Out-of-Pocket Maximums• Preventive care is covered 100 percent, regardless of deductible.
• The deductible ($1,500/individual; $3,000/family) must be met before SCANA pays any portion of non-preventive care claims.
• One member of the family can meet the entire family deductible.
• Prescription benefits are not paid by SCANA until the Choice plan deductible is met, with the exception of certain preventivegeneric drugs through the SCANA Pharmacy.
• Both medical and prescription claims count toward the deductible and toward out-of-pocket maximums.
• Vision and dental expenses do not contribute to the deductible nor out-of-pocket maximums.
2017 Choice Medical Plan Premiums
Plan Employee Only Employee/Spouse Employee/Dependents Employee/Family
SCANA ChoicePer Pay $10.04 $37.70 $33.92 $62.82
Annual $261.04 $980.20 $881.92 $1,633.32
If you are adding a dependent, see form on page 45.
8 Your Benefits. Your Choice.
2017 Prescription Benefits
SCANA PharmacyIn Network
Retail or Mail OrderPer Rx Out-of-Pocket
Maximum
Employee pays amounts below after deductible is met.
Preventive Generic Medications1 Free (not subject to
deductible)30%
$100/31-day $250/90-dayNon-preventive Generic
Medications and Preferred Brand Medication
25% 30%
Non-Preferred Brand 50% None
Specialty Medications 31-day supply only
CVS Specialty Pharmacy2 ONLY 50%
$250/31-day
90-day Prescriptions: Only available at the SCANA Pharmacy or Caremark Mail Order Pharmacy.3
Out-of-Network Benefits: Available with 50% coinsurance for generic and preferred brand only.
1 Specific generic medications included can change from time to time without notice. 2 CVS is an independent company providing specialty pharmacy services on behalf of BlueCross. 3 Caremark is an independent company providing prescription drug benefits on behalf of BlueCross.
Prescription benefits are included in the SCANA Choice plan. You pay negotiated
prescription costs in full until your deductible is met (except certain preventive generics
through SCANA Pharmacy), and these costs count toward your deductible. Once you meet
your out-of-pocket maximum, covered prescription medications are paid in full by the plan.
Drug Card Prescription Drug Coverage
With more than 64,000 network pharmacies to choose from, it’s easy to find one that’s near you. If you don’t present your ID card or don’t use a network pharmacy, you’ll have to file a claim and you may not be reimbursed for the full amount you paid.
SCANA Pharmacy
Employees can save money and time by using the SCANA Pharmacy. Pharmacists are available for in-depth counseling. You can pick up prescriptions at the corporate campus or have them delivered to you through interoffice mail.
Specialty Drugs
Specialty drugs treat conditions such as cancer, hepatitis, multiple sclerosis or rheumatoid arthritis, just to name a few.
The exclusive provider for specialty drugs is Caremark. Visit The Edge for a list of specialty drugs. You may contact CVS Specialty Pharmacy at 800-237-2767.
Mail-Service Program
Caremark Mail Order Pharmacy is convenient and can save you money if you take prescription drugs on a regular basis. You’ll receive up to a 90-day supply of your prescription drugs at one time with free standard shipping. Getting started is easy! Use the form in the back of this booklet.
Over-the-Counter
Except for liquid Zantac and nicotine replacement, medications available over-the-counter, regardless of strength or formulation, are not covered by the prescription benefit.
Convenience and savings
9Your Benefits. Your Choice.
Dental Plan Highlights and RatesWhen you go to the dentist, present your BlueCross ID card to make sure the dentist applies your benefits correctly.
With BlueCross dental benefits, you receive benefits whether or not you and your eligible
dependents visit an in-network dentist. When you visit an in-network dentist, you’ll enjoy
lower out-of-pocket expenses as our providers have agreed to lower their fees. And you
won’t be balance-billed for charges above the allowable amounts.
Dental coverage for you and your family
Benefits Dental Plan
Calendar Year Maximum (Class I, II and III expenses) $1,500 per person
Annual DeductibleIndividual/Family $50 per person/$150 per family
Reimbursement Levels Based on Reasonable and Customary Allowances
Class I - Preventive & Diagnostic Care• Oral Exams (Two per year)• Routine Cleanings (Two per year)• Full Mouth X-rays or Panoramic X-ray (One every three years)• Bitewing X-rays (Two per year)• Fluoride Application (Two per year)• Sealants (Limited to posterior tooth for a person age 6-18/One treatment
per tooth every three years)• Space Maintainers (Limited to non-orthodontic treatment)• Emergency Care to relieve pain
No charge
Class II - Basic Restorative Care Fillings, Root Canal Therapy, Osseous Surgery, Dental Consultation, Periodontal Scaling and Root Planing Denture Adjustments and Repairs, Extractions, Oral Surgery (Surgical removal of impacted wisdom teeth is covered under the Medical Plan)
You pay 20% after deductible
Class III - Major Restorative CareCrowns, Dentures, Bridges, Dental Implants (up to plan maximum)
You pay 50% after deductible
Class IV – Orthodontia (Limited to dependent children under the age of 19) $1,500 lifetime limit (payments made monthly)
You pay 50% after deductible
Pretreatment review is suggested when dental work in excess of $300 is proposed. Have your provider send an undated claim form along with the proposed treatment plan to BlueCross for a pretreatment estimate to be sent to you and your dentist detailing what services your plan will cover and how much it will pay.
2017 Dental Plan Premiums
Employee Only Employee/Spouse Employee/Dependents Employee/Family
Per Pay $3.59 $7.64 $6.82 $10.76
Annual $93.34 $198.64 $177.32 $279.76
Your Benefits. Your Choice.10
To find locations near you, visit www.EyeMedVisionCare.com or call Member Services toll free at 866-723-0513. Identify yourself as a member by presenting the BlueCross ID card provided to you. You pay the provider directly for purchases that exceed the covered allowed amounts.The provider files the claim on your behalf.
Vision benefits through EyeMed Vision Care are a separate election from the SCANA Choice medical plan.
Employee Only
Employee/ Spouse
Employee/Dependents
Employee/Family
Per Pay Period
$0.91 $1.74 $1.83 $2.69
Annual Cost
$23.66 $45.24 $47.58 $69.94
Out-of-Network Reimbursements
If you visit an out-of-network provider, you are responsible for paying the provider in full at the time of service. You will need to submit a claim form for reimbursement. To get a claim form, call Member Services at 866-723-0513 or visit our website.
Exams, Contacts and Glasses
You are eligible for a comprehensive eye exam and standard lenses or contacts once every 12 months (from last visit/purchase) from a participating provider.
You have a $135 allowance to purchase frames once every 24 months (from last purchase). If your frames or contacts cost more than the $135 allowance, you are responsible for paying the remaining balance less 20 percent.
With your vision benefit through EyeMed, you have access to a national network of
providers, including LensCrafters, Target Optical, most Pearle Vision and Sears Optical
locations, and many independent doctors of optometry. EyeMed Vision Care is an
independent company that offers vision benefit programs on behalf of BlueCross. With
thousands of locations to choose from, you are certain to find a provider close to your
home or office that offers appointment times convenient for you.
Benefits are valid once per benefit period. Once you have used your in-network benefits, unlimited pairs of eyeglasses and contacts are available at discounted prices through a participating provider. See provider for details. Benefits and/or discounts cannot be used in conjunction with other discounts, coupons or promotions. This information is intended as a summary of benefits only. It does not describe all the terms, provisions and limitations of your plan. Participating providers are independent contractors solely responsible for vision examinations and products. Locations are subject to change. Please call 866-723-0513 to verify participation.
See the savings
Your Benefits. Your Choice. 11
Vision Care Services Member CostOut-of-Network Reimbursement
Exam with Dilation as Necessary Covered in full $60
Exam Options
Standard Contact Lens Fit and Follow-Up Up to $55N/A
Premium Contact Lens Fit and Follow-Up 10% off retail price
Frames
Any available frame at provider location $135 allowance, 20% off balance over $135 $82
Standard Plastic Lenses
Single Vision/Bifocal/Trifocal/Lenticular Covered in full $78/$97/$107/$150
Standard Progressive Lens Covered in full $149
Premium Progressive Lens 80% of charge less $120 allowance $149
Lens Options
UV Treatment/Tint (Solid and Gradient) / Standard Plastic Scratch Coating
$15
N/AStandard Polycarbonate - Adults $40
Standard Polycarbonate - Children under 19 $0
Standard Anti-Reflective Coating $45
Polarized/Other Add-Ons 20% off retail price
Contact Lenses (Contact lens allowance includes materials only)
Conventional $135 allowance, 15% off balance over $135 $125
Disposable $135 allowance, plus balance over $135 $125
Medically Necessary Covered in full $210
Laser Vision Correction
Lasik or PRK from U.S. Laser Network 15% off retail price or 5% off promotional price
N/A
Additional Pairs Benefit Members also receive a 40% discount off com-plete pair eyeglass purchases and a 15% discount off conventional contact lenses once the funded benefit has been used.
N/A
Benefit Frequency
Examination/Lenses or Contact Lenses Once every 12 months
Frame Once every 24 months
Either standard lenses or contact lenses are covered every calendar year; not both.
Plan Exclusions:1) Orthoptic or vision training, subnormal vision aids and any
associated supplemental testing; Aniseikonic lenses2) Medical and/or surgical treatment of the eye, eyes or supporting
structures3) Any eye or Vision Examination, or any corrective eyewear required
by a Policyholder as a condition of employment; Safety eyewear4) Services provided as a result of any Workers’ Compensation law,
or similar legislation, or required by any governmental agency orprogram whether federal, state or subdivisions thereof
5) Plano (non-prescription) lenses and/or contact lenses6) Non-prescription sunglasses7) Two pair of glasses in lieu of bifocals
8) Services or materials provided by any other group benefit planproviding vision care
9) Services rendered after the date an Insured Person ceases to becovered under the Policy, except when Vision Materials orderedbefore coverage ended are delivered, and the services renderedto the Insured Person are within 31 days from the date of suchorder
10) Lost or broken lenses, frames, glasses, or contact lenses will notbe replaced except in the next Benefit Frequency when VisionMaterials would next become available
Vision benefits
12 Your Benefits. Your Choice.
Health Savings Account (HSA)
• To contribute to an HSA you must be enrolled in the Choiceplan. You cannot be enrolled in Medicare, Medicaid, TRICARE orhave received VA medical benefits in the past three months.
• You must have an account with HSA Bank to receive yourseed money and take advantage of payroll deduction foryour contribution.
• You cannot contribute to both an HSA and a healthcare FSA.
• If you enroll in Medicare after turning age 65, you can nolonger contribute to an HSA, and the annual contribution limitis prorated.
• The maximum amount you can contribute to an HSA isprorated by the number of months you are enrolled in theChoice plan for the year.
• SCANA will contribute $400 for individual and $800 forfamily coverage to new and re-enrolling HSAs. The moneywill be available in all accounts opened at HSA Bank as ofJanuary 2, 2017.
• You cannot use your HSA funds for over-the-countermedications and supplies, unless you have a prescription.
• For tax-free reimbursement of medical expenses fordependents, the dependent must otherwise qualify as a taxdependent of the account holder. Consult your tax adviserfor more details.
• The penalty for nonqualified HSA withdrawals is20 percent.
Health Care FSA
• Available to employees working 32 or more hours per week,specifically those who waive SCANA coverage or who are noteligible to contribute to HSA.
• Health care FSA balances up to $500 carry over at theend of the calendar year.
• You cannot use your FSA funds for over-the-countermedications and supplies, unless you have a prescription.
See next page for a chart summarizing HSAs and health care FSAs.
Dependent Care Flexible Spending Account (FSA)
• All employees may elect to enroll and contribute to adependent care FSA, regardless of whether you participatein SCANA’s medical plan.
• Funds can be used for eligible day care, after-school andelder care expenses and programs.
• Receipts must be submitted for reimbursement.
• Minimum contribution amount per year is $50 and themaximum amount is $5,000.
• Funds must be in account to use.
• Funds not used by the end of the calendar year willbe forfeited.
SCANA offers three types of optional accounts for you to make pretax contributions to
help with health care or dependent care expenses. The IRS determines the maximum
amount of money that can be contributed each year and maintains the list of qualified
expenses. Always keep your receipts so you can verify, if audited, that your purchases
were allowed. If you want to establish an optional account, you must log in to PeopleSoft
and enroll during this open enrollment period. The three account types are:
HSA and FSA
13Your Benefits. Your Choice.
For HSAs • Seed money will be prorated based on
when the HSA is opened: Q1 = $400/$800;Q2 = $300/$600; Q3 = $200/$400;Q4 = $100/$200.
• Seed money cannot exceed $800 per family(includes spouses who both work at SCANA).
For Health Care FSAs • Annual maximum contribution is $2,600.
HSA Health Care FSA
Description Actual bank account owned by employee that allows saving and paying for qualified medical, dental and vision expenses tax-free
Spending account that allows employee to pay for qualified medical, dental and vision expenses tax-free
Medical plan eligibility Choice Plan Not required
Interest earning Yes No
SCANA contribution Seed money ($400/$800)* None
Annual maximum contribution $3,400 single; $6,750 family** $1,000 catch-up if eligible (age 55+)
$2,600 ($50 minimum)
Access funds Debit card, checks or Internet banking Debit card or submit receipts
Account balance carryover Balance rolls from year to year Balances up to $500 carry over at year end
Portability Account is owned and retained by employee upon termination
Employee generally forfeits balance upon termination
Availability of funds Funds must be in account to use Annual designated amount available for use January 1
Contributions Payroll deduction amount set during open enrollment period and changes can be made throughout year via PeopleSoft Self Service; other after-tax contributions can be made via check/money order
Annual amount determined during open enrollment and can only be changed after qualifying event (marriage, birth, death, etc.)
Administered by HSA Bank (see page 14) WageWorks (see page 15)
* Amount prorated based on date account is opened.** Amount prorated based on the number of months you are enrolled in the Choice plan for the year.
For more information, refer to the FSA and HSA information on The Edge, visit the IRS website for rules and regulations, or consult your tax adviser.
Understanding the differences between HSAs and FSAs
14 Your Benefits. Your Choice.
What is an HSA?
Health savings accounts (HSAs) work in combination with an HSA-compatible health plan. The HSA allows you to contribute funds on a pretax or tax-deductible basis, which you may use to pay for eligible medical expenses.
What are the advantages of an HSA?
• Funds Roll Over Annually There is no “use it or lose it” rule. If you don’t use your funds, you can save them for future, eligible medical expenses.
• Tax Advantages An HSA provides you triple tax savings: pretax funds can be used to contribute to your account; tax-free earnings through investment; and tax-free withdrawals for qualified medical expenses.
• You Own the Account Even if your HSA-compatible coverage ends, you can still use your HSA funds tax-free for eligible medical expenses.
• Additional Retirement Savings After age 65, you can withdraw funds (subject to applicable taxes) for purposes other than medical expenses, without penalty.
• Long-term Investment Opportunities You can invest your HSA dollars through HSA Bank’s investment partners, who offer stocks, bonds and mutual funds. For more information, visit www.hsabank.com/investments.
Note: Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. All HSAs with HSA Bank are FDIC insured.
• You’re in Charge You choose when to use your HSA or pay out of pocket.
Eligible medical expenses
An eligible medical expense is an expense that pays for health care services, equipment or medications as described in IRS Publication 502*. In general, your HSA can be used for:
• Expenses applied to your health plan deductible
• Dental care services
• Vision care services
• Prescription drugs and medicines
• Certain medical equipment
* A list of Qualified Medical Expenses can be found in IRS Publication 502, www.irs.gov/pub/irs-pdf/p502.pdf.
Learn more
Visit HSA Bank’s website at: www.hsabank.com/hsabank/education/cdh-demos.
HSA Bank Client Assistance Center
800-357-6246, Monday – Friday, 7 a.m. – 9 p.m., CT; and Saturday, 9 a.m. – 1 p.m., CT askus@hsabank.com www.hsabank.com 605 N. 8th Street, Suite 320, Sheboygan, WI 53081
What can a Health Savings Account (HSA) do for you?
The Ernst & Young financial planner line can help you understand how an HSA fits into your financial plan. Their assistance is available at no cost to you: 866-724-1946.
HSA Bank is an independent company that administers some health savings accounts on behalf of BlueCross. Please consult your tax adviser regarding your personal
situation and whether this is the right program for you.
Your Benefits. Your Choice. 15
All employees are eligible for a health care FSA, specifically those who waive SCANA coverage or are ineligible to contribute to an HSA; however, you cannot contribute to both an HSA and a health care FSA.
Use the WageWorks Health Care Card.
Use your WageWorks Health Care Card instead of cash or credit at health care providers and pharmacies for eligible services, goods and prescriptions. You will only be able to use your card for over-the-counter (OTC) drugs at the pharmacy counter if a valid prescription is presented at the time of purchase. You still will be able to use your card for non-drug OTC items and devices, such as bandages and contact lens solution, as long as you shop at merchants that have an industry standard (IIAS) inventory system that can verify the eligibility of items at checkout. An updated list of IIAS merchants is maintained at www.sigis.com. Always remember to save receipts when using the card. The IRS requires you keep them for your tax records, and you will also need them if we request documentation for verification.
Using your FSA is easy.
When you elect a health care FSA, your account is funded with the full amount you’ve chosen at the beginning of the year. As soon as that happens, it’s ready to use for eligible expenses. Throughout the year, you “pay your account back” with pre-tax contributions from your paycheck.
You can also choose a WageWorks Dependent Care FSA to help with the cost of care for eligible children or aging parents while you are at work. A dependent care FSA works a lot like a health care FSA, but your account is funded several times a year, so funds are available as contributions are taken from your paycheck.
Sign up during open enrollment. See how much you could save at www.FSAWorks4Me.com.
Open a WageWorks® FSA and save on everyday expenses
Health care FSA balances up to $500 carry over at the end of the calendar year.
WageWorks is an independent company that provides FSA administration on behalf of the employer group, SCANA. Please consult your tax adviser regarding your personal situation and
whether this is the right program for you.
Questions?Helpful tips, guides, video tutorials and FAQs are available online at www.wageworks.com. WageWorks Customer Service professionals also are standing by to help you. Just call 877-WageWorks (877-924-3967), Monday – Friday, 8 a.m. – 8 p.m. EST.
16
It’s an emergency! Or … is it?
Emergency roomDefinitely head for the hospital with potentially life-threatening conditions such as:
• Heavy bleeding
• Loss of consciousness
• Major injuries, such as broken bones
• Severe pain or severe allergic reaction
• Suspected heart attack
• Head trauma
Urgent careThese clinics are less costly than an ER and could be a convenient choice for minor emergencies. Most offer shorter waits, walk-in services, and sometimes perks such as online check-in. Urgent care could be good for:
• Cold, cough, sore throat
• Flu, respiratory infections
• Minor fractures and sprains
• Eye, ear or skin infections
• Minor cuts and animal bites
It’s important to get to an emergency
room in a life-or-death situation. But it’s
also smart to know when the ER is really
your best option.
An ER visit could involve hours of
waiting and hundreds of dollars. You’ll
see a doctor who doesn’t know you —
and if you show up for something
minor like a cold or a sprain, you could
delay treatment for others who have
true emergencies.
Your primary care physician should be
your first call for routine medical care.
If your doctor’s office is closed, here
are some guidelines to help you
protect your health while saving time
and money.
17Your Benefits. Your Choice.
It’s a big decision. Who will you turn to when you have a nagging health problem, a sick
child or symptoms that might be serious — or might not? The online Doctor and Hospital
Finder makes the decision a little easier.
You can search by city or ZIP code for providers near your home or work. Or narrow your search to find providers in certain specialties, such as pediatricians or allergists.
If you already have a doctor’s name, you can see whether he or she is in your network. You can even do an advanced search for providers who match your gender or language preferences.
Other tools, such as quality reports and patient reviews, provide extra insight about the doctors and facilities you’re considering. It’s worth taking a little time to check them out — and make sure you end up with exactly the kind of health services you want and need.
Find the right doctor, choose the right care
To use the Doctor and Hospital Finder, log in to your My Health Toolkit account. Select the Resources tab, then click Find a Doctor or Hospital.
Find other in-network providers
• To locate a dentist near you, log in to your My Health Toolkit account. Select the Resources tab, click Find a Doctor or Hospital, then click the Dental Directory link.
• To locate an in-network pharmacy, log in to your My Health Toolkit account. Select the Benefits tab, then click Find a Pharmacy.
My Health Toolkit®
JKL SurgeryCenter
3.4 miles
XYZ Hospital2.2 milesABC Medical
Center1.2 miles
18 Your Benefits. Your Choice.
SCANA offers you options for life, accident and disability insurance. If the basic coverage doesn’t meet your needs, you can elect supplemental coverage using payroll deduction to cover the costs. To name or change beneficiaries for life insurance, see form on page 47.
Insurance type Coverage options Cost Notes
Life Basic = 2x base pay, up to $1.25M (hired prior to 1/1/13) 1x base pay, up to $1.25M (hired on or after 1/1/13)
Supplemental available up to 6x base pay pending Evidence of Insurability
Basic coverage at no cost to employee
Supplemental rates on next page; employee pays full cost with after-tax dollars
Beginning Jan. 1 after the employee’s 65th birthday, coverage amount reduces by 35%.
Premium adjusts accordingly.
Current enrollees with supplemental at one times their annual earnings can increase their supplemental coverage by one level, up to $500,000, without Evidence of Insurability, not to exceed the plan maximum of $1.25M when combined with basic life insurance.
Accidental Death & Dismemberment
Basic = 2x base pay, up to $500K (prior to 1/1/13) 1x base pay, up to $500K
(on or after 1/1/13)
Supplemental available up to 2x base pay to a maximum of $500,000 when combined with basic AD&D insurance.
Basic coverage at no cost to employee
Supplemental rates on next page; employee pays full cost with after-tax dollars
Beginning Jan. 1 after the employee’s 65th birthday, coverage amount reduces by 35%.
Supplemental coverage increases if your salary increases throughout the year; premium adjusts accordingly.
Spouse $10K - $100K Based on employee age and amount of coverage selected (see supplemental life insurance rates)
Employee pays full cost with after-tax dollars
Evidence of Insurability is required if you want to increase your coverage during open enrollment or due to a qualified family status change.
Dependent $10K per child until age 23 $0.55 per pay period, regardless of number of dependents covered
Employee pays full cost with after-tax dollars
For SCANA married couples, only one parent may cover their dependent(s).
Short-term disability
Basic = 66 2/3% base pay replacement
Supplemental available for 100% base pay replacement for up to 6 weeks
Basic coverage at no cost to employee
Supplemental rates based on salary; employee pays full cost with pretax dollars
Employee may also supplement using: PTO at 2.7 hours per day or transition bank at 8 hours per day
A five-day (40-hour) elimination period applies to all approved cases, except accidents.
Benefits begin on sixth day of absence (or 41st hour) and continue up to 1,040 hours in rolling 12-month period.
Long-term disability
Basic = 50% base pay replacement
Supplemental available for 66 2/3% base pay replacement
Basic coverage at no cost to employee
Supplemental rates based on salary; employee pays full cost with pretax dollars
Recertification required for continuation of benefits.
Benefits begin after 26 weeks of occupational or non-occupational injury or illness with approved application for benefits.
Life, accident and disability insurance
For help determining your coverage needs, contact the Ernst & Young financial planner line at 866-724-1946.
19Your Benefits. Your Choice.
Supplemental life insurance cost (same for spouse), per $1,000 of coverage
Age Per Pay Period Rate
≤ 34 $0.0212
35-39 $0.0295
40-44 $0.0415
45-49 $0.0628
50-54 $0.0960
55-59 $0.1795
60-64 $0.2585
65-69 $0.4791
70-74 $0.8580
75+ $0.8580
AD&D supplemental cost per pay period, per $1,000 of coverage
Employee-only supplemental coverage option
Rate
1x base pay$ .012
2x base pay
Short-term disability (100 percent of
base pay coverage for the first six weeks) CALCULATION EXAMPLE:
Disability rate is based on salary: $.30 per $100 of salary
Employee has a base salary of $50,000 and chooses to buy-up coverage for STD and/or LTD:
$50,000/$100 = $500 $0.30 x $500 = $150
$150/26 pay periods = $5.77 per pay period
Long-term disability (66 2/3 percent of
base pay coverage)
STD buy-up
$5.77 per pay period
LTD buy-up
$5.77 per pay period
Rates and coverage amounts adjust, as necessary, during the pay period following a change in age or salary.
20 Your Benefits. Your Choice.
Life is not a spectator sport — but sometimes it feels like you’re tackling some really tough
problems. We provide an Employee Assistance Program (EAP) that can help, whether or not
your challenges are job-related.
Help getting over life’s hurdles
SCANA employees and family members are eligible for the EAP benefit. Each person receives three counseling sessions and three life management services per contract year free of charge. For more information, call 800-968-8143 or visit www.FirstSunEAP.com.
First Sun EAP administers the Employee Assistance Program. Because First Sun is a separate company, it is responsible for all services related to this program. If you haven’t sought help from the EAP, you might be surprised at all the situations in which it can be helpful. They range from counseling for a family crisis to referrals for pet professionals.
CounselingWe will pay for up to three confidential sessions for you and each of your household members. When you are challenged by personal or emotional issues, licensed counselors are available to help you evaluate the issue and develop a plan for dealing with it. Some examples:
• Marital, relationship or family conflicts
• Crisis intervention
• Mental health or substance abuse issues
• Handling stress, grief, loss or trauma
• Concerns about workplace issues or work-life balance
Life managementThe EAP can provide help with practical problems — how to draw up a living will, for instance. These services include:
• Help finding elder care or child care
• Financial advice for retirement, reorganizing the budget or dealing with a crisis
• Legal consultation from licensed attorneys
• Resources for finding the right school or college
• Adoption assistance
• A pet care program
21
Everyday choices for a happy, healthy life.
Wellness is more than
just seeing a doctor
when you are sick.
It means making
day-to-day decisions
that can put you on
the path to a long,
healthy life. There are
some risk factors you
can’t change — your
age, for example, or
health problems that
run in the family. So it
makes sense to focus
on risk factors you
can change.
MoveAim for 30–60 minutes of physical activity each day. Exercise doesn’t have to take place in a gym — get creative and find activities that you enjoy. Go for a walk, ride your bike, swim, jog, jump rope or even dance!
EatFill half of your plate with fruits and veggies. Swap out sugary sodas with water. Choose whole grains, such as wheat, oatmeal and brown rice, instead of refined grains like white bread and white rice. Reach for lean proteins and calcium-rich foods.
CareTake care of your body. Make sure you get enough sleep at night. Don’t smoke — if you do, find the help you need to quit. Schedule your annual physical. If you notice symptoms of a health issue, don’t procrastinate — see your doctor.
FeelGet mentally fit by finding ways to de-stress. Block off some “me time” in your busy schedule. Stay connected to your friends and family. Volunteer for something you’re passionate about. Read a new book or start a journal. Practice being grateful for one thing each day.
22 Your Benefits. Your Choice.
NOTE: Please read this notice carefully and keep it with your important papers. If you enroll in one of the plans approved by Medicare that offers prescription drug coverage, you may need to give a copy of this notice when you join. This notice shows you have been enrolled in a creditable health plan and are not required to pay a higher premium.
Intended AudienceThis notice is intended for anyone eligible for Medicare (employee or dependent) who is eligible for prescription drug coverage through the SCANA Choice Plan.
About This NoticeThis notice has information about your current SCANA prescription drug coverage and Medicare Part D, the prescription drug coverage available through Medicare. Important highlights of this notice are:
• Your next opportunity to enroll in Medicare D is October 15- December 7, 2016. This annual enrollment is available to those eligible for Medicare.
• SCANA has determined that your current prescription drug benefit is, on average for all plan participants, expected to pay out at least as much as the standard Medicare prescription drug coverage. Therefore, the SCANA prescription drug plan is creditable coverage.
• Creditable coverage means you may enroll for Medicare D during the 2017 enrollment period outlined above and not pay higher premiums.
If you or one of your dependents is eligible for Medicare, you or they have the option of continuing your existing health plan with prescription drug coverage from the Company or enrolling in the Medicare prescription drug coverage.
IMPORTANT: If you decide to enroll in Medicare prescription drug coverage, you are not eligible to continue the SCANA medical and prescription drug plans. Your coverage will be terminated. Also, even though your current prescription drug coverage with the Company is creditable, if you drop it and have a break in creditable coverage of 63 days or more before enrolling in the Medicare prescription drug coverage, you could be subject to paying higher premiums for coverage.
Limited Income AssistanceFor people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this additional help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov, or call them at 800-772-1213 (TTY 800-325-0778).
For More Information About This NoticeContact the SCANA Employee Resource Center at 803-217-4444 if you require further information about this notice. You may receive this notice at other times in the future, such as before the next enrollment period for Medicare prescription drug coverage, or if this coverage changes. You also may request a copy of this notice.
Women’s Health and Cancer Rights Act NoticeThe Women’s Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between breasts, prostheses, and complications resulting from a mastectomy (including lymphedemas). You may contact the Employee Resource Center at 803-217-4444 for more information.
Special Enrollment NoticeIf you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in the SCANA health plans if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
If either of the following two events occur, you will have 60 days from the date of the event to request enrollment in your employer’s plan:
• Your dependents lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because they are no longer eligible.
• Your dependents become eligible for a state’s premium assistance program.
To request special enrollment or obtain more information, contact the Employee Resource Center at 803-217-4444.
Important notice from SCANA about your health plan and Medicare
23Your Benefits. Your Choice.
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2014. Contact your State for more information on eligibility –
ALABAMA – Medicaid COLORADO – Medicaid
Website: http://www.medicaid.alabama.gov
Phone: 1-855-692-5447
Medicaid Website: http://www.colorado.gov/
Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943
ALASKA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA – CHIP FLORIDA – Medicaid
Website: http://www.azahcccs.gov/applicants
Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150 IDAHO – Medicaid MONTANA – Medicaid
Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/Premiu
Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml
24 Your Benefits. Your Choice.
2
mAssistance/tabid/1510/Default.aspx
Medicaid Phone: 1-800-926-2588
Phone: 1-800-694-3084
INDIANA – Medicaid NEBRASKA – Medicaid
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
Website: www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
IOWA – Medicaid NEVADA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900 KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
MINNESOTA – Medicaid NORTH CAROLINA – Medicaid
Website: http://www.dhs.state.mn.us/
Click on Health Care, then Medical Assistance
Phone: 1-800-657-3629
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
MISSOURI – Medicaid NORTH DAKOTA – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-755-2604
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2014. Contact your State for more information on eligibility –
ALABAMA – Medicaid COLORADO – Medicaid
Website: http://www.medicaid.alabama.gov
Phone: 1-855-692-5447
Medicaid Website: http://www.colorado.gov/
Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943
ALASKA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA – CHIP FLORIDA – Medicaid
Website: http://www.azahcccs.gov/applicants
Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150 IDAHO – Medicaid MONTANA – Medicaid
Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/Premiu
Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml
25
3
OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
Website: http://health.utah.gov/upp
Phone: 1-866-435-7414
OREGON – Medicaid VERMONT– Medicaid
Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP
Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462
Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 1-855-242-8282
RHODE ISLAND – Medicaid WASHINGTON – Medicaid
Website: www.ohhs.ri.gov
Phone: 401-462-5300
Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/index.aspx
Phone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059
Website: http://www.badgercareplus.org/pubs/p-10095.htm
Phone: 1-800-362-3002
TEXAS – Medicaid WYOMING – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
Website: http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
To see if any other states have added a premium assistance program since July 31, 2014, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 OMB Control Number 1210-0137 (expires 10/31/2016)
Your Benefits. Your Choice.
Your Benefits. Your Choice.26
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
I. Introduction
This Notice describes Our1 legal obligations and your legal rights regarding Your Protected Health Information held by Us under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Among other things, this Notice describes how Your Protected Health Information may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law.
The HIPAA Privacy Rule protects only certain medical information known as “protected health information.” Generally, protected health information is individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a group health plan, that relates to:
1. your past, present or future physical or mental health or condition;
2. the provisions of health care to you; or
3. the past, present or future payment for the provision of health care to you.
The Plan provides health benefits to the eligible employees of SCANA Corporation (the “Plan Sponsor”) and their eligible dependents. The SCANA Pharmacy provides covered prescription drugs and services to Plan participants.
II. Our Privacy ObligationsWe are required by federal and applicable state law to protect the privacy of individually identifiable health information about you that We create or receive (“Your Protected Health Information”), to provide you with this Notice of Our legal duties and privacy practices, to provide notice to affected individuals following a breach of unsecured protected health information, and follow the terms of this Notice that are currently in effect. When We use or disclose Your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
III. Uses and Disclosures Without Your Written Authorization
We may use and disclose to others Your Protected Health Information without your written Authorization for the following purposes. For each category, we will explain what we mean and present some
examples. Not every use or disclosure in a category will be listed. However, the ways We are permitted to use and disclose information will fall within one of the categories. The amount of health information used or disclosed will be limited to information that excludes most direct identifiers, such as name, address, and Social Security number, unless more information is needed. If additional information is needed, it will be limited to the “minimum necessary” to accomplish the purpose of the use or disclosure.
A. Treatment. We may disclose medical information about you to facilitate medical treatment services. For example, the Plan may disclose Your Protected Health Information to your health care provider for its provision, coordination, or management of your health care and related services. SCANA Pharmacy may use or disclose Your Protected Health Information as necessary to maintain a patient profile on you, which may include information about you, your medical condition, medications, and any allergies you may have. SCANA Pharmacy may also use and disclose Your Protected Health Information in dispensing prescription medicines and related products and services, including counseling you and your caregivers about proper use of your medications.
B. Payment. We may use and disclose Your Protected Health Information for payment purposes. For example, the Plan may use or disclose Your Protected Health Information to obtain payment for your coverage and to determine and fulfill the Plan’s responsibility to provide health benefits, to make coverage determinations, administer claims and coordinate benefits with other coverage you may have. The Plan also may disclose Your Protected Health Information to another health plan or a health care provider for its payment activities — for example, for the other health plan to determine your eligibility or coverage, or for the health care provider to obtain payment for health care services provided to you. SCANA Pharmacy may use Your Protected Health Information to obtain payment for covered prescription drugs provided to you, or to assist another provider in obtaining payment for covered services it provides to you.
C. Health Care Operations. We may use and disclose Your Protected Health Information for Our health care operations. For example, We may use and disclose Your Protected Health Information to do business planning, arrange for medical review and conduct quality assessment and improvement activities. We also may disclose Your Protected Health Information to another health plan or a health care provider that has or had a relationship with you for it to conduct quality assessment and improvement activities; accreditation, certification, licensing, or credentialing activities; or for the purpose of health care fraud and abuse detection or compliance — for example, for
SCANA Corporation, Group Health PlansNotice of Privacy Practices
Your Benefits. Your Choice. 27
the other health plan to perform case management or evaluate health care provider performance, or for the health care provider to evaluate the outcomes of treatments or conduct training programs to improve health care skills.
D. To Business Associates. We may contract with individuals or entities known as Business Associates to perform various functions on Our behalf or to provide certain types of services. In order to perform these functions or to provide these services, Business Associates will receive, create, maintain, transmit, use and/or disclose Your Protected Health Information, but only after they agree in writing with us to implement appropriate safeguards regarding Your Protected Health Information. For example, We may disclose Your Protected Health Information to a Business Associate to administer claims or to provide support services, such as utilization management, pharmacy benefit management or subrogation, but only after the Business Associate enters into a Business Associate Agreement with Us. Business Associates are required to comply with HIPAA requirements to safeguard Your Protected Health Information.
E. To Comply with the Law. We may use and disclose Your Protected Health Information to the extent required to comply with applicable law.
F. Disclosures to the Health Plan Sponsor. We may disclose Your Protected Health Information to certain employees or other Individuals under the control of the Plan Sponsor as necessary for them to carry out the Plan Sponsor’s responsibilities to administer Plan payment and health care operations activities.
G. Health-Related Communications. We may contact you to give you information about health-related benefits and services that may be of interest to you. We may also contact you to provide appointment or refill reminders or information about treatment alternatives or other health-related benefits and services that may be useful to you.
H. Public Health Activities. As required by law, We may disclose Your Protected Health Information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting births and deaths; notifying people of recalls of products they may be using; reporting child abuse or neglect (only if you agree or when required by law); reporting domestic violence (only if you agree or when required by law); reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
I. Health Oversight Activities. We may disclose Your Protected Health Information to a government agency that is legally responsible for oversight of the health care system or for ensuring compliance with the rules of government benefit programs such as Medicare or Medicaid, or other regulatory programs for which health information is necessary for determining compliance.
J. Judicial and Administrative Proceedings. We may disclose Your Protected Health Information in the course of a judicial or administrative proceeding in response to a subpoena, discovery request or legal order or other lawful process, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested information.
K. Law Enforcement Officials. We may disclose Your Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order or other process authorized by law.
L. Health or Safety. We may disclose Your Protected Health Information to prevent or lessen a serious and imminent threat to the health or safety of an Individual or the public.
M. Organ and Tissue Donation. If you are an organ donor, We may release Your Protected Health Information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
N. Specialized Government Functions. We may disclose Your Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State.
O. Workers’ Compensation. We may disclose Your Protected Health Information as necessary to comply with workers’ compensation laws.
P. Research. We may disclose Your Protected Health Information to researchers when:
1. the individual identifiers have been removed; or,
2. when an institutional review board or privacy board has (a) reviewed the research proposal; and (b) established protocols to ensure the privacy of the requested information, and approves the research.
IV. Required Disclosures The following is a description of disclosures of Your Protected Health Information We are required to make.
A. Government Audits. We are required to disclose Your Protected Health Information to the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining Our compliance with HIPAA requirements.
B. Disclosures to You. When you request, We are required to disclose to you the portion of Your Protected Health Information that contains medical records, billing records, and any other records used to make decisions regarding your health care or health care benefits. We are also required, when requested, to provide you with an accounting of most disclosures of Your Protected Health Information.
Your Benefits. Your Choice.28
V. Other DisclosuresA. Personal Representatives. We will disclose Your Protected Health
Information to individuals authorized by you, or to an individual designated as your personal representative, attorney-in-fact, etc., so long as you provide us with a written notice/authorization and any supporting documents (i.e., power of attorney). Note: Under the HIPAA Privacy Rule, We do not have to disclose information to a personal representative if We have reasonable belief that:
1. you have been, or may be, subject to domestic violence, abuse or neglect by such person;
2. treating such person as your personal representative could endanger you; or,
3. in the exercise of professional judgment, it is not in your best interest to treat the person as your personal representative.
B. Authorizations. Other uses or disclosures of Your Protected Health Information not described above will only be made with your written authorization. You may revoke your written authorization at any time, so long as the revocation is in writing. Once We receive your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation.
We will obtain a written authorization for any use or disclosure of psychotherapy notes, except:
1. to carry out the following treatment, payment, or health care operations: use by the originator of the psychotherapy notes for treatment; use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual; and
2. a use or disclosure that is: required by the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining the Plan’s compliance with the HIPAA privacy rule; permitted by law; for health oversight with respect to the oversight of the originator of the psychotherapy notes; to a coroner or medical examiner for the purpose of identifying a decedent; or to avert a serious threat to health or safety.
Please note that We do not use Your Protected Health Information for marketing or fundraising efforts. We do not sell Your Protected Health Information. We do not use or disclose Your Protected Health Information that is genetic information for underwriting purposes as prohibited by the Genetic Information Nondiscrimination Act (GINA) of 2008.
VI. Your Individual RightsA. Right to Inspect and Copy Your Protected Health Information.
You may request access to Our records that contain Your Protected Health Information in order to inspect and request copies of the records. If Your Protected Health Information is maintained or used in an “electronic health record”, you may obtain a copy of the information in an electronic format and direct the copied information to be transmitted to another individual or organization. Under limited circumstances, We may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, We reserve the right to charge you copying and mailing costs.
We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed by submitting a written request to the Privacy Office at the address below.
B. Right to Request Amendment of Your Records. You have the right to request that We amend Your Protected Health Information that you believe is incorrect or incomplete. To make such a request, please obtain an amendment request form from the Privacy Office and submit the completed form, including the reason for the amendment, to the Privacy Office. We may deny your request for amendment if it is not in writing or does not include a reason to support the request. In addition, We may deny your request if you ask Us to amend information that:
1. is not part of the medical information kept by or for Us;
2. was not created by Us, unless the person or entity that created the information is no longer available to make the amendment;
3. is not part of the information that you would be permitted to inspect and copy; or,
4. is already accurate and complete.
If We deny your request, you have the right to file a statement of disagreement with Us and any future disclosures of the disputed information will include your statement.
C. Right to Receive An Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of Your Protected Health Information. The accounting will not include:
1. disclosures for purposes of treatment, payment or health care operations (except to the extent required by law, if the Plan maintains Your Protected Health Information as an electronic health record);
2. disclosures made to you;
Your Benefits. Your Choice. 29
3. disclosures made pursuant to your authorization;
4. disclosures made to friends or family in your presence or because of an emergency;
5. disclosures for national security purposes; and,
6. disclosures incidental to otherwise permissible disclosures.
To request this list of accounting of disclosures, you must submit your request in writing to the Privacy Office. Your request must state a time period of not longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be provided free of charge. For additional lists, We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
D. Right to Request Additional Restrictions. You may request restrictions on Our use and disclosure of Your Protected Health Information. For example, you could ask that We not use or disclose information about a surgery you had or a prescription drug you take. While We will consider requests for additional restrictions carefully, We are not required to agree to a requested restriction unless your request is to restrict Our disclosure of Your Protected Health Information to a health plan when such information would be used for health care operations or payment, the disclosure is not otherwise required by law, and Your Protected Health Information relates solely to a health care item or service paid for entirely out of pocket by you (or a person other than the Plan on your behalf). If you wish to request additional restrictions, please obtain a request form from the Privacy Office and submit the completed form to the Privacy Office. You will be given a written response.
E. Right to Receive Confidential Communications. We will accommodate any reasonable request for you to receive Your Protected Health Information by alternative means of communication or at alternative locations. Your request must specify how or where you wish to be contacted. Please note that in certain situations, such as eligibility and enrollment information, the Plan (but not the SCANA Pharmacy) is obliged to communicate directly with the employee rather than a dependent unless the request clearly states that disclosure of that information to the employee could endanger you.
F. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically. You may obtain a copy of this Notice at the “Health, Wealth, and Career” Web page on the SCANA Intranet site or you may contact the Privacy Office at the address below.
G. Right to Receive Notification. You are entitled to receive notice from Us if the confidentiality of any of Your Protected Health Information maintained in an unsecured form is compromised.
H. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that the Plan or SCANA Pharmacy has violated your privacy rights or disagree with a decision that We made about access to Your Protected Health Information, you may contact the Plan’s Privacy Office. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Secretary. The Plan will not retaliate against you if you file a complaint with it or the Secretary.
VII. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on September 9, 2013.2
B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If We change this Notice, We may make the new notice terms effective for all of Your Protected Health Information that We maintain, including any information created or received prior to issuing the new notice. If We change this Notice, We will send the new notice to you if you are then covered by the Plan. You also may obtain any new notice by contacting the Privacy Office.
C. Limitation on Application of Notice. This Notice does not apply to information that does not identify an Individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an Individual. In addition, the Plan may use or disclose “summary health information” to the Plan Sponsor for its purposes of obtaining premium bids (although the Plan will not use or disclose genetic information for this purpose) or modifying, amending or terminating the Plan. Summary health information is information that summarizes claims history, claims expenses or types of claims experienced by Individuals for whom the Plan Sponsor provides benefits under the Plan and from which the Individual identifying information, except for five-digit zip codes, has been deleted. The Plan and Plan Sponsor also may use or disclose eligibility and enrollment information without your Authorization.
VIII. Privacy OfficeSCANA Corporation 220 Operation Way Cayce, SC 29033-3701
Telephone: 1-800-335-6974 Email: Privacy@scana.com
1 For purposes of this Notice of Privacy Practices, “Our,” “We,” “Us,” or “Plan” refers to the following components of the SCANA Corporation Organized Health Care Arrangement: the medical benefits, prescription drug benefits, vision benefits, dental benefits, employee assistance program (medical portion only), and SCANA Pharmacy benefits of the SCANA Corporation Health and Welfare Plan; the SCANA Corporation Health Care Flexible Spending Account Plan; and the medical, dental, vision and SCANA Pharmacy benefits under the SCANA Corporation Retiree Welfare Benefits Plan.
2 This Notice was subsequently modified on September 15, 2016, to reflect the adoption of the SCANA Corporation Retiree Welfare Benefits Plan.
Your Benefits. Your Choice.30
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information :
What is the Health Insurance Marketplace?
Can I Save Money on my Health Insurance Premiums in the Marketplace?
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
How Can I Get More Information?
Form Approved OMB No. 1210-0149 (expires 1-31-201 )
Judy Verona 803-217-7033
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information :
What is the Health Insurance Marketplace?
Can I Save Money on my Health Insurance Premiums in the Marketplace?
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
How Can I Get More Information?
Form Approved OMB No. 1210-0149 (expires 1-31-201 )
Judy Verona 803-217-7033David Simmons at 803-217-8099
Your Benefits. Your Choice. 31
PART B: Information About Health Coverage Offered by Your Employer
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
Your eligible Dependents include the following. For your non-spouse who meets one or more of the criteria below, dependent status applies regardless of whether coverage is available through another employer and regardless of student or marital status:
1. Your lawful spouse pursuant to a marriage that is legally recognized under the laws of the issuing state, territory or country. Divorced spouses are not eligible for coverage under the plan even if the employee is ordered by the court to provide health coverage.
2. Your child who is your biological son or daughter under the age of 26, your stepson or stepdaughter under age 26 (under age 23 for dental coverage).
3. Your child who is 26 years of age or older, is primarily supported by you, and is incapable of self-sustaining employment because of a mental or physical disability. You should provide proof of the child’s condition and dependence to the SCANA Benefits Team within 31 days after the child’s 26th birthday. During the next two years, the Plan may, from time to time, ask for proof of continuation of the condition and dependence. After that, the Plan may require proof no more than once a year.
4. An individual for whom you have legal guardianship, who lives with you and depends on you for support and who is under age 26 (under age 23 for dental coverage).
5. An individual who is part of a Qualified Medical Child Support Order.
6. An individual, under age 26 (for medical coverage) and under age 23 for dental coverage, who has been placed with you for foster care by an authorized placement agency or court.
7. Any child under the age of 26 whom you adopt, including a child who is placed with you for adoption, will be eligible for Dependent insurance upon the date of placement with you. A child will be considered placed for adoption when you become legally obligated to support that child, totally or partially, prior to that child’s adoption being finalized. If a child placed for adoption is not adopted, all health coverage ceases when the placement ends, and will not be continued.
SCANA Corporation and its Subsidiaries 57-0784499
220 Operation Way, MC-C131 803-217-9000
Cayce SC 29033
VP of Human Resources c/o Manager of Benefits
803-217-8099 SCANABenefits@scana.com
3
PART B: Information About Health Coverage Offered by Your Employer
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
Full-time (i.e. regularly scheduled to work 32 or more hours per week)
3
PART B: Information About Health Coverage Offered by Your Employer
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
3
32
1
of 1
1
:SC
AN
A C
hoic
e Pl
anC
over
age
Perio
d:
01/1
/201
7 –
12/3
1/20
17
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Cov
erag
e fo
r: In
divi
dual
|Pla
n Ty
pe: P
PO
Que
stio
ns: C
all 1
-877
-705
-542
8 or
visi
t us a
t ww
w.s
outh
caro
linab
lues
.com
. For
EA
P ca
ll 1-
800-
968-
8143
or v
isit u
s at w
ww
.firs
tsun
eap.
com
. If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms
used
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CU
nifo
rmG
loss
ary.
pdf o
r cal
l 1-8
77-7
05-5
428
to re
ques
t a c
opy.
Bl
ueC
ross
Blu
eShi
eld
of S
outh
Car
olin
a is
an in
depe
nden
t lic
ense
e of
the
Blue
Cro
ss a
nd B
lue
Shie
ld A
ssoc
iatio
n
This
is o
nly
a su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.sou
thca
rolin
ablu
es.c
om o
r by
calli
ng 1
-877
-705
-542
8. F
or th
e E
mpl
oyee
Ass
istan
ce P
rogr
am (E
AP)
, you
can
get
the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.firs
tsun
eap.
com
or b
y ca
lling
1-8
00-9
68-8
143.
Impo
rtan
t Que
stio
nsA
nsw
ers
Why
this
Mat
ters
:
Wha
t is
the
over
all
dedu
ctib
le?
$1,5
00pe
rson
/$3,
000
fam
ily in
-net
wor
k $3
,000
pers
on/$
6,00
0fa
mily
out
-of-
netw
ork.
C
ombi
ned
for M
edic
al a
nd P
harm
acy.
Doe
sn’t
appl
y to
in-n
etw
ork
prev
entiv
e ca
re o
r pre
vent
ive
gene
ric d
rugs
at t
he S
CA
NA
pha
rmac
y.
You
mus
t pay
all
the
cost
s up
to th
e de
duct
ible
amou
nt b
efor
e th
is pl
an
begi
ns to
pay
for c
over
ed se
rvic
es y
ou u
se.
Che
ck y
our p
olic
y or
plan
do
cum
ent t
o se
e w
hen
the
dedu
ctib
le st
arts
ove
r (us
ually
, but
not
alw
ays,
Janu
ary
1st).
See
the
char
t sta
rtin
g on
pag
e 2
for h
ow m
uch
you
pay
for
cove
red
serv
ices
afte
r you
mee
t the
ded
uctib
le.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
? N
o.
You
don
’t ha
ve to
mee
t ded
uctib
les
for s
peci
fic se
rvic
es, b
ut se
e th
e ch
art
star
ting
on p
age
2 fo
r oth
er c
osts
for s
ervi
ces t
his p
lan
cove
rs.
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
?
$3,0
00 p
erso
n/$6
,000
fam
ily in
-net
wor
k $6
,000
per
son/
$12,
000
fam
ily o
ut-o
f-ne
twor
k.
Com
bine
d fo
r Med
ical
and
Pha
rmac
y.
The
out-
of-p
ocke
t lim
it is
the
mos
t you
cou
ld p
ay d
urin
g a
cove
rage
per
iod
(usu
ally
one
yea
r) fo
r you
r sha
re o
f the
cos
t of c
over
ed se
rvic
es.
This
limit
help
s you
plan
for h
ealth
car
e ex
pens
es.
Wha
t is
not i
nclu
ded
in
the
out–
of–p
ocke
t lim
it?
Prem
ium
s, pe
nalti
es fo
r fai
lure
to o
btai
n pr
e-au
thor
izat
ion
for s
ervi
ces,
bala
nce-
bille
d ch
arge
s, an
d he
alth
car
e th
is pl
an d
oesn
’t co
ver
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t–of
–po
cket
lim
it.
Is
ther
e an
ove
rall
annu
al
limit
on w
hat t
he p
lan
pays
? N
o.
The
char
t sta
rting
on
page
2 d
escr
ibes
any
lim
its o
n w
hat t
he p
lan w
ill p
ay fo
r sp
ecific
cov
ered
serv
ices
, suc
h as
off
ice
visit
s.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. For
a li
st o
f pre
ferr
ed p
rovi
ders
, see
w
ww
.sou
thca
rolin
ablu
es.c
om o
r cal
l 1-8
00-
810-
BL
UE
(258
3). F
or a
list
of E
AP
in-n
etw
ork
prov
ider
s, se
e w
ww
.firs
tsun
eap.
com
or c
all
1-80
0-96
8-81
43.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s plan
will
pa
y so
me
or a
ll of
the
cost
s of c
over
ed se
rvic
es.
Be a
war
e, y
our i
n-ne
twor
k do
ctor
or h
ospi
tal m
ay u
se a
n ou
t-of-n
etw
ork
prov
ider
for s
ome
serv
ices
. Pl
ans u
se th
e te
rm in
-net
wor
k, p
refe
rred
, or p
artic
ipat
ing
for p
rovi
ders
in
thei
r net
wor
k. S
ee th
e ch
art s
tarti
ng o
n pa
ge 2
for h
ow th
is pl
an p
ays d
iffer
ent
kind
s of p
rovi
ders
. D
o I
need
a re
ferr
al to
see
a
spec
ialis
t?
No.
Y
ou c
an se
e th
e sp
ecia
list y
ou c
hoos
e w
ithou
t per
miss
ion
from
this
plan
.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvic
es th
is pl
an d
oesn
’t co
ver a
re li
sted
on
page
9. S
ee y
our
polic
y or
plan
doc
umen
t for
add
ition
al in
form
atio
n ab
out e
xclu
ded
serv
ices
.
33
Page
2 o
f 11
•C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $
15) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usu
ally
whe
n yo
u re
ceiv
e th
e se
rvic
e.
•C
oins
uran
ce is
your
shar
e of
the
cost
s of a
cov
ered
serv
ice,
cal
cula
ted
as a
per
cent
of t
he a
llow
ed a
mou
nt fo
r the
serv
ice.
For
exa
mpl
e, if
the
plan
’s al
low
ed a
mou
nt fo
r an
over
nigh
t hos
pita
l sta
y is
$1,0
00, y
our c
oins
uran
ce p
aym
ent o
f 20%
wou
ld b
e $2
00.
This
may
cha
nge
if yo
u ha
ven’
t met
you
r ded
uctib
le.
•Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-
netw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed
amou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffer
ence
. For
exa
mpl
e, if
an
out-o
f-ne
twor
k ho
spita
l cha
rges
$1,
500
for a
n ov
erni
ght s
tay
and
the
allo
wed
am
ount
is $
1,00
0, y
ou m
ay h
ave
to p
ay th
e $5
00 d
iffer
ence
. (Th
is is
calle
d ba
lanc
e bi
lling
.) •
This
plan
may
enc
oura
ge y
ou to
use
in-n
etw
ork
prov
ider
s by
cha
rgin
g yo
u lo
wer
ded
uctib
les,
cop
aym
ents
and
coi
nsur
ance
amou
nts.
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
fYou
U
se a
n
In-n
etw
ork
Prov
ider
Your
Cos
t IfY
ou
Use
an
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce o
r cl
inic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
---
----N
one-
-----
Spec
ialis
t visi
t 20
% c
oins
uran
ce
afte
r ben
efit
year
de
duct
ible
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
-----
--Non
e---
---
Oth
er p
ract
ition
er o
ffic
e vi
sit
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Chi
ropr
actic
car
e is
limite
d to
12
visit
s per
m
embe
r per
ben
efit
year
.
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
Cov
ered
at 1
00%
40
% c
oins
uran
ce a
fter
bene
fit y
ear d
educ
tible
--
-----N
one-
-----
If y
ou h
ave
a te
st
Dia
gnos
tic te
st (x
-ray
, blo
od
wor
k)
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
-----
--Non
e---
---
Imag
ing
(CT/
PET
scan
s, M
RIs
)
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired.
Pen
alty
for n
ot
obta
inin
g pr
e-au
thor
izat
ion
is $5
00 fo
r ou
tpat
ient
faci
litie
s. Pe
nalty
app
lies t
o pr
ovid
ers i
n-ne
twor
k an
d m
embe
rs o
ut-o
f-ne
twor
k.
34
Page
3 o
f 11
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
fYou
U
se a
n
In-n
etw
ork
Prov
ider
Your
Cos
t IfY
ou
Use
an
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
drug
s to
tr
eat y
our i
llnes
s or
co
nditi
on
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
co
vera
ge is
ava
ilabl
e at
w
ww
.sout
hcar
olin
ablu
es.c
om.
Gen
eric
dru
gs
SCA
NA
Pha
rmac
y:
No
Cha
rge
for
certa
in P
reve
ntiv
e G
ener
ic M
edic
atio
ns
and
25%
coi
nsur
ance
fo
r Non
-Pre
vent
ive
Gen
eric
Med
icat
ions
; 30
% c
oins
uran
ce u
p to
$10
0(re
tail
and
mai
l ord
er)
50%
coi
nsur
ance
(re
tail)
31-d
ay su
pply
SC
AN
A p
harm
acy
and
reta
il 90
-day
supp
ly S
CA
NA
Pha
rmac
y an
d m
ail o
rder
Pr
even
tive
Gen
eric
med
icat
ions
are
free
at t
he
SCA
NA
Pha
rmac
y; su
bjec
t to
dedu
ctib
le a
nd
30%
coi
nsur
ance
at r
etai
l or m
ail o
rder
. N
on P
reve
ntiv
e G
ener
ic M
edic
atio
ns:
$100
/31-
day
Per R
x ou
t-of-
pock
et m
axim
um
$250
/90-
day
Per R
x ou
t-of-
pock
et m
axim
um
At S
CA
NA
Pha
rmac
y or
Mai
l Ord
er
Pref
erre
d br
and
drug
s
SCA
NA
Pha
rmac
y:
25%
coi
nsur
ance
; 30
% c
oins
uran
ce u
p to
$10
0 (re
tail
and
mai
l ord
er)
50%
coi
nsur
ance
(re
tail)
31-d
ay su
pply
SC
AN
A P
harm
acy
and
reta
il 90
-day
supp
ly S
CA
NA
Pha
rmac
y an
d m
ail o
rder
$1
00/3
1-da
y Pe
r Rx
out-o
f-po
cket
max
imum
$2
50/9
0-da
y Pe
r Rx
out-o
f-po
cket
max
imum
Non
-Pre
ferr
ed b
rand
dru
gs
SCA
NA
Pha
rmac
y,
reta
il, a
nd m
ail o
rder
50
% c
oins
uran
ce
Not
Cov
ered
31
-day
supp
ly re
tail
90-d
ay su
pply
mai
l ord
er
No
Per R
x ou
t-of-
pock
et m
axim
um
Spec
ialty
dru
gs
Car
emar
k sp
ecia
lty
phar
mac
y on
ly 5
0%
Not
Cov
ered
Li
mite
d to
a 3
1-da
y su
pply
$2
50 P
er R
x ou
t-of-
pock
et m
axim
um
If y
ou h
ave
outp
atie
nt
surg
ery
Faci
lity
fee
(e.g
., am
bula
tory
su
rger
y ce
nter
)
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired.
Pe
nalty
for n
ot o
btai
ning
pre
-au
thor
izat
ion
is $5
00. P
enal
ty a
pplie
s to
prov
ider
s in-
netw
ork
and
mem
bers
out
-of
-net
wor
k.
Phys
icia
n/su
rgeo
n fe
es
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
-----
--Non
e---
---
If y
ou n
eed
imm
edia
te
med
ical
atte
ntio
n
Em
erge
ncy
room
serv
ices
20
% c
oins
uran
ce
afte
r ben
efit
year
de
duct
ible
20%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
-----
--Non
e---
---
Em
erge
ncy
med
ical
tra
nspo
rtatio
n
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
20%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
-----
--Non
e---
---
35
Page
4 o
f 11
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
fYou
U
se a
n
In-n
etw
ork
Prov
ider
Your
Cos
t IfY
ou
Use
an
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
Urg
ent c
are
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
20%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
-----
--Non
e---
---
If y
ou h
ave
a ho
spita
l st
ay
Faci
lity
fee
(e.g
., ho
spita
l ro
om)
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired.
Pen
alty
for n
ot
obta
inin
g pr
e-au
thor
izat
ion
is de
nial
of r
oom
and
bo
ard.
Pen
alty
app
lies t
o pr
ovid
ers i
n-ne
twor
k an
d m
embe
rs o
ut-o
f-ne
twor
k.
Phys
icia
n/su
rgeo
n fe
e 20
% c
oins
uran
ce
afte
r ben
efit
year
de
duct
ible
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
-----
--Non
e---
---
If y
ou h
ave
men
tal
heal
th, b
ehav
iora
l he
alth
, or s
ubst
ance
ab
use
need
s
Men
tal/
Beha
vior
al h
ealth
ou
tpat
ient
serv
ices
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired
exce
pt fo
r off
ice
visit
s. Pe
nalty
for n
ot o
btai
ning
pre
-aut
horiz
atio
n is
$500
. Pen
alty
app
lies t
o pr
ovid
ers i
n-ne
twor
k an
d m
embe
rs o
ut-o
f-ne
twor
k. E
AP
is lim
ited
to
3 C
ouns
elin
g se
ssio
ns o
r Life
Man
agem
ent
sess
ions
per
ben
efit
year
.
Men
tal/
Beha
vior
al h
ealth
in
patie
nt se
rvic
es
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired.
Pen
alty
for n
ot
obta
inin
g pr
e-au
thor
izat
ion
is de
nial
of r
oom
and
bo
ard.
Pen
alty
app
lies t
o pr
ovid
ers i
n-ne
twor
k an
d m
embe
rs o
ut-o
f-ne
twor
k.
Subs
tanc
e us
e di
sord
er
outp
atie
nt se
rvic
es
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired
exce
pt fo
r off
ice
visit
s. Pe
nalty
for n
ot o
btai
ning
pre
-aut
horiz
atio
n is
$500
. Pen
alty
app
lies t
o pr
ovid
ers i
n-ne
twor
k an
d m
embe
rs o
ut-o
f-ne
twor
k. E
AP
is lim
ited
to 3
C
ouns
elin
g se
ssio
ns o
r Life
Man
agem
ent s
essio
ns
per b
enef
it ye
ar.
Subs
tanc
e us
e di
sord
er
inpa
tient
serv
ices
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired.
Pen
alty
for n
ot
obta
inin
g pr
e-au
thor
izat
ion
is de
nial
of r
oom
an
d bo
ard.
Pen
alty
app
lies t
o pr
ovid
ers i
n-ne
twor
k an
d m
embe
rs o
ut-o
f-ne
twor
k.
If y
ou a
re p
regn
ant
Pren
atal
and
pos
tnat
al c
are
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
-----
--Non
e---
---
36
Page
5 o
f 11
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
fYou
U
se a
n
In-n
etw
ork
Prov
ider
Your
Cos
t IfY
ou
Use
an
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
Del
iver
y an
d al
l inp
atie
nt
serv
ices
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired.
Pen
alty
for n
ot
obta
inin
g pr
e-au
thor
izat
ion
is de
nial
of r
oom
and
bo
ard.
Pen
alty
app
lies t
o pr
ovid
ers i
n-ne
twor
k an
d m
embe
rs o
ut-o
f-ne
twor
k.
37
Page
6 o
f 11
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
fYou
U
se a
n
In-n
etw
ork
Prov
ider
Your
Cos
t IfY
ou
Use
an
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
hea
lth
need
s
Hom
e he
alth
car
e 20
% c
oins
uran
ce
afte
r ben
efit
year
de
duct
ible
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired.
Pen
alty
for n
ot
obta
inin
g pr
e-au
thor
izat
ion
is de
nial
of a
ll ch
arge
s. Pe
nalty
app
lies t
o pr
ovid
ers i
n-ne
twor
k an
d m
embe
rs o
ut-o
f-ne
twor
k.
Reh
abili
tatio
n se
rvic
es
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Ther
apy
visit
s (up
to 6
0 co
mbi
ned
per y
ear)
now
in
clud
e tre
atm
ent f
or c
hild
ren
with
aut
ism
(spe
ech,
cog
nitiv
e, p
hysic
al, o
ccup
atio
nal o
r oth
er
ther
apy)
. A
pplie
d Be
havi
oral
Ana
lysis
(ABA
) th
erap
y is
still
con
sider
ed in
vest
igat
iona
l and
is
not c
over
ed.
Chi
ropr
actic
visi
ts (u
p to
12
per
year
) are
cou
nted
sepa
rate
ly.
Reh
abili
tatio
n an
d H
abili
tatio
n se
rvic
es a
re c
ombi
ned.
Pr
e-au
thor
izat
ion
is re
quire
d. P
enal
ty fo
r not
ob
tain
ing
pre-
auth
oriz
atio
n is
$500
. Pen
alty
ap
plie
s to
prov
ider
s in-
netw
ork
and
mem
bers
ou
t-of-
netw
ork.
Hab
ilita
tion
serv
ices
20
% c
oins
uran
ce
afte
r ben
efit
year
de
duct
ible
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Ther
apy
visit
s (up
to 6
0 co
mbi
ned
per y
ear)
now
in
clud
e tre
atm
ent f
or c
hild
ren
with
aut
ism
(spe
ech,
cog
nitiv
e, p
hysic
al, o
ccup
atio
nal o
r oth
er
ther
apy)
. A
pplie
d Be
havi
oral
Ana
lysis
(ABA
) th
erap
y is
still
con
sider
ed in
vest
igat
iona
l and
is
not c
over
ed.
Chi
ropr
actic
visi
ts (u
p to
12
per
year
) are
cou
nted
sepa
rate
ly.
Reh
abili
tatio
n an
d H
abili
tatio
n se
rvic
es a
re c
ombi
ned.
Pr
e-au
thor
izat
ion
is re
quire
d. P
enal
ty fo
r not
ob
tain
ing
pre-
auth
oriz
atio
n is
$500
. Pen
alty
ap
plie
s to
prov
ider
s in-
netw
ork
and
mem
bers
ou
t-of-
netw
ork.
Skill
ed n
ursin
g ca
re
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
No
prio
r hos
pita
lizat
ion
requ
ired.
120
-day
co
mbi
ned
max
imum
visi
ts fo
r ski
lled
nurs
ing
faci
lity,
reha
bilit
atio
n ho
spita
l and
sub-
acut
e fa
cilit
ies.
Dur
able
med
ical
equ
ipm
ent
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Pre-
auth
oriz
atio
n is
requ
ired
for p
urch
ases
ove
r $1
,000
. Pen
alty
for n
ot o
btai
ning
pre
-au
thor
izat
ion
is de
nial
of a
ll ch
arge
s. Pe
nalty
ap
plie
s to
prov
ider
s in-
netw
ork
and
mem
bers
ou
t-of-
netw
ork.
38
Page
7 o
f 11
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
fYou
U
se a
n
In-n
etw
ork
Prov
ider
Your
Cos
t IfY
ou
Use
an
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
Hos
pice
serv
ice
20%
coi
nsur
ance
af
ter b
enef
it ye
ar
dedu
ctib
le
40%
coi
nsur
ance
afte
r be
nefit
yea
r ded
uctib
le
Lim
ited
to 6
mon
ths p
er m
embe
r per
ben
efit
year
. Pre
-aut
horiz
atio
n is
requ
ired.
Pen
alty
for n
ot
obta
inin
g pr
e-au
thor
izat
ion
for i
n-ne
twor
k an
d ou
t-of-
netw
ork
outp
atie
nt fa
cilit
ies i
s den
ial o
f all
char
ges.
If y
our c
hild
nee
ds
dent
al o
r eye
car
e
Eye
exa
m
Not
Cov
ered
N
ot C
over
ed
See
your
Em
ploy
er fo
r ben
efit
deta
ils.
Gla
sses
N
ot C
over
ed
N
ot C
over
ed
See
your
Em
ploy
er fo
r ben
efit
deta
ils.
Den
tal c
heck
-up
Not
Cov
ered
N
ot C
over
ed
See
your
Em
ploy
er fo
r ben
efits
det
ails.
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Serv
ices
You
r Pla
n D
oes
NO
T C
over
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er e
xclu
ded
serv
ices
.)
•A
cupu
nctu
re
•C
osm
etic
surg
ery
•D
enta
l Car
e (A
dult)
•D
enta
l Car
e (C
hild
)
•H
earin
g A
ids
•In
ferti
lity
treat
men
t
•R
outin
e E
ye C
are
(Adu
lt)
•R
outin
e E
ye C
are
(Chi
ld)
•Lo
ng-te
rm c
are
•R
outin
e Fo
ot C
are
unle
ss in
the
case
of
diab
etes
or p
erip
hera
l vas
cula
r dise
ase,
whe
n m
edic
ally
nec
essa
ry.
Oth
er C
over
ed S
ervi
ces
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er c
over
ed s
ervi
ces
and
your
cos
ts fo
r the
se
serv
ices
.)
•Ba
riatri
c su
rger
y fo
r tre
atm
ent o
f clin
ical
ly
seve
re o
besit
y, a
s def
ined
by
the
body
mas
s in
dex
(BM
I) is
cov
ered
onl
y at
Blu
e D
istin
ctio
n C
ente
rs
•C
hiro
prac
tic c
are
•M
ost c
over
age
prov
ided
out
side
the
Uni
ted
Stat
es.
See
ww
w.s
outh
caro
linab
lues
.com
.
•N
on-e
mer
genc
y ca
re w
hen
trave
ling
outs
ide
the
U.S
.
•Pr
ivat
e-du
ty n
ursin
g
•W
eigh
t los
s pro
gram
(onl
y if
asso
ciat
ed w
ith
ap
prov
ed b
aria
tric
surg
ery)
39
Page
8 o
f 11
Your
Rig
hts
to C
ontin
ue C
over
age:
If y
ou lo
se c
over
age
unde
r the
pla
n, th
en, d
epen
ding
upo
n th
e ci
rcum
stan
ces,
Fede
ral a
nd S
tate
law
s may
pro
vide
pro
tect
ions
that
allo
w y
ou to
kee
p he
alth
cov
erag
e. A
ny su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m
you
pay
whi
le c
over
ed u
nder
the
plan
. Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e m
ay a
lso a
pply
.
For m
ore
info
rmat
ion
on y
our r
ight
s to
cont
inue
cov
erag
e, c
onta
ct th
e pl
an a
t 1-8
77-7
05-5
428.
You
may
also
con
tact
you
r sta
te in
sura
nce
depa
rtmen
t, th
e U
.S. D
epar
tmen
t of
Labo
r, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a, o
r th
e U
.S. D
epar
tmen
t of
Hea
lth a
nd
Hum
an S
ervi
ces a
t 1-8
77-2
67-2
323
x615
65 o
r ww
w.c
ciio
.cm
s.gov
. Yo
ur G
rieva
nce
and
App
eals
Rig
hts:
If
you
hav
e a
com
plai
nt o
r are
diss
atisf
ied
with
a d
enia
l of c
over
age
for c
laim
s und
er y
our p
lan,
you
may
be
able
to a
ppea
l or f
ile a
grie
vanc
e. F
or
ques
tions
abo
ut y
our r
ight
s, th
is no
tice,
or a
ssist
ance
, you
can
con
tact
any
or a
ll of
the
follo
win
g:
•1-
877-
705-
5428
or v
isit u
s at w
ww
.sou
thca
rolin
ablu
es.c
om
•Th
e D
epar
tmen
t of L
abor
’s E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-E
BSA
(327
2) o
r ww
w.d
ol.g
ov/e
bsa/
heal
thre
form
The
Affo
rdab
le C
are
Act N
otic
es:
•Th
e A
ffor
dabl
e C
are
Act
requ
ires m
ost p
eopl
e to
hav
e he
alth
car
e co
vera
ge th
at q
ualif
ies a
s “m
inim
um e
ssen
tial c
over
age.
” T
his p
lan
does
pr
ovid
e m
inim
um e
ssen
tial c
over
age.
•Th
e A
ffor
dabl
e C
are
Act
est
ablis
hes a
min
imum
val
ue st
anda
rd o
f ben
efits
of a
hea
lth p
lan.
The
min
imum
val
ue st
anda
rd is
60
perc
ent (
actu
aria
l va
lue)
. Th
is he
alth
cov
erag
e do
es m
eet t
he m
inim
um v
alue
stan
dard
for t
he b
enef
its it
pro
vide
s.
40
Page
9 o
f 11
Lang
uage
Acc
ess
Serv
ices
:
•Sp
anish
: Pa
ra o
bten
er a
siste
ncia
en
espa
ñol,
llam
e al
núm
ero
de a
tenc
ión
al c
lient
e qu
e ap
arec
e en
la p
rimer
a pá
gina
de
esta
not
ifica
ción
.
•Ta
galo
g: U
pang
mak
akuh
a ng
tulo
ng sa
Tag
alog
, taw
agan
ang
num
ero
ng c
usto
mer
serv
ice
na m
akik
ita sa
una
ng p
ahin
a ng
pau
naw
ang
ito.
•N
avaj
o:
•C
hine
se: 如需中文服务,请致电列于本通知首页的客户服务号码。
–––
––––
––––
––––
––––
–––T
o see
exam
ples o
f how
this
plan
migh
t cov
er cos
ts for
a sa
mple
medi
cal s
ituat
ion, s
ee th
e nex
t pag
e.–––
––––
––––
––––
––––
––
41
Page
10
of 1
1
Hav
ing
a ba
by
(nor
mal
del
iver
y)
Man
agin
g ty
pe 2
dia
bete
s (ro
utin
e m
aint
enan
ce o
f a
wel
l-con
trolle
d co
nditi
on)
Abo
ut th
ese
Cov
erag
e Ex
ampl
es:
Thes
e ex
ampl
es sh
ow h
ow th
is pl
an m
ight
cov
er
med
ical
car
e in
giv
en si
tuat
ions
. Use
thes
e ex
ampl
es to
see,
in g
ener
al, h
ow m
uch
finan
cial
pr
otec
tion
a sa
mpl
e pa
tient
mig
ht g
et if
they
are
co
vere
d un
der d
iffer
ent p
lans
.
A
mou
nt o
wed
to p
rovi
ders
: $7,
540
Pl
an p
ays
$4,7
30
Patie
ntpa
ys $
2,81
0
Sam
ple
care
cos
ts:
Hos
pita
l cha
rges
(mot
her)
$2,7
00
Rou
tine
obst
etric
car
e $2
,100
H
ospi
tal c
harg
es (b
aby)
$9
00
Ane
sthe
sia
$900
La
bora
tory
test
s $5
00
Pres
crip
tions
$2
00
Rad
iolo
gy
$200
V
acci
nes,
othe
r pre
vent
ive
$40
Tot
al
$7,5
40
Patie
ntpa
ys:
Ded
uctib
les
$1,5
00
Cop
ays
$0
Coi
nsur
ance
$1
,160
Li
mits
or e
xclu
sions
$1
50
Tot
al
$2,8
10
Thes
e nu
mbe
rs a
ssum
e th
e pa
tient
has
gi
ven
notic
e of
her
pre
gnan
cy to
the
plan
. If
you
are
preg
nant
and
hav
e no
t gi
ven
notic
e of
you
r pre
gnan
cy, y
our
cost
s m
ay b
e hi
gher
. Fo
r mor
e in
form
atio
n, p
leas
e co
ntac
t: 1-
877-
705-
5428
.
A
mou
nt o
wed
to p
rovi
ders
: $5,
400
Pl
an p
ays
$2,9
50
Patie
nt p
ays
$2,4
50
Sam
ple
care
cos
ts:
Pres
crip
tions
$2
,900
M
edic
al E
quip
men
t and
Sup
plie
s $1
,300
O
ffic
e V
isits
and
Pro
cedu
res
$700
E
duca
tion
$300
La
bora
tory
test
s $1
00
Vac
cine
s, ot
her p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Patie
nt p
ays:
Ded
uctib
les
$1,5
00
Cop
ays
$0
Coi
nsur
ance
$8
70
Lim
its o
r exc
lusio
ns
$80
Tot
al
$2,4
50
This
is
nota
cos
t es
timat
or.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
act
ual c
osts
un
der t
his p
lan.
The
act
ual
care
you
rece
ive
will
be
diff
eren
t fro
m th
ese
exam
ples
, and
the
cost
of
that
car
e w
ill a
lso b
e di
ffer
ent.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
42
1
1of
11
Que
stio
ns: C
all 1
-877
-705
-542
8 or
visi
t us a
t ww
w.s
outh
caro
linab
lues
.com
. For
EA
P ca
ll 1-
800-
968-
8143
or v
isit u
s at w
ww
.firs
tsun
eap.
com
. If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms
used
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CU
nifo
rmG
loss
ary.
pdf o
r cal
l 1-8
77-7
05-5
428
to re
ques
t a c
opy.
Bl
ueC
ross
Blu
eShi
eld
of S
outh
Car
olin
a is
an in
depe
nden
t lic
ense
e of
the
Blue
Cro
ss a
nd B
lue
Shie
ld A
ssoc
iatio
n
Que
stio
ns a
ndan
swer
sab
out t
he C
over
age
Exam
ples
:
Wha
t are
som
e of
the
assu
mpt
ions
beh
ind
the
Cov
erag
e Ex
ampl
es?
•C
osts
don
’t in
clud
e pr
emiu
ms.
•
Sam
ple
care
cos
ts a
re b
ased
on
natio
nal
aver
ages
supp
lied
by th
e U
.S.
Dep
artm
ent o
f Hea
lth a
nd H
uman
Se
rvic
es, a
nd a
ren’
t spe
cific
to a
pa
rticu
lar g
eogr
aphi
c ar
ea o
r hea
lth p
lan.
•
The
patie
nt’s
cond
ition
was
not
an
excl
uded
or p
reex
istin
g co
nditi
on.
•A
ll se
rvic
es a
nd tr
eatm
ents
star
ted
and
ende
d in
the
sam
e co
vera
ge p
erio
d.
•Th
ere
are
no o
ther
med
ical
exp
ense
s for
an
y m
embe
r cov
ered
und
er th
is pl
an.
•O
ut-o
f-po
cket
exp
ense
s are
bas
ed o
nly
on tr
eatin
g th
e co
nditi
on in
the
exam
ple.
•
The
patie
nt re
ceiv
ed a
ll ca
re fr
om in
-ne
twor
k pr
ovid
ers.
If t
he p
atie
nt h
ad
rece
ived
car
e fr
om o
ut-o
f-ne
twor
k pr
ovid
ers,
cos
ts w
ould
hav
e be
en h
ighe
r.
Wha
t doe
s a
Cov
erag
e Ex
ampl
e sh
ow?
For e
ach
treat
men
t situ
atio
n, th
e C
over
age
Exa
mpl
e he
lps y
ou se
e ho
w d
educ
tible
s,
copa
ymen
ts, a
nd c
oins
uran
ce c
an a
dd u
p. It
al
so h
elps
you
see
wha
t exp
ense
s mig
ht b
e le
ft up
to y
ou to
pay
bec
ause
the
serv
ice
or
treat
men
t isn
’t co
vere
d or
pay
men
t is l
imite
d.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y ow
n ca
re n
eeds
?
N
o. T
reat
men
ts sh
own
are
just
exa
mpl
es.
The
care
you
wou
ld re
ceiv
e fo
r thi
s co
nditi
on c
ould
be
diff
eren
t bas
ed o
n yo
ur
doct
or’s
advi
ce, y
our a
ge, h
ow se
rious
you
r co
nditi
on is
, and
man
y ot
her f
acto
rs.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y fu
ture
exp
ense
s?
N
o. C
over
age
Exa
mpl
es a
re n
ot c
ost
estim
ator
s. Y
ou c
an’t
use
the
exam
ples
to
estim
ate
cost
s for
an
actu
al c
ondi
tion.
Th
ey a
re fo
r com
para
tive
purp
oses
onl
y.
You
r ow
n co
sts w
ill b
e di
ffer
ent d
epen
ding
on
the
care
you
rece
ive,
the
pric
es y
our
prov
ider
s ch
arge
, and
the
reim
burs
emen
t yo
ur h
ealth
pla
n al
low
s.
Can
I us
e C
over
age
Exam
ples
to c
ompa
re p
lans
?
Y
es. W
hen
you
look
at t
he S
umm
ary
of
Bene
fits a
nd C
over
age
for o
ther
pla
ns,
you’
ll fin
d th
e sa
me
Cov
erag
e E
xam
ples
. W
hen
you
com
pare
pla
ns, c
heck
the
“Pat
ient
Pay
s” b
ox in
eac
h ex
ampl
e. T
he
smal
ler t
hat n
umbe
r, th
e m
ore
cove
rage
th
e pl
an p
rovi
des.
Are
ther
e ot
her c
osts
I sh
ould
co
nsid
er w
hen
com
parin
g pl
ans?
Y
es. A
n im
porta
nt c
ost i
s the
pre
miu
m
you
pay.
Gen
eral
ly, t
he lo
wer
you
r pr
emiu
m, t
he m
ore
you’
ll pa
y in
out
-of-
pock
et c
osts
, suc
h as
cop
aym
ents
, de
duct
ible
s, a
nd c
oins
uran
ce. Y
ou
shou
ld a
lso c
onsid
er c
ontr
ibut
ions
to
acco
unts
such
as h
ealth
savi
ngs a
ccou
nts
(HSA
s), f
lexi
ble
spen
ding
arr
ange
men
ts
(FSA
s) o
r hea
lth re
imbu
rsem
ent a
ccou
nts
(HR
As)
that
hel
p yo
u pa
y ou
t-of-
pock
et
expe
nses
.
Your Benefits. Your Choice. 43
Benefits: The items or services covered by your health insurance plan.
Claim: A request for payment that you or your health care provider submits to your health insurance company after you receive services.
Coinsurance: Your share of the costs for a covered health care service, calculated as a percentage. You pay coinsurance plus any deductibles you owe. For example, say your health plan’s allowed amount for an office visit is $100 and you’ve met your deductible. Your coinsurance payment of 20 percent would be $20. Your health plan pays the rest of the allowed amount.
Deductible: The amount you pay for services received before your health plan begins to pay. For example, if your deductible is $1,000, your health plan will not pay for covered services until you’ve met the $1,000 deductible. After that, your health plan will pay for all covered services until the end of that benefit year.
Dependent: A child, spouse or other family member covered by a subscriber’s health plan. For example, an employer- sponsored health plan may cover the employee (subscriber), plus the employee’s spouse and their children (dependents).
Facility: The location where you receive health care services. For example, a medical facility could be a doctor’s office or a hospital.
Network: The facilities, providers and suppliers your health plan contracts with to provide health care services. You will typically pay less for services received in network versus out of network.
Out of pocket: These are your costs for medical care expenses that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance and copayments for covered services plus all costs for services that aren’t covered.
Subscriber: The person who enrolls in a health plan. There is only one subscriber per health plan. The subscriber can add eligible dependents to a family health plan.
Preauthorization: A decision that a service or type of treatment is medically necessary. Certain services require preauthorization before you receive them, except in an emergency. You may also hear this referred to as precertification or prior authorization.
Premium: The amount you pay for your health plan, usually biweekly or monthly.
Preventive services: Routine health care that includes screenings, checkups and counseling to prevent illnesses or other health problems.
Provider: This can refer to the medical professional who delivers care or the location where you receive health care services. For example, your provider could be a doctor, specialist, nurse practitioner or hospital.
Primary care physician (PCP): The main doctor and prima-ry contact for your health care services. Your PCP coordinates care if you need to see other doctors or medical specialists.
Radiology: Procedures such as X-rays, ultrasounds and magnetic resonance imaging (MRI) that are used to detect medical conditions.
Specialist: A doctor or health care professional who focuses on a specific area of medicine. For example, pediatricians, dermatologists and cardiologists are specialists.
Sometimes health care lingo can be confusing. But it’s important to understand your
health benefits and how they work. Here are some common terms to help.
Helpful terms: Words commonly used in health care
Your Benefits. Your Choice.44
Spousal coverage is available only if the SCANA participant’s spouse does not have access to employer-sponsored group health care through his or her former or current employer.
Access to sponsored health care
What does access to sponsored health care mean? Access means that your spouse has the ability to receive health care through a former or current employer, or through a self-employed plan offered to all employees of the company.
Access does not include
• Individual health care plans your spouse purchases as a self-employed person.
• Plans available through membership in a trade or professional organization
Some common examples
Spouse has access to employer-sponsored care Spouse is a teacher and has access to the state’s health plan. You would not be able to cover him/her under SCANA’s plan.
Self-employed spouses who have/or do not have medical plans in their businesses Spouse is a freelance nurse who works for a hospital and is not offered a group medical plan by the hospital. You would be able to cover him/her under SCANA’s plan.
Spouse is a self-employed home builder who employs 12 people and offers a group medical plan to them but elects SCANA coverage You would not be able to cover him/her under SCANA’s plan.
Spouse has access to Medicare or TRICARE For Life Spouse is retired from the Army and has access to TRICARE For Life. You would be able to cover him/her under SCANA’s plan.
Professional associations that offer access to coverage Spouse works as a commercial artist and can purchase medical insurance through a national art guild, of which she is a member. You would be able to cover him/her under SCANA’s plan.
Spousal coverage
If you are a SCANA employee on SCANA’s medical plan and are electing to provide medical coverage for your spouse under SCANA’s health care plan, you will be required to certify that your spouse does not have access to employer-sponsored group medical coverage.
Providing false or misleading information related to this provision may result in loss of coverage under this Plan for you and your dependents retroactive to the date you provided the false or misleading information. You may also be required to repay any amounts paid by the Plan for you and your dependent(s) since you provided the false or misleading information, or if greater, the company share of the premium.
45Your Benefits. Your Choice.
PLEASE PRINT IN INK OR TYPE
Employee Name ________________________________________________ Social Security Number __________________
Address/Mail Code _________________________________________________ Your Employee ID # _________________
Employees wanting to add or change dependent information associated with their benefits coverage must forward the required documentation* to the Employee Resource Center at MC C131 for updates to be made. If you add a dependent or spouse to your insurance coverage, this documentation is required first:
• Adding a spouse – a copy of a marriage license, Social Security card and proof of joint ownership (federal/state tax return, mortgage statement, bank statement, lease agreement, credit card statement, property tax, etc.)
• Adding a dependent – a copy of long form birth certificate and Social Security card
Dependent Information
Name Birthdate SSN RelationMedical
Y/NDental
Y/NLife Ins.
Y/N
I am responsible for the accuracy of the information submitted above and for notifying SCANA of any changes in my spouse’s eligibility for other coverage within 31 days of that change by submitting another Spousal Health Coverage Affidavit to the Benefits Team. I understand that any false information submitted is a violation of SCANA’s Code of Conduct and will be subject to disciplinary action up to and including termination of employment. I also understand that I will not receive a refund for any premiums paid as a result of false information.
Signature:_________________________________________________________ Date: _____________________________
SUBMIT FORM AND REQUIRED DOCUMENTATION TO 220 Operation Way MC C131 Cayce, SC 29033
* Additions/changes will not be made without receipt of this information.
SCANA Corporation Dependent Change FormSee page 31 for definitions of eligible dependents.
47Your Benefits. Your Choice.
PLEASE PRINT IN INK OR TYPE
Employee Name ________________________________________________ Social Security Number __________________
Address/Mail Code _________________________________________________ Your Employee ID # _________________
I reserve the right to change this designation at any time. I revoke any and all previous beneficiary designations prior to the effective date shown below.
TYPES OF BENEFICIARY
1 = Regular or Sole Beneficiary
2 = Co-Beneficiary – Share as Specified
3 = Contingent Beneficiary – To receive in the event of the death of the primary beneficiary.
If more than one contingent beneficiary is designated, payment will be made in equal shares or all to the last survivor.
Designate the distribution of the proceeds as a percentage of the total amount.
Beneficiary Name/AddressThe information below is required for benefit assignment.
Type of Beneficiary
(1, 2, 3)
Whole Percentages
Only
Name _________________________________
Address _______________________________
______________________________________
Date of Birth _____________________
Relationship ______________________
SS# ____________________________
Name _________________________________
Address _______________________________
______________________________________
Date of Birth _____________________
Relationship ______________________
SS# ____________________________
Name _________________________________
Address _______________________________
______________________________________
Date of Birth _____________________
Relationship ______________________
SS# ____________________________
Signature ______________________________________________________ Effective Date ________________________
RETURN TO 220 Operation Way MC C131 Cayce, SC 29033
SCANA Corporation Life Insurance Beneficiary Form
Mail this form to:
Enter ID # below if not shown or if different from above
Number of New prescriptions:
Number of Refill prescriptions:
Please use blue or black ink, capital letters, and fill in both sides of this form.
Shipping Address. To ship to an address different from the one printed above, please make changes here.
New Prescriptions - Mail your new prescriptions with this form.
Refills - Order by Web, phone, or write in Rx number(s) below.
We may package all of these prescriptions together unless you tell us not to.
Refills. To order mail service refills, enter your prescription number(s) here.
A
B
Use this addressfor this order only.
Apt./Suite #
City State ZIP Code
Street Name
-- --Daytime Phone #: Evening Phone #:
Last Name First Name MI Suffix (JR, SR)
1) 2) 3) 4)
5) 6) 7) 8)
Prescription Plan Sponsor or Company Name
BC 27131
CAREMARK PO BOX 94467PALATINE, IL 60094-4467
On behalf of BlueCross, Caremark assists in the administration of the prescription drug program. Caremark is an independent company that provides pharmacy benefits management.
.
Tell us about the people getting prescriptions. If there are more than two people, please complete another form.
1st person with a refill or new prescription. This person needs: Easy open caps Spanish forms and labels
Tell us about new allergies or health information for this person. Only tell us about new information.Allergies:
Health Information:
Special Instructions:
Electronic Check. Pay from your bank account. First time users register online or call Customer Care.
Bill Me Later®. Works like a credit card. First time users register online or call Customer Care.
Credit or Debit Card. (VISA®, MasterCard®, Discover®, or American Express®)Fill in this oval to use your card on file.Fill in this oval to use a new card or to update your card expiration date.
Check or Money Order. Amount: $Regular delivery is free and will take 7 to 10days from the day you send this form.
• Faster delivery charges may change.• Faster delivery is for shipping time, not processing time.• Faster delivery can only be sent to a street address, not a PO box.
C
D
How would you like to pay for this order? Fill in the oval to choose a payment.E
2nd person with a refill or new prescription. This person needs: Easy open caps Spanish forms and labels
ErythromycinCephalosporin CodeineAspirinNoneSulfa Other:
Peanuts
Arthritis Asthma Diabetes Acid Reflux GlaucomaHigh Blood PressureOther:
High Cholesterol Migraine Osteoporosis Prostate Issues
Penicillin
Heart ProblemThyroid
Gender: M F Date of Birth:Date new prescription written:
Doctor’s Last Name Doctor’s First Name Doctor’s Phone #
Tell us about new allergies or health information for this person. Only tell us about new information.Allergies:
Health Information:
ErythromycinCephalosporin CodeineAspirinNoneSulfa Other:
Peanuts
Arthritis Asthma Diabetes Acid Reflux GlaucomaHigh Blood PressureOther:
High Cholesterol Migraine Osteoporosis Prostate Issues
Penicillin
Heart ProblemThyroid
Gender: M F Date of Birth:Your E-Mail:
Your E-Mail:
Date new prescription written:
Doctor’s Last Name Doctor’s First Name Doctor’s Phone #
Fill in this oval if you DO NOT want to use this payment method for future orders.
2nd Business Day ($17)Next Business Day ($23)
If you want faster delivery, choose:
Credit Card Holder Signature/Date
Exp.Date
Suffix(JR,SR)
Suffix(JR,SR)
Business days are only
Monday-Friday
Your Benefits. Your Choice. 51
Benefit 2017 Options
Medical SCANA Choice PlanWaive
Spousal coverage m Yes, I am electing to cover my spouse under SCANA’s medical plan and certify that my spouse does not have access to employer-sponsored group medical coverage. I understand that any false information submitted is a violation of SCANA’s Code of Conduct and will be subject to disciplinary action up to and including termination of employment
Dental ComprehensiveWaive
Vision Waive
Supplemental Life (up to 6x base pay) Evidence of Insurability may be required
1x 2x 3x 4x 5x 6x
Supplemental AD&D (up to 2x base pay)
1x 2x
Spouse life Evidence of Insurability required
$10,000 $20,000 $50,000 $100,000
Dependent life (same rate regardless of number of dependents)
Elect Waive
Short-term disability Buy up to 100% base pay replacement for up to 6 weeks
Do not buy up
Long-term disability Buy up to 66 2/3% base pay replacement Do not buy up
Health savings account (HSA) eligibility
m Yes, I am eligible for a health savings account because I am: • Not covered by any other health plan, including my spouse’s health insurance • Not receiving benefits from my own or my spouse’s Health Care FSA • Not enrolled (or have already disenrolled) from any part of Medicare or TRICARE • Have not received Veteran’s medical benefits in the past 90 days • Not claimed as a dependent on another person’s tax return
HSA contribution Annual contribution = $____________ Waive contribution
Dependent care flexible spending account (FSA) contribution
Annual contribution = $____________ Waive contribution
Health care flexible spending account (FSA) contributionAvailable if you waive medical coverage or are not eligible to contribute to an HSA
Annual contribution = $____________ Waive contribution
Go paperless m Yes, I currently receive paper copies of benefits communications (i.e., summary plan descriptions and documents required to be furnished under Section 104(b)(4) of ERISA). I agree to go paperless, with the understanding that I can request a paper copy of a communication at any time by calling 803-217-4444.
Enrollment Checklist for:Employee Name: _______________________________________ Employee ID: _______________
Use the list below to circle your 2017 benefit elections.
For a summary of your current benefits coverage, log in to PeopleSoft (HR) and choose “View Current Benefit Elections” under My Health.
Employee only
Employee/ Spouse
Employee/ Dependents
Employee/ Family
Employee only
Employee/ Spouse
Employee/ Dependents
Employee/ Family
Employee only
Employee/ Spouse
Employee/ Dependents
Employee/ Family
53
Clip and keep this wallet card.#
When you need medical advice call
877-705-5428 Reliable health care answers
A service brought to you by
24-hour Customer Service
Contact Information
Topic Resource Phone Website
Health, wealth and career related questions
Employee Resource Center 803-217-4444 The Edge
24-hour customer serviceBlueCross BlueShield of South Carolina Customer Service
877-705-5428SouthCarolinaBlues.com My Health Toolkit
Prescription costs, drug lists SCANA Pharmacy803-217-9173 866-769-9039
Health on The Edge
Mail-order prescriptions Caremark Mail Order Pharmacy 888-963-7290 SouthCarolinaBlues.com
Specialty drugs CVS Specialty Pharmacy 800-237-2767 SouthCarolinaBlues.com
Health savings account HSA Bank 800-357-6246 hsabank.com
Flexible spending account WageWorks 877-924-3967FSAworks4me.com wageworks.com
Employee Assistance Program First Sun EAP 800-968-8143 www.FirstSunEAP.com
Disability and FMLA MetLife 877-638-8262 Health on The Edge
Financial planning for spending/savings accounts and benefits coverage
Ernst & Young 866-724-1946 SCANA.eyfpc.com
Two BlueCross representatives are on site at SCANA during normal business hours to help you with your benefits needs.
Visit
www.EyeMedVisionCare.comOr call 866-723-0513.*
* When calling, please provide your full name and date of birth. EyeMed Vision Care is an independent company that offers vision benefits on behalf of your health plan.
Clip and keep this wallet card.#
Questions about your vision benefits?
A service brought to you by
54SCANA-19259-9-2016BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
We are excited to have you as part of the BlueCross
family. Our goal is to help you get the most out of your
benefit plan. Getting more information or answers to
your questions is easy. Simply visit us online at
www.SouthCarolinaBlues.com