healthmedical plans

pharmacy plan

Mayo Clinic partnership

dental plans

vision plans

healthcare accounts

employee wellness

2016 benefits guide

Revised 06-08-16

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Medical Plans

Within 30 calendar days of your eligibility/hire date or a qualified life event or during the annual Open Enroll-ment period, you may enroll in one of the three medical plan options. Each medical plan offers one or more medical networks from which to choose your medical providers.

Please refer to page 3 of the Benefits Guide | Administration for information about coverage effective dates.

cfo.asu.edu/hr-benefits | Faculty Services: 480-727-9900 | Employee Services: 855-ASU-5081 (855-278-5081)

Exclusive Provider Organization (EPO)

An EPO is similar to a traditional HMO and provides the lowest-cost benefit because it uses contracted network physicians, hospitals, ancillary healthcare providers and facilities. You have access to any physician (including specialists) within your network without notifying the Plan Administrator.

Preferred Provider Organization (PPO)

With a PPO, you can use both in-network and out-of-network tiers of physicians, hospitals and facilities. In-network services cost less out-of-pocket, but the out of-network tier offers more provider choices.

Health Savings Account (HSA) Option with HealthFund HSA

The HSA Option is a high-deductible health plan with both in-network and out-of-network benefit levels. You have access to any physician (including specialists) without authorization.

The HealthFund HSA is an account that is used in conjunction with the HSA Option. It allows tax-free contributions and earnings to pay your out-of-pocket healthcare-related expenses.

Medical NetworksAetna SelectSM (Open Access)Blue Cross/Blue Shield of ArizonaCIGNAUnitedHealthcare Choice EPO

Aetna Choice POS IIBlue Cross/Blue Shield of Arizona

UnitedHealthcare Options PPO

Aetna Choice POS II

Plan Documents

For EPO, PPO and HSASummary of Benefits and CoverageVisit ADOA Benefit Options for easy-to-understand summaries of EPO, PPO and HSA medical plan benefits and coverage.

More InfoGlossary of Health Coverage and Medical TermsNotice for MembersFrequently Asked Questions

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Medical Plans Comparison

Plan Year DeductibleEPO PPO HSA Option with HealthFund

In-network In-network Out-of-network In-network Out-of-network

Individual none $500 $1,000 $1,300 $2,600

Family Aggregrate none $1,000 $2,000 $2,600 $5,200

Out-of-Pocket Maximum (Includes Deductible)EPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

Individual n/a n/a n/a $2,000 $5,000

Family n/a n/a n/a $4,000 $10,000

Out-of-Pocket Maximum (Excludes Deductible)EPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

Individual none $1,000 $4,000 n/a n/a

Family none $2,000 $8,000 n/a n/a

Family (Lifetime Maximum)

none none none n/a n/a

Office Visits (Preventative)EPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

PCP $15 $15 after deductible

50% after deductible

$0 50% coinsurance after deductible

OB/GYN $10 $10 subject to deductible

50% subject to deductible

$0 50% coinsurance after deductible

Specialist $30 $30 50% after deductible

$0 50% coinsurance after deductible

Non-Preventative ServicesEPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

PCP $15 $15 after deductible

50% after deductible

10% coinsurance after deductible

50% coinsurance after deductible

OB/GYN $10 $10 after deductible

50% after deductible

10% coinsurance after deductible

50% coinsurance after deductible

Specialist $30 $30 after deductible

50% after deductible

10% coinsurance after deductible

50% coinsurance after deductible

The following summary compares your cost for covered services by plan.

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Medical Plans Comparison continued

Outpatient ServicesEPO PPO HSA Option with HealthFund

In-network In-network Out-of-network In-network Out-of-network

Ambulance $0 $0 after deductible

50% after deductible

10% coinsurance after deductible

10% coinsurance after deductible

ER $125* *Waived if admitted

$125* after deductible

*Waived if admitted

$125* after deductible

*Waived if admitted

10% coinsurance after deductible

10% coinsurance after deductible

Urgent Care $40 $40 subject to deductible

50% after deductible

10% coinsurance after deductible

50% coinsurance after deductible

Hospital AdmissionsEPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

Admission $150 $150 after deductible

50% after deductible

10% coinsurance after deductible

50% coinsurance after deductible

International CoverageEPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

Emergency and urgent care only on a reimbursement basis

Emergency and urgent care only at in-network benefit level. Other services covered at

the out-of-network benefit level on a reimbursement basis

Emergency and urgent care only. Other services covered at

the out-of-network benefit level on a reimbursement basis

Mammogram (Preventative)EPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

$0 $0 after deductible

50% after deductible

$0 50% coinsurance after deductible

Durable Medical EquipmentEPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

$0 $0 after deductible

50% after deductible

10% coinsurance after deductible

50% coinsurance after deductible

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Chiropractic (Limited to 20 Visits/Plan YearEPO PPO HSA Option with HealthFund

In-network In-network Out-of-network In-network Out-of-network

$15 $15 after deductible

50% after deductible

10% coinsurance

after deductible

50% coinsurance

after deductible

RadiologyEPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

$0 $0 after deductible

50% after deductible

10% coinsurance

after deductible

50% coinsurance

after deductible

Home Health ServicesEPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

Days/Plan Year 42 42 42 42 days 10% coinsurance after deductible

42 days 50% coinsurance after deductible

Bariatric SurgeryEPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

20% 20% Not covered 20% coinsurance

after deductible

50% coinsurance

after deductible

Behavioral HealthEPO PPO HSA Option with HealthFund HSA

In-network In-network Out-of-network In-network Out-of-network

Inpatient $150 $150 after deductible

50% after deductible

10% coinsurance

after deductible

50% coinsurance

after deductible

Outpatient $15 $15 after deductible

50% after deductible

10% coinsurance

after deductible

50% coinsurance

after deductible

Important: All PPO and HSA out-of-network benefits are subject to reasonable and customary charges as defined by the insurance industry.

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Medical Premiums

More information about the Healthcare Accounts: pages 17 and 18.

HSA Medical Option – Aetna Choice (HealthFund HSA contributions not included in premiums)

Pay Period MonthlyEmployee Employee University Total

Employee $ 9.23 $20.00 $372.00 $392.00

Employee + Spouse $27.69 $60.00 $771.00 $831.00

Employee + Child $23.54 $51.00 $504.00 $555.00

Family $51.23 $111.00 $859.00 $970.00

EPO Plans - Aetna Select, Blue Cross Blue Shield of AZ, CIGNA, UnitedHealthcare ChoicePay Period MonthlyPlans Employee Employee University TotalEmployee $18.46 $40.00 $550.00 $590.00

Employee + Spouse $54.92 $119.00 $1,130.00 $1,249.00

Employee + Child $46.62 $101.00 $734.00 $835.00

Family $102.00 $221.00 $1,238.00 $1,459.00

PPO Plans - Aetna Choice, Blue Cross Blue Shield of AZ, UnitedHealthcare OptionsPay Period MonthlyPlans Employee Employee University TotalEmployee $ 47.08 $102.00 $ 559.00 $661.00

Employee + Spouse $ 99.23 $215.00 $1,182.00 $1,397.00

Employee + Child $ 66.46 $144.00 $ 791.00 $ 935.00

Family $115.85 $251.00 $1,379.00 $1,630.00

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Medical Plans

Nurse Line

A dedicated team of physicians, nurses and dietitians are available 24/7 for member consultations. Individuals needing medical advice or who have treatment questions can call the toll-free nurse line:

American Health Holding 866-244-8977Aetna 800-556-1555CIGNA 800-968-7366UnitedHealthcare 800-401-7396

Medical Management Services Available

When you choose medical coverage, you get more than basic healthcare coverage. You get personalized medical management programs at no additional cost. Each medical network provides medical management services as follows:

American Health Holding (AHH) serves Blue Cross Blue Shield of Arizona network only

Aetna serves only Aetna members

CIGNA serves only members enrolled with the CIGNA network

UnitedHealthcare serves only UnitedHealthcare members

Professional, experienced staff work on your behalf to make sure you are getting the best care possible and that you are properly educated on all aspects of your treatment.

Utilization Management

AHH, Aetna, CIGNA and UnitedHealthcare provide prior authorization and utilization review when members require non-primary care services. Prior to any elective hospitalization and/or certain outpatient procedures, you or your doctor must contact your designated medical management vendor for authorization. Please refer to your Plan Document for the specific list of services that require prior authorization. Each vendor has a dedicated line to accept calls and inquiries:

American Health Holding 866-244-8977Aetna 800-333-4432CIGNA 800-968-7366UnitedHealthcare 800-896-1067

Case Management

Case management is a collaborative process whereby a case manager from your designated medical management vendor works with you to assess, plan, implement, coordinate, monitor and evaluate the services you may need. Often, case management is used with complex treatments for severe health conditions. The case worker uses available resources to achieve cost effective health outcomes for both the member and the medical plans.

Disease Management

The purpose of disease management programs is to reach out to you and/or your dependents who want help managing their health conditions or information about complex or chronic health conditions. The programs are typically designed to improve self-management skills and help

make lifestyle changes that promote healthy living. The following disease management programs are available to all members, regardless of their selected networks:• Asthma• Diabetes• Chronic Obstructive Pulmonary

Disease• Congestive Heart Failure• Pregnancy/Maternity• Coronary Artery Disease

If you are eligible or become eligible for one of the programs above, a disease manager from your designated medical management vendor will assess your needs and work with your physicians to develop a personalized plan. Your personalized plan will establish goals and steps to help you positively change your specific lifestyle habits and improve your health.

Your assigned disease manager may also:• Provide tips on how to keep your

diet and exercise program on track• Help you to maintain your necessary

medical tests and annual exams• Offer tips on how to manage stress

and help control the symptoms of stress

• Assist with understanding your doctor’s treatment plan

• Review and discuss medications, how they work and how to use them

Participation is optional, private and tailored to your specific needs. Generally a disease manager will work with you as quickly or as slowly as you like allowing you to complete the program at your own pace. Over the course of the program, participants learn to incorporate healthy habits and improve their overall health.

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Pharmacy Plan

Limited Prescription Drug CoveragePrescription drug coverage will generally be limited to medications that do not have an equally effective over-the-counter substitute. If traveling outside of the U.S., pharmacy benefit coverage applies only to emergencies on a reimbursement basis.

Non-covered DrugsCertain medications are not covered as part of the plan. If you find such a drug has been prescribed for you, discuss an alternative treatment with your doctor.

FormularyThe formulary is the list of medications chosen by a committee of doctors and pharmacists to help you maximize the value of your prescription benefit. Formulary changes can occur during the plan year. Medications that no longer offer the best therapeutic value are deleted from the formulary. Ask your pharmacist to verify the current copay amount when your prescription is filled. Sharing this information with your doctor helps ensure you get the best value, which saves you and your plan money.

Medication Prior AuthorizationPrescriptions for certain medications may require clinical approval before

they can be filled, even with a valid prescription. These prescriptions may be limited to quantity, frequency, dosage or may have age restrictions. The authorization process may be initiated by you, your local pharmacy, or your physician by calling MedImpact at 1-888-648-6769.

Step Therapy ProgramStep therapy promotes the use of safe, cost-effective and clinically appropriate medications. This program requires that members try a generic alternative medication that is safe and equally effective before a brand name medication is covered. For a complete list of drugs under this program, please refer to the Formulary Lookup in the MedImpact Member Portal.

Specialty Pharmacy ProgramCertain medications used for treating chronic or complex health conditions are handled through the Walgreens Specialty Pharmacy Program. This program helps you monitor your medication needs and also provides patient education. The program includes monitoring of specific injection drugs and other therapies requiring complex administration methods and special storage, handling and delivery. Specialty

medications are limited to a 30-day supply and may be obtained only at a Walgreens retail pharmacy or by calling 1.888.782.8443.

A Specialty Care Representative may contact you to facilitate your enrollment in the Specialty Pharmacy Program. You also may enroll directly into the program by calling 1.888.782.8443.

MedImpact Member Portal See your pharmacy benefit. –Drug Search – Research more than17,000 medications. –Benefit Highlights – View your current copayment amounts and other pharmacy benefit considerations. –Formulary Lookup – Determine drug coverage and obtain a cost estimate for a selected medication. –Pharmacy Locator – Find a participating pharmacy near you.–PersonalHealth Rx® – Print your prescription history for a physician visit or tax reporting. –Health & Wellness – Health tips plus info on diseases and health conditions. –General Pharmacy Locator – Find a pharmacy without registration. Select General Pharmacy Locator.

Mail-order PharmacyYou may fill your prescription through the Walgreens mail-order service by submitting a 90-day written prescription along with two copayments using the mail service prescription order form. Prescription Order Form | Walgreens Mail Service

HSA members: Available only when co-payments apply.

Retail PharmacyIf you elect and enroll in any medical plan, MedImpact will be the network of drugstores, supermarkets and discount stores for pharmacy benefits. To fill any prescriptions at a network pharmacy, you must present your medical card. The cost of prescriptions filled out-of-network will not be reimbursed. HSA members: Preventive prescriptions have a copay. Non-preventive prescriptions are subject to a deductible.

Generic$10 Retail (30-day supply) $25 Retail (90-day supply)$20 Mail Order (90-day supply)

Preferred (Formulary)$20 Retail (30-day supply)$50 Retail (90-day supply)$40 Mail Order (90-day supply)

Non-Preferred (Non-Formulary)$40 Retail (30-day supply)$100 Retail (90-day supply)$80 Mail Order (90-day supply)

NOTE: If your doctor prescribes a brand name drug and indicates that the generic equivalent is acceptable, but you decline the generic, you will be responsible the copay, plus retail cost of the brand name minus the retail cost of the generic.

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Mayo Clinic Partnership

Mayo Clinic | Phoenix campus 56th St. and Mayo Blvd.

• Mayo Clinic Hospital – Inpatient care• Mayo Clinic Specialty Building – Outpatient specialty care

Mayo Clinic | Scottsdale campus134th St. and Shea Blvd.

• Mayo Clinic Building – outpatient specialty care• 240 exam rooms, pharmacy

Mayo Clinic Family Medicine | Thunderbird92nd St. and Thunderbird

• Primary care• Obstetrical care• Women’s Health Internal Medicine• Newborn and pediatric care• Cardiac rehab

Mayo Clinic Family Medicine | ArrowheadN. 75th Ave. Glendale

• Primary care• Newborn and pediatric care• Laboratory• X-rays• Anticoagulation monitoring

Arizona State University is pleased to partner with Mayo to bring its employees options for in-network access to Mayo’s integrated team of medical experts.

You and your dependents can receive the very best health care from some of the nation’s leading physicians at Mayo Clinic who are contracted with all medical networks – Aetna, Blue Cross Blue Shield of Arizona, CIGNA and UnitedHealthcare. Mayo Clinic and ASU have developed a strong collaborative partnership over the past several years, working together on a wide range of joint initiatives, including:

• An ASU Nursing program (BSN) on Mayo Clinic’s Phoenix campus• Dual degree programs, including MD/JD, MD/MBA and MD/BioInformatics • Multiple collaborative research projects

About Mayo Clinic

Mayo Clinic is known for its unique, integrated approach, with physicians working together as a team on behalf of patients and their families. Since expanding to Arizona in 1987, Mayo Clinic evolved into the Valley’s premier academic medical center, serving over 100,000 of patients each year. Mayo delivers healthcare services in more than 65 medical and surgical specialties, including nationally recognized programs in cancer treatment and organ transplantation.

Mayo also has outstanding programs in medical education and research, including clinical trials led by world-class Mayo Clinic investigators that allow eligible participants access to new research treatments in addition to playing an active role in their own health care. Mayo Clinic has several facilities located throughout the Valley at the following locations:

More Info MayoClinic.org

Appointments 480-301-8484 | 800-446-2279 Online Appointment Request: MayoClinic.orgIn some cases, your insurance plan will require a physician referral.

Mayo Clinic Healthy Living online portal This confidential, personalized system gives employees access to the Mayo Clinic Health Assessment, health information and resources, and also is the tool for self-reporting approved activities that are part of the Health Impact Program (HIP).

Dental Plans

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Within 30 calendar days of your eligibility/hire date or a qualified life event or during the annual Open Enroll-ment period, you may enroll in one of the two dental plan options. There are two plan types: Prepaid/DHMO and Indemnity/Preferred Provider Organization (PPO).

Please refer to page 3 of the Benefits Guide | Administration for information about coverage effective dates.

How to Choose the Best Dental Plan for You and Your FamilyWhen choosing between a prepaid/DHMO plan and an indemnity/PPO plan, you should consider the following: dental history, level of dental care required, costs/budget and provider in the network.

If you already have a dentist, make sure he/she participates in the plan you are considering.

Prepaid/DHMO PlanTotal Dental Administrators Health Plan, Inc. (TDAHP)

• You MUST use a Participating Dental Provider (PDP) to provide and coordinate all of your dental care.

• Participating providers are located in Arizona and Utah.• The dentist you select must participate in the DHMO

plan.• No annual deductible or maximums.• No claim forms.• No waiting periods.• Pre-existing conditions are covered.• Specific copayments for services.• Specific lab fees for prosthodontic materials.

TDAHP online866-921-7687 Member Services

Dental Plans

Each family member may choose a different general dentist. You can select or change your dentist by contacting TDAHP at 866-921-7687 or by using the “Change/Select Your Participating Provider” function online (use link). Members may self-refer to dental specialists within the network.

Specialty care copayments are listed in the plan booklet. Specialty services not listed are provided at a discounted rate. This discount includes services at a Pedodontist, Prosthodontist and TMJ care.

TDAHP Plan Document

More than 85% of Arizona’s licensed dentists participate in the Delta Dental PPO Plus Premier plan and agree to accept Delta’s allowable fee as payment in full after any deductibles and/or copayments are met. Amounts billed by network providers in excess of the allowable fee will not be billed to the patient.

If you see a nonparticipating dentist, Delta will still provide benefits, although typically at reduced levels. You may need to submit a claim form for eligible expenses to be paid.

Delta Plan Document

Indemnity/PPO Plan Delta Dental PPO Plus Premier

• You may see a licensed dentist anywhere in the world.

• You have a maximum benefit of $2,000 per person per plan year for dental services. Maximum annual benefit will exclude Preventive Class I services, which include office visits, oral exams, cleaning, fluoride treatment and x-rays.

• There is a maximum lifetime benefit of $1,500 per person for orthodontia.

• Benefits may be based on reasonable and customary charges.

Delta Dental Online Claim Form800-352-6132

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Dental Plans Comparison

Services Total Dental Administrators Delta DentalPlan Type Prepaid/DHMO Indemnity/PPODeductibles None $50/$150Preventive Care Co-pay Co-insuranceOffice Visit $0 $0 - Deductible WaivedOral Exam $0 $0 - Deductible Waived*Prophylaxis/Cleaning $0 $0 - Deductible Waived*Fluoride Treatment $0 (to age 15)** $0 - Deductible Waived* (to age 18)X-Rays $0 $0 - Deductible Waived*

Basic RestorationOffice Visit $0 $0*Sealants $10 per tooth (to age 17) 20% (to age 19)Fillings Amalgams: $10-$37;

Resin: $26-$7620%

Extractions Simple: $30; Surgical: $60 20%Periodontal Gingivectomy $225 20%Oral Surgery $30-$145 20%

Major RestorativeOffice Visit $0 $0*Crowns $270 + $185 Lab Fee 50%Dentures $300 + $275 Lab Fee 50%Fixed Bridgework $270 + $185 Lab Fee 50%Crown/Bridge Work $75 50%Inlays $250-$327 Not Covered

OrthodontiaChild $2,800-$3,400 See LifetimeAdult $3,200-$3,700

Maximum BenefitsAnnual Combined Preventive Care, Basic and Major Services

No Dollar Limit $2,000 per person

Orthodontia (Lifetime) No Dollar Limit $1,500 per person

TMJ Services/ExamsTMJ Exams, services, etc. 20% Discount Not Covered

International CoverageCoverage for emergency care only. Maximum allowable reimbursement is $50, less member costs that would normally be charged for the procedure.

Coverage provided when requirements included in Section 5.10 of the Plan Document are met.

*Routine visits and exams are covered only two times per year at 100 percent.**Fluoride treatment covered 100 percent once per plan year up to age 15. Additional treatment subject to applicable copayments.This is a summary only; please see plan descriptions for detailed provisions.

Important: All PPO benefits are subject to reasonable and customary charges as defined by the insurance industry.

Dental Premiums

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Pay Period MonthlyEmployee Employee University TOTAL

Delta Dental Employee $14.30 $30.98 $4.96 $35.94

Employee + Child $23.34 $50.56 $9.92 $60.48

Employee + Spouse $30.33 $65.71 $9.92 $75.63

Family $48.26 $104.56 $13.70 $118.26

Total Dental AdministratorsEmployee $1.86 $4.03 $4.96 $8.99

Employee + Child $3.50 $7.59 $9.92 $17.51

Employee + Spouse $3.72 $8.06 $9.92 $17.98

Family $6.12 $13.27 $13.70 $26.97

Vision Plans

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Within 30 calendar days of your eligibility/hire date or a qualified life event or during the annual Open Enroll-ment period, you may enroll in the Avesis Advantage Program. If you do not wish to enroll in the premium-due vision plan, you will automatically be enrolled in the free Avesis Discount Program.

Please refer to page 3 of the Benefits Guide | Administration for information about coverage effective dates.

Avesis Advantage ProgramEmployees are responsible for the full premium of this voluntary plan.

Program Highlights• Yearly coverage for a vision exam, glasses or contact lenses• Extensive provider access throughout the state • $600 maximum allowance for LASIK surgery• Unlimited discounts on additional optical purchases• Increased in-network contact lens allowance• Hearing discount plan (see below)

How to Use the Advantage ProgramFind a provider – Use the Avesis website or call customer service at 888-759-9772. Although you also can receive out-of-network care, using an in-network provider will allow you to maximize your vision care benefit.

Schedule an appointment – Identify yourself as an Avesis member employed by the State of Arizona when scheduling.

Out-of-network BenefitsIf services are received from a non-participating provider, you will pay the provider in full at the time of service and submit a claim to Avesis for reimbursement. The claim form and itemized receipt should be sent to Avesis within three months of the date of service to be eligible for reimbursement. The Avesis claim form can be obtained at the website avesis.com. Reimbursement will be made directly to the member. Avesis Vision Plan Document | Frequently Asked Questions

Member Website | Out-of-network claim form

Avesis Discount ProgramIf you do not enroll in the Advantage Program (fully-insured plan), you will automatically be enrolled in the Discount Program at no cost. This program will provide each member with substantial discounts on vision exams and corrective materials.

How to Use the Discount ProgramFind a provider – Go to avesis.com or call customer service at 888-759-9772. Schedule an appointment – Identify yourself as an Avesis discount card holder employed by the State of Arizona. To provide and/or update dependent information, call customer service at 888-759-9772.

In-network Benefits OnlyAvesis providers who participate in the Avesis Discount Vision Care Program offer negotiated fees for products and services so members receive substantial discounts on services and materials they need to maintain healthy eyesight. Providers who don’t participate in the program will not honor any the discounted fees. The member will be responsible for full retail payment.

Avesis Discount Hearing ProgramThis hearing discount plan is available to both Advantage and Discount program members and their eligible dependents at no cost. It offers access to EPIC Hearing Health Care national network and savings on all name brand hearing aid technology.

866-956-5400 Be sure to identify yourself as an Avesis member employed by the State of Arizona.

Avesis Online

888-759-9772

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Vision Plans Comparison

Individuals may enroll in the Avesis Advantage Vision Care Program. Individuals who waive the Avesis Advantage Program coverage will automatically be enrolled in the Avesis Discount Vision Care Program and will receive an Avesis discount card at no cost.

Examination FrequencyLenses FrequencyFrame FrequencyExamination CopayOptical Materials Copay (Lenses & Frames Combined)

Once every 12 monthsOnce every 12 monthsOnce every 12 months$10 copay$0

Once per 12 monthsOnce per 12 monthsOnce per 12 months20% discount Refer to schedule below

Single Vision LensesBifocal LensesTrifocal LensesLenticular LensesStandard Progressive Lenses

Selected Lens Tints & Coatings

Covered-in-fullCovered-in-fullCovered-in-fullCovered-in-fullUniform discounted fee schedule less the allowance for Standard LensesUniform discounted fee schedule

20% discount 20% discount 20% discount 20% discount 20% discount

20% discount

Frequency and Copay

Standard Spectacle Lenses

Frame

Frame Covered up to $100-$150 retail value ($50 wholesale cost allowance)

20% Discount

Contact Lenses (In Lieu of Frame/Spectacle Lenses)

ElectiveMedically Necessary

10-20% discount & $150 allowanceCovered-in-full

10-20% Discount10-20% Discount

Lasik/PRK

Lasik/PRK$600 maximum allowance for one or both eyes.

This benefits is in addition to the corrective eyewear benefit.

$20 Discount

Advantage Vision Care Discount Vision CareAvesis Vision Plans

In-network Benefits

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Single Vision LensesBifocal LensesTrifocal LensesLenticular LensesProgressive LensesLens Tints & Coatings

Up to $33 reimbursementup to $50 reimbursementUp to $60 reimbursementUp to $110 reimbursementUp to $60 reimbursementNo Benefits

No BenefitNo BenefitNo BenefitNo BenefitNo BenefitNo Benefit

Standard Spectacle Lenses

Frames

Frames Up to $50 reimbursement No Benefit

Contact Lenses (In Lieu of Frame/Spectacle Lenses)

ElectiveMedically Necessary

Up to $150 reimbursementUp to $300 reimbursement

No BenefitNo Benefit

Lasik/PRK

Lasik/PRK Up to $600 reimbursement No Benefit

Covered as out-of-network and will be reimbursed based on the Avesis reimbursement schedule

No coverage

International Coverage

Examination FrequencyLenses FrequencyFrame FrequencyExamination

Once every 12 monthsOnce every 12 monthsOnce every 12 monthsUp to $50 reimbursement

No BenefitNo BenefitNo BenefitNo Benefit

Advantage Vision Care Discount Vision CareAvesis Vision Plans

Frequency

Out-of-network Benefits

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Vision Premiums

Advantage Vision Care

Avesis Vision Plans

Pay Period MonthlyEmployee University Employee University

Employee $1.84 N/A $3.99 N/A

Employee + Spouse $5.97 N/A $12.94 N/A

Employee + 1 Child $5.89 N/A $12.76 N/A

Family $7.43 N/A $16.10 N/A

Discount Card (Avesis): Free

Healthcare Accounts

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Within 30 calendar days of your eligibility/hire date or a qualified life event or during the annual Open Enrollment period, you may enroll in one of three healthcare accounts that helps increase your take-home pay:

• Healthcare Flexible Spending Account• Limited Healthcare Flexible Spending Account• HealthFund Health Saving Account

You contribute on a pre-tax basis and then reimburse yourself on a tax-free basis for eligible expenses.

Please refer to page 3 of the Benefits Guide | Administration for information about coverage effective dates.

Important: If you are an HSA Option medical plan participant, your election is limited to one or both of the following:• HealthFund Health Savings Account; and/or• Limited Healthcare Flexible Spending Account for dental and vision expenses only.

The IRS will not allow the submission of the same eligible expenses to both a HealthFund HSA and a Healthcare FSA in the same plan year.

An FSA allows you to use pre-tax dollars for health care expenses not covered by your insurance. It reduces your taxable income, which saves you money. Eligible healthcare expenses can be reimbursed by submitting claims and supporting documentation to the claims administrator, ASIFlex. Some healthcare expenses can be paid at the point of service with an ASIFlex-issued debit card.

Contribution Limits• You may contribute up to $2,550 to pay uninsured, eligible healthcare expenses for both you and your tax-qualified

dependents each calendar year (January–December).• If you and your spouse both work and the plan is offered by both employers, you can each contribute $2,550.• If you contributed to another employer’s FSA during the calendar year and that employer is not part of the Arizona

University System (ABOR, ASU, NAU and UA), you can contribute up to $2,550 through ASU’s plan.

Use It or Lose It • Beginning with the 2016 plan year, participants will be allowed to carry over up to $500 in unused funds into the next

plan year (effective with the 2017 plan year). Otherwise, unused funds exceeding $500 do not roll over from calendar year to calendar year, so estimate your expenses carefully using ASIFlex’s tax savings calculator. Claims must be submitted by April 30 each year for expenses incurred in the previous calendar year (FSA Eligible Expenses).

Deadline to submit claims: By April 30, 2015, for 2014 claims; By April 30, 2016, for 2015 claims New enrollment is required each year during the annual Open Enrollment period for the next calendar plan year (January–December).

IMPORTANT: If you elect a Limited Healthcare Flexible Spending Account, reimbursement is restricted to dental and vision expenses.

Healthcare Flexible Spending Account (FSA) and Limited Healthcare Flexible Spending Account (FSA)

ASIFlex

ASIFlex Mobile App

FSA Store

FSA Frequently Asked Questions

FormsFSA Forms

ASIFlex Card Application

Useful linksPlan DocumentsFSA Plan Document 2nd Amendment 3rd Amendment 4th Amendment

FSA Participant Plan Info

Healthcare Accounts continued

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HealthFund Health Savings Account (HSA)

HSA 2016 IRS Maximum Contributions

University Mandatory Contributions

Employee Younger than 55 Voluntary Contribution

Employee Age 55 or Older Voluntary Contribution

(additional $1,000)

Single coverage: $3,350 $720 Up to $2,630 Up to $3,630

Other than single coverage: $6,750 $1,440 Up to $5,310 Up to $6,310

As an Aetna HSA Option medical plan participant, a HealthFund Health Savings Account (HSA) will be established in your name after you complete the customer identification process. (As required under Section 326 of the USA Patriot Act, Aetna is required to confirm some of your personal information to establish your account.)

HSA monies are used to pay uninsured healthcare expenses for you and your tax-qualified dependents using a debit card. There are some fees for using the savings account.

Annual contribution limits are established every year by the IRS based on the HSA medical option plan level of coverage. It is each participant’s responsibility to manage contributions in accordance with federal guidelines to ensure that contributions do not exceed the limits.

Eligible participants can enroll, increase, decrease or stop contributions to their health savings account at any time by submitting a completed HSA Payroll Deduction Authorization form (cfo.asu.edu/hr-forms#health) to HR Benefits secure fax 480-993-0007.

• Payroll-deducted contributions are withheld on a pre-tax basis and will be effective on the first day of the pay period following receipt of the completed form.

• The contribution remains in effect until a new authorization is received or until coverage in the Aetna HSA Option medical plan ends.

• The annual election amount is divided by the number of biweekly pay dates in the calendar year. If effective the first pay period that ends in January, the amount is divided by 26.

• For faculty paid over nine (9) months (academic year):• No contributions are made during the summer. Upon return to work in the fall, the annual election remaining

balance is divided by the number of pay dates remaining in the calendar year. Example: Annual election as of Jan. 1, 2016 is $2,000. $76.92 will be withheld during spring semester (10 pay dates Jan. 8, 2016 through May 13, 2016). Upon return to work, remaining balance of $1,230.80 is divided by 10 (pay dates Aug. 19, 2016 through Dec.23, 2016).

• The annual election amount remains in effect until a new HSA Payroll Deduction Authorization form is completed and submitted to HR Benefits.

HSA funds roll over from year-to-year. Once your funds reach $2,000, they can be invested with PayFlex similar to funds in an individual retirement account (IRA).

Please allow up to three (3) business days from our regular biweekly pay dates for HSA contributions to be posted to your PayFlex account.www.payflexdirect.com/EmployeeLogin.aspx

More InfoFrequently Asked Questions

Employee Wellness

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Employee Wellness ProgramThis program is dedicated to supporting faculty and staff in establishing and maintaining healthy lifestyles. The Employee Wellness Program coordinates services and programs on each campus accessible to all benefits-eligible faculty and staff.

The program incorporates various health screenings such as cholesterol, blood pressure, skin cancer, osteoporosis and more. Additional offerings include a variety of health education classes, flu shots and health-related articles and resources. All screenings and classes are free unless otherwise specified.

Well Devils NewsOur email newsletter contains wellness news and information about wellness classes on all Phoenix metro area campuses.

Learn Morecfo.asu.edu/hr-wellness

Annual Mayo Clinic Health AssessmentThe newest addition to Wellness is the Mayo Clinic Health Assessment, a professionally developed confidential questionnaire designed to help members (including spouses) become knowledgeable about their health.

The Health Assessment takes 15 minutes to complete and offers members an opportunity to improve their health through lifestyle changes. Upon completion of the Health Assessment, members may also be eligible for FREE one-on-one telephonic EmbodyHealth Coaching. Participants choose from five EmbodyHealth modules: Healthy Weight, Exercise, Stress, Tobacco Cessation and Nutrition.

Take the Health Assessment www.bewellstaywell.az.gov

Employee Assistance OfficeThis office is an on-campus employee Behavioral Health and Organizational Consultation service. Behavioral Health services are provided free of charge, regardless of whether the problem arises in one’s personal life or in the workplace. The staff of licensed professionals, representing several mental health fields including Psychology, Psychiatry and Social Work, will help to resolve a range of personal, work and family problems that affect your well-being. All benefits-eligible faculty and staff, their immediate families and committed partners can access this free service, which is available at the Downtown, Polytechnic, Tempe and West campuses.

Organization consultations and facilitations are provided at the request of department leadership. The EAO works

with the client organization to assess performance, development, training and personnel needs, and utilizes organizational behavior expertise to generate a comprehensive implementation plan.

AppointmentsAt the Downtown, Polytechnic, Tempe and West campuses 480-965-22718 a.m. – 5 p.m., Monday-Fridaycfo.asu.edu/hr-eao

Health Impact Program (HIP)Benefits-eligible State of Arizona employees, including university faculty and staff, can earn a monetary incentive by participating in the Health Impact Program (HIP), an incentive-based employee wellness program that begins again in January 2016. To successfully complete the program, employees must report their participation in a variety of preventive health activities, screenings and educational opportunities.

HIP encourages prevention as the first line of defense against chronic disease. It also helps individuals manage pre-existing conditions and enjoy greater total health and well-being.

Learn More: cfo.asu.edu/hr-HIP

Program Components To participate, employees must register on the Mayo Clinic Healthy Living online portal. This confidential, personalized system gives employees access to the Mayo Clinic Health Assessment health information and resources, and also is the tool for self-reporting all other HIP-approved activities.

Program participants must achieve 500 total points within the program period to be eligible for the cash incentive. Employees can engage in multiple activities in each of the determined categories (activities/exercise, preventive screenings and nutrition/other), but must select at least ONE activity in each category to be eligible for the incentive.