2018 Benefits Guide For New Employees
WHAT’S INSIDE
Benefit Coverage Overview..................................................3
Health Insurance .................................................................... 4
Dependent Coverage ........................................................... 5
Pharmacy Benefits ................................................................. 6
Dental Coverage ..................................................................... 7
Vision Coverage .................................................................... 7
Flexible Spending Accounts ............................................... 8
Other Benefits ....................................................................... 9
Retirement Plans .................................................................. 10
Making Your Elections .........................................................12
2018 Rates Summary ...........................................................13
Who to Contact ......................................................................14
Welcome New Employees!
We are pleased to have you join our Cardinal family at the University ofLouisville. We encourage you to thoroughly review our overview of benefitoptions listed in this guide. In addition to this overview, we would encourage youto review the Summary of Benefits forour health, dental and vision plans. TheseSummary of Benefits can be found on theUofL Benefits website at louisville.edu/hr/benefits.
Disclaimer:
This presentation and benefit communication highlights many of the University Of Louisville’s benefits. Every effort has been made to ensure the
accuracy of this information. However, the actual administration of the plans is governed by the plan documents and insurance agreements. In the event of a discrepancy between this communication and the plan documents and agreements, the plan documents and agreements take precedence.
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BENEFIT COVERAGE OVERVIEW: WHO, WHAT, WHEN AND HOW
Who is eligible for benefits?
Regular status employees (faculty and staff) with a full time equivalency (FTE) of 80% or greater.
Regular status part-time employees and temporary part-time lecturers with FTE 40% up to 79%.
Eligible dependents of employees that meet the above requirements for health, dental and vision. See health plans page for detailed dependent information.
What benefits are available?
The University of Louisville has a generous benefits package for faculty and staff that includes; health &pharmacy, dental, vision and life insurance. Also available are flexible spending accounts, short term and longterm disability coverage and 403(b) and 457(b) retirement savings plans.
When do my benefits begin?
Benefit coverage for employees that meet the eligibility requirements begin on the first date of employment orat the time of a qualifying event.
HOW DO I ENROLL? You have 30 days from your date of hire or your qualifying event to make your benefit elections. You will make your benefit elections online via the employee self-service portal, ULink. Typically within your first week, you will receive an email notification that you are set up to enroll. The email willprovide access directions. If you do not receive an email within two weeksof your start date, contact Benefits at (502) 852-6258. Remember you have 30 days from your start date to make your elections, not the date you receive the email.
ULink can be accessed from any computer with internet access. Computersare also available at the Human Resources office (1980 Arthur Street) if you need any additional assistance.
30 Days
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HEALTH INSURANCE There are four different health plans to choose from with Anthem Blue Cross Blue Shield. Each health planutilizes the Anthem Blue Access PPO Network.
Four Health Plan Options
EPO (Employer Provider Organization) PCA High with HealthEquity Account PPO (Preferred Provider Organization) PCA Low with Health Equity Account
Basic Comparison Overview
EPO
In-network level of coverage only
NO out-of-network level of coverage
NO annual deductible
Has required copayments andcoinsurance to meet
PPO
Both in-network and out-of-network coverage
Has required copayments andcoinsurance to meet
Encourages you to use networkproviders by charging lowerdeductibles, copayments andcoinsurance amounts
PCA High and Low
Both in-network and out-of-network coverage
University funded benefitallowance based on level coverageyou select
Separate “preloaded” HealthEquity(PCA) debit card usable first day ofeffective coverage
What is a PCA High or Low Plan and how does it work?
PCA High or Low Plan with a Health Equity Account generally have a higher deductible than PPO and EPOplans. However, with the HealthEquity Account, the university will contribute a set amount to your accountthat can be used towards your deductible. Any unused balances roll to the next year, up to three times the annual amount.
Deductibles
How much will the university contribute to the HealthEquity Account you can use toward your deductible?
PCA High PCA Low Per person $1,000 $2,000 Per family $3,000 $4,000
Employee $500 Employee + Spouse/QA $1,000
Employee + Child(ren) / Family $2,000
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What Happens After Deductible is Reached?
The plan generally pays 90% PCA High/ 80% PCA Low (for participating providers). You then pay the remaining balance (10% PCA High / 20% PCA Low).
PCA High Per person $4,000 Per family $9,000
PCA Low $5,000 $10,000
Maximum Out of Pocket for PCA High and Low Plans
Health Management Program Premium Incentive
Employees that are enrolled in the group health plan are eligible for a $40 monthly premium incentive byparticipating in Get Healthy Now, UofL’s health management program.
For enrollment information with Get Healthy Now and information about what participating entails and whatit can do for you, visit louisville.edu/gethealthynow or call 852-7755.
Dependent Coverage Dependents can be covered under the health, dental and vision plans as long as they meet the followingcriteria:
* Spouses or qualifying adults of covered UofL employees. Refer to the definition of a qualifying adult below for more detail.
* Child(ren) (natural children, step children,foster children, legally adopted children, andchildren placed for adoption) to the end of thecalendar year in which they turn 26 even if theyare married; not living with parents; attendingschool; not financially dependent on theirparents; or eligible to enroll in their employer’shealth plan.
Who can be a qualifying adult?
* Child(ren) of the employee or the employee’s spouse of any age when such children are incapable of self-support because of a total and permanent disability; and
* Child(ren) age 26 and under for whom the employee is required to provide health care coverage under a qualified medical childsupport order (QMCSO), regardless of wherethe child resides or if the child is dependentupon the employee for support.
To be considered a qualifying adult, the person must meet ALL of the following criteria. They must be:
; Over 18 years old
; the same or younger generation of theemployee (as used in KRS 391.010), if a bloodrelative (or relative by adoption or marriage)
; residing in the employee's household for atleast 12 months
; financially interdependent (i.e., have jointchecking account or joint mortgage) for atleast 12 months
; unmarried
; not eligible for Medicare
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PHARMACY BENEFITS All employees enrolled in a health plan are automatically enrolled inthe Express Scripts Pharmacy Benefit plan. For your convenience, yourAnthem BlueCross BlueShield ID card will be a combination ID card for health and Express Scripts prescription coverage. You can find the Express Scripts formulary (list of covered drugs and pricing online at louisville. edu/hr/benefits/pharmacy).
Benefit ID Card
When you enroll in ahealth plan you will
receive a combination Retail
(30 day supply)
Generic $8.00
Brand Formulary You pay 25% up to $60 max
Non-Formulary You pay 40% up to $100 max
$16.00
You pay 15% up to $120 max
You pay 35% up to $200 max
Anthem BlueCrossMail/Home Delivery(90 day supply for approx. 2 co-pays) BlueShield ID card for
health and Express Scriptspharmacy benefits foreach covered member. You must present your insurance ID card for
medical and pharmacybenefits.
KY Rx Coalition
The Know Your Rx Coalition can help you to control prescription costs, by offering free prescription counseling services for any University of Louisville health plan member. You can contact them M-F 8:00 a.m. to 6:00 p.m., at 855-218-KYRx or online at www.kyrx.org. You can contact the KY Rx Coalition about the following topics and more:
* To find lower cost alternatives * To help with mail order * To ask about side effects, drug interactions, and over the counter medications
2018 HEALTH PLAN RATES The following monthly rates1 are for full time active employees that are paid over 12 months. See pg 14 for all rates.
EPO PPO PCA High PCA Low
Employee Coverage 136.12 118.58 67.12 65.00
Employee + Spouse/QA 495.04 456.46 343.24 211.64
Employee + Children 268.21 236.63 144.01 65.00
Employee + Family 553.24 500.62 346.24 166.78
Two Employee Family 2 135.52 109.21 52.50 52.50
1 The health plan rates do not include the $40 per month premium incentive from participation in the health management program, Get Healthy Now. If you plan to participate in Get Healthy Now, deduct $40 from the monthly rate above to get your final cost.
2 Spouse/QA must be full-time employee and also have child(ren) covered in plan.
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DENTAL COVERAGE There are two options with MetLife for dental insurance, the basic plan and the enhanced plan. The enhanced plan offers a greater annual maximum benefit and adult orthodontia.
You may visit any dentist, however, out-of pocket expense is less with greater savings when utilizing an in-network provider. Remember, when visiting an out-of-network provider you will be responsible for charges above the in-network covered benefit allowance by the MetLife plan.
Find a Provider
To find a participating dentist, visit www.metlife.com/mybenefits and enter ‘University of Louisville’ or call 1-866-832-5756.
VISION COVERAGE The vision provider, Davis Vision, has a national network of credentialedpreferred providers. With Davis Vision, you have access to great in-network benefits at provider locations nationwide, including increasedallowance towards frames and contacts when selecting from the DavisVision collection, or using a VisionWorks store location.
Find a Provider
To find a network provider, visit davisvision.com and click “Find a Provider” to locate a provider near you, including Visionworks locations.
Dependent Coverage for Dental and Vision
Dependents can be covered on the dental and vision plans. The criteria is the same as for health insurance. Please refer to page 5 for full dependent coverage details.
2018 DENTAL AND VISION RATES The following monthly rates are for full & part time active employees that are paid over 12 months. See pg 14 for all rates.
DENTAL RATES BASIC ENHANCED
Employee Coverage 21.27 42.52 50.20 77.62
24.93 49.83 58.82 90.96
Employee + Spouse/QA Employee + Children Employee + Family
VISION RATES
3.70 6.71 7.11 10.21
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FLEXIBLE SPENDING ACCOUNTS (FSA) With a Flexible Spending Account (FSA), you can set aside pre-tax dollars to pay for eligible health and daycare expenses. You may enroll in one or both, but you need to be aware of the contribution limits. Any moneydeposited in your FSA and not used by the end of the university’s grace period (which extends to March 15 each year), will be forfeited. For more detailed information about FSAs, visit louisville.edu/hr/benefits/fsa.
HEALTH CARE FSA Annual contributions can be from $150 to $2,600 per calendar year.
* The total annual contribution is available from the account start date.
* Eligible expenses are any healthcare expense approved by the IRS for reimbursement through the plan.
* You will receive a FSA card to use at locations such as pharmacies, medical, dental and vision offices and hospitals. Expenses canalso be submitted for reimbursement to Discovery Benefits(www.discoverybenefits.com).
Eligible expenses
You can find a comprehensive list of eligible expenses on Discovery Benefits website at www.discoverybenefits.com/employees/eligible-expenses.
DEPENDENT CARE FSA Annual employee contributions can be from $150 up to $5,000 per household per calendar year.
* Dependent Care can be used on your natural, adopted and foster children who have not reached theirthirteenth birthday and family members who cannot care for themselves. All dependents must live withyou for more than half the year and be claimed on your federal tax return.
* Participants receive reimbursements up to the total amount contributed through each payroll deduction.
* Reimbursements are received by faxing, emailing or mailing claim forms to Discovery Benefits (www.discoverybenefits.com).
Keep your Receipts! You must submit substantiation for expenses when requested by Discovery Benefits. The expenses must have been made from your account(s) between now and March 15th of the following year for reimbursement.
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OTHER BENEFITS Life insurance, AD&D, Long & Short Term Disability & More
LIFE INSURANCE The university provides life insurance at twice your base annual salary adjusted to the nearest $1000 (maximumof $200,000). There is no cost to eligible employees, but you need to complete the MetLife enrollment/beneficiary form.
ACCIDENTAL DEATH & DISMEMBERMENT The university provides Accidental Death and Dismemberment (AD&D) insurance equal to the amount of lifeinsurance. There is no cost to eligible employees.
ADDITIONAL TERM LIFE INSURANCE Additional term life insurance is available as a supplement to your basic life insurance coverage provided byUofL. If you purchase additional coverage for yourself, you also can purchase it for your spouse or child(ren).Rates are listed on the enrollment form, provided to you at New Employee Orientation.
* Employees may purchase additional term life coverage of up to $300,000. Maximum coverage for spousesis $25,000.
* This is a one time guaranteed issue offer. During future annual open enrollments you may bump upone level of coverage if you have already elected additional term life, without a statement of health.Otherwise, any initial enrollment (other than at your time of hire) or any increase above one level ofcoverage would require approval by MetLife through a statement of health.
LONG TERM DISABILITY Long term disability is a benefit provided at no cost to you. If you become totally disabled while insured andremain so for six months, the university's LTD plan will pay the greater of 60% of your monthly base salary or 60% of your monthly average earnings from the past two years up to a monthly max benefit amount of $5,000.Note: LTD benefit begins when your university retirement contributions begin.
OPTIONAL SHORT TERM DISABILITY An Income Protector Plan is available as an option to university employees. This supplements lost wagesdue to a covered off-the-job injury or sickness. You can enroll or drop coverage at anytime. You do not need a qualifying event. For more details, call Humana’s enrollment center at 800-463-7420 or email [email protected].
US LEGAL SERVICES Pre-paid legal services are available through US Legal at a monthly rate of $18.75. For more detail on what is covered and how it works, visit louisville.edu/hr/benefits/additional/pre-paid-legal.
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RETIREMENT SAVINGS 403(b) PLAN The university offers a 403(b) retirement plan to all regular status (80% or greater full time
equivalency) faculty and staff. After one year of eligible service, you are eligible to receive the 7.5% university contribution and 2.5% match. You can participate with your own contributions at any time.
HOW THE UNIVERSITY CONTRIBUTION WORKS After one year of eligible service, the university will contribute 7.5% of your base salary to your retirementwith no contribution needed from you. In addition, if you contribute 2.5%, the university will match the 2.5% for a total of 10% salary contribution to your retirement savings.
How to Enroll in the University Contribution
After one year of eligible service at the university, you will be automatically enrolled into the 7.5% contribution.You will receive a notification letter from the university with additional instructions on how to access the account and set up the 2.5% match, if desired.
GET STARTED INVESTING NOW You have the option of participating by investing your own money before completing one year of service. The Employee Supplemental option is agreat opportunity to start saving.
How to Enroll
To get started investing your own money at your time of hire, notify our Retirement Administrators at (502) 852-3555 or by email at [email protected], to set up an account on the Netbenefits website for you.
Once the account has been established, notification will be sent to yourUofL email address. The email will contain a set of instructions to guideyou through the process of completing the enrollment online.
The Netbenefits website is the master administrator for the Universityof Louisville Retirement Plans. Employees will enter all contribution elections and investment changes on this website.
PROVIDERS You can invest your savings and the university’s contributions with one or both investment providers.
Fidelity: 1-800-343-0860 | www.fidelity.com/atwork or www.netbenefits.com.
TIAA: 1-800-842-2252 | www.tiaa.org
Schedule a One-on-one Retirement Investment
Consultation
Retirement investment representatives from Fidelity
and TIAA are available on both the University
of Louisville Belknap orHealth Sciences Campuses
throughout each month.
To schedule;
Fidelity: Call 1-800-642-7131 or go online to www.
fidelity.com/atwork/reservations.
TIAA: Call 1-800-732-8353 or go online at tiaa.org/
schedulenow.
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403(b) RETIREMENT PLAN (CONTINUED)
Three Year Cliff Vesting Schedule
The University of Louisville has a three year cliff vesting schedule for the 403(b) plan. Employer contributionsand earnings will be fully 100% Vested upon completion of three years of continuous service.
* Employees who return to the University after a break in service, will be subject to the same Vesting requirements as for new hires, regardless of the duration of the separation. Credit will be given for prioryears of service.
* Employees who voluntarily resign or are dismissed from the University prior to completing three years ofservice will forfeit all University contributions and earnings.
WAIVING THE 12-MONTH WAITING PERIOD If you worked at another college or university, a non-profit research organization, or a Kentucky state governmental agency (with no break in service between jobs) prior to joining the university, you may be able towaive the waiting period for the retirement plan. Break in service means that you were not employed betweenthe time you left your former employer and before joining the University of Louisville. You may also waive the 12-month wait if you have been rehired at U of L and previously participated in the retirement plan.
When coming from another institution:
On your previous employer’s letterhead, signed by your department head or human resources director, pleaseprovide the following information to our Retirement Administrators. (852-3555 or [email protected]).
Name Date of termination SSN (last 4 digits) Job title Date of hire FTE (your full time equivalency)
457(b) DEFERRED COMPENSATION PLANS Another place to invest pre tax dollars for retirement, in addition to the UofL 403(b) Plan. IRS contribution limits are the same as 403(b). Employees can participate in both the 403(b) and the 457(b) at the same time. Two Plans are offered:
* UofL 457(b) Plan: You may participate with either Fidelity Investments or TIAA-CREF or both. Enrollment applications and salary deferral forms are available online at louisville.edu/hr/forms.
* KY Deferred Compensation: Contact Customer Service Center (Frankfort, KY): 1-800-542-2667; or www.kentuckydcp.com.
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MAKING YOUR ELECTIONS You must make your selections within 30 days of your start date.
MAKING YOUR ELECTIONS Remember, you have 30 days from your start date to make your selections.
* Benefits are effective on your date of hire. Any missed premiums will bededucted on your next paycheck.
* You may only make your selection once during those 30 days.
* Allow three weeks to receive your ID cards from the day you make yourelections online.
What if I don’t make an election in my first 30 days?
If you do not make an election in your first 30 days, you will not have any health, dental or vision insurance. You will be able to add insurance during the annual open enrollment period, or if you have a qualifying event.
ADDING YOUR BENEFICIARIES Once you have received your email to enroll in your benefits via ULink, you can also update your beneficiariesfor your basic and/or additional term life insurance.
To select or update basic life beneficiaries: Login to ULink > click on the Faculty & Staff tab > click on Benefits Summary > click on Basic Life. Then select edit to add a beneficiary and choose the allocation percent.Select the beneficiary’s name to edit the individual’s personal information (i.e. if you need to add a socialsecurity number). You can update your beneficiaries at any time.
If you elect additional term life insurance and wish to have a different beneficiary than your basic life, youjust need to click on the Addl Term Life – Employee link in ULink, and edit to add a beneficiary. Please note that you must wait one business day after you enroll to return to ULink and update your additional term lifebeneficiaries.
Annual QUALIFYING EVENT Open
Enrollment You may only make changes to your health, dental, vision and flexible spending coverage during our annual open enrollment period or within 30 days of a Benefits qualifying event. Examples of a qualifying event are: coverage at the university
* Birth or adoption of a child * Change in your employment is by calendar year. Everystatus (ex: full time to part time) fall, there is an annual open
* Marriage, divorce or legal enrollment to make yourseparation * Dependent loses or gainsinsurance eligibility benefit elections for the
* Spouse’s change in insurance upcoming calendar year,eligibility due to loss or gain of * Death beginning January 1.employment.
30 Days
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2018 RATES SUMMARY The health plan rates listed below do not include the $40 per month premium incentive from participation in the health management program, Get Healthy Now. If you plan to participate in Get Healthy Now, deduct $40from the monthly rate above to get your final cost.
HEALTH PLAN RATES FOR FULL TIME ACTIVE EMPLOYEES
12 Month Employee Monthly Rate 10 Month Employee Monthly Rate
EPO PPO PCA High PCA Low EPO PPO PCA High PCA Low
Employee Coverage $136.12 $118.58 $67.12 $65.00 $163.34 $142.30 $80.54 $78.00
Employee + Spouse/QA $495.04 $456.46 $343.24 $211.64 $594.05 $547.75 $411.89 $253.97
Employee + Children $268.21 $236.63 $144.01 $65.00 $321.85 $283.96 $172.81 $78.00
Employee + Family $553.24 $500.62 $346.24 $166.78 $663.89 $600.74 $415.49 $200.14
Two Employee Family 1 $135.52 $109.21 $52.50 $52.50 $162.62 $131.05 $63.00 $63.00 1 Spouse/QA must be a full-time employee and also have child(ren) covered in the plan.
HEALTH PLAN RATES FOR PART-TIME ACTIVE EMPLOYEES
12 Month Employee Monthly Rate 10 Month Employee Monthly Rate
EPO PPO PCA High PCA Low EPO PPO PCA High PCA Low
Employee Coverage $353.24 $334.96 $281.18 $247.74 $423.89 $401.95 $337.42 $297.29
Employee + Spouse/QA $850.91 $810.70 $692.39 $555.33 $1,021.09 $972.84 $830.87 $666.40
Employee + Children $631.43 $598.52 $501.73 $403.93 $757.72 $718.22 $602.08 $484.72
Employee + Family $1,092.16 $1,037.32 $876.00 $689.10 $1,310.59 $1,244.78 $1,051.12 $826.92
DENTAL RATES VISION RATES
12 Month Employee 10 Mo Employee
Basic Enhanced Basic Enhanced
Employee Coverage $21.27
$42.52
$50.20
$77.62
$24.93
$49.83
$58.82
$90.96
$25.52 $29.92
$51.02 $59.80
$60.24 $70.58
$93.14 $109.15
Employee + Spouse/QA
Employee + Children
Employee + Family
12 Month Employee 12 Mo 10 Mo
Employee Coverage $3.70
$6.71
$7.11
$10.21
$4.44
$8.05
$8.53
$12.25
Employee + Spouse/QA
Employee + Children
Employee + Family
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WHO DO I CONTACT? For anything not listed below, or for general questions, please do not hesitate to contact the University of Louisville Human Resources Benefits Department at (502) 852-6258.
IMPORTANT INFORMATION FOR FUTURE REFERENCE (FILL IN THE BLANK)
Your Employee ID# Your UofL User Name:
Who Phone Email/Website What to Contact About UNIVERSITY OF LOUISVILLE CONTACT INFORMATION
University of LouisvilleBenefits Department
University of LouisvillePayroll Department
University of LouisvilleIT Help Desk
University of LouisvilleGet Healthy Now
(502) 852-6258 www.louisville.edu/hr or [email protected]
louisville.edu/it/departments/consulting/helpdesk
louisville.edu/gethealthynow
General questions
(502) 852-2978 Paychecks, deductions, W-4 tax form updates
(502) 852-7997 Questions about email accounts and other IT related topics
(502) 852-7755 Premium incentive for health planparticipants and general wellness
center questions
INSURANCE CONTACT INFORMATION
Anthem Blue Cross Blue Shield (Medical)
MetLife (Dental)
Davis Vision (Vision)
Discovery Benefits
Express Scripts
KY Rx Coalition
1-855-747-1137 www.anthem.com
metlife.com/mybenefits
www.davisvision.com
www.discoverybenefits.com
www.express-scripts.com
www.kyrx.org
Questions for health planparticipants about coverage
1-866-832-5756 Questions about dental coverage
1-877-923-2847 (client code 7631) Questions about vision coverage
1-866-451-3399 Questions about your flexiblespending accounts
1-800-298-6890 Any pharmacy issues
1-855-218-KYRx Help find lower cost prescriptions, etc. RETIREMENT ACCOUNT CONTACT INFORMATION
Fidelity
TIAA
Fidelity Individual Consultations
TIAA Individual Consultations
Kentucky Deferred Compensation
1-800-343-0860 www.fidelity.com/atwork
www.tiaa.org
www.fidelity.com/atwork/reservations
www.tiaa.org/schedulenow
www.kentuckydcp.com
Retirement account information
1-800-842-2252 Retirement account information
1-800-642-7131 To schedule a one-on-one consultation
1-800-732-8353 To schedule a one-on-one consultation
1-800-542-2667 Retirement account information for 457(b) KY deferred comp plan OTHER CONTACT INFORMATION
Human Development Company(EAP)
1-800-877-8332 or (502) 589-HELP www.humandev.com
Any personal needs (counseling,etc)
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ADDITIONAL BENEFITS
INFORMATION & SUMMARY OF
BENEFITS DOCUMENTS
Includes: 2018 Plan Comparison Chart
Summary of Benefits EPO PPO
PCA High PCA Low Dental Vision
Short Term Disability
Notice of Privacy Practices
For more detailed summary of benefits (SBC) forms,
visit louisville.edu/hr/benefits.
http://louisville.edu/hr/benefits
University of Louisville 2018 Health Plan Comparison
EPO PPO PCA HIGH PCA LOW
TYPE OF SERVICE Network (Anthem Blue Access PPO
Network) Out-of-network
Network (Anthem Blue Access PPO
Network) Out-of-network
Network (Anthem Blue Access PPO
Network) Out-of-network
Network (Anthem Blue Access PPO Network)
Out-of-network
Annual Allowance Does not apply Does not apply Does not apply Does not apply
$500 Individual
Does not apply
$500 Individual
Does not apply
$1,000 Employee+ Spouse
$1,000 Employee+ Spouse
$2,000 Employee+ Child(ren)
$2,000 Employee+ Child(ren)
$2,000 Family $2,000 Family
Annual Deductible None
None $250 per person $500 per person $1,000 per person $2,000 per person $2,000 per person $4,000 per person
None $750 per family $1,500 per family $3,000 per family $6,000 per family $4,000 per family $8,000 per family Annual Medical Out-of-pocket Maximum (Copays and deductibles accumulate toward the out-of-pocket maximum)
$2,000 per person
N / A
$2,250 per person $4,500 per person $4,000 per person $8,000 per person $5,000 per person $10,000 per person
$4,000 per family $4,750 per family $13,500 per family $9,000 per family $18,000 per family $10,000 per family $20,000 per family
Physician office ( OBGYN visits covered as Primary Care ) PCP= Primary Care Physician
$20 PCP; $0 PCP UofL Physicians
Not Covered $15 PCP;
$0 PCP UofL Physicians 60% after deductible
90% after deductible; UofL PCP will apply a
$20 discount off the normal network
discount
60% after deductible
80% after deductible; UofL PCP will apply a
$20 discount off the normal network
discount
50% after deductible
$35 Specialist Not Covered $30 Specialist
Preventive Care Routine physicals, Well-child check-ups and routine immunizations
100% Not Covered 100% 60% after deductible 100% 60% after deductible 100% 50% after deductible
Mammography screenings Routine GYN exams 100% Not Covered 100% 60% after deductible 100%
60% after deductible 100%
50% after deductible
Lab, X-ray or other preventive tests 100% Not Covered 100% 60% after deductible 100%
60% after deductible 100%
50% after deductible
Inpatient Hospital
Inpatient care Plan pays 90% Not Covered 90% after deductible 60% after deductible 90% after deductible 60% after deductible
80% after deductible
50% after deductible
Physician Inpatient care Plan pays 90% Not Covered 90% after deductible 60% after deductible 90% after deductible 60% after deductible
80% after deductible
50% after deductible
TYPE OF SERVICE EPO PPO PCA High PCA Low
Outpatient Network Out-of-network Network Out-of-network Network Out-of-network Network Out-of-network
Outpatient surgery - facility 100% after $100 copay Not Covered 90% after deductible 60% after deductible 90% after deductible
60% after deductible
80% after deductible
50% after deductible
Physician Outpatient services (other than office visit)
90% Not Covered
100% after copays ULP $0 copay
Anthem Network $15 copay $30 Specialist
60% after deductible 90% after deductible 60% after deductible
80% after deductible
50% after deductible
Lab Services 100% Not Covered 100% 60% after deductible 100% 60% after deductible 100% 50% after deductible
X-Ray and Major Diagnostics Plan pays 90% Not Covered 90% after deductible 60% after deductible
90% after deductible
60% after deductible
80% after deductible
50% after deductible
Emergency Room 100% after $100
copay 100% after $100
copay 100% after $100
copay 60% after deductible 90% after deductible
90% after deductible. 60% non-emergency
80% after deductible
80% after deductible. 60% non-emergency
Mental Health & Substance Abuse
Inpatient care Plan pays 90% Not Covered 90% after deductible 60% after deductible 90% after deductible 60% after deductible
80% after deductible
50% after deductible
Outpatient care - per visit $20 copay or $0 copay if UofL Physician
Not Covered $15 copay or $0 copay if UofL Physician
60% after deductible 90% after deductible 60% after deductible
80% after deductible
50% after deductible
Vision
Vision Exam (one routine exam per year)
100% after $20 copay Not Covered
100% after copays ULP $0 copay Anthem
Network $15 copay $30 Specialist
60% 90% after deductible 60% after deductible
80% after deductible
50% after deductible
Prescription Drugs EPO PPO PCA HIGH PCA LOW Retail Prescription Drug Generic Retail
Generic Retail - $8.00 Generic Retail - $8.00 Generic Retail - $8.00 Generic Retail - $8.00
Prescription Drug Brand Formulary Retail
Brand Formulary Retail - You Pay 25%, up to $60 maximum
Brand Formulary Retail - You Pay 25%, up to $60 maximum
Brand Formulary Retail - You Pay 25%, up to $60 maximum
Brand Formulary Retail - You Pay 25%, up to $60 maximum
Prescription Drug Non Formulary Retail
Non- Formulary Retail - You Pay 40%, up to $100 maximum
Non- Formulary Retail - You Pay 40%, up to $100 maximum
Non- Formulary Retail - You Pay 40%, up to $100 maximum
Non- Formulary Retail - You Pay 40%, up to $100 maximum
Mail Order (90 day supply) Prescription Drug Generic Mail Order
Generic Mail Order - $16.00 Generic Mail Order - $16.00 Generic Mail Order - $16.00 Generic Mail Order - $16.00
Prescription Drug Brand Formulary Mail Order
Brand Formulary Mail Order - You Pay 15%, up to $120 maximum
Brand Formulary Mail Order - You Pay 15%, up to $120 maximum
Brand Formulary Mail Order - You Pay 15%, up to $120 maximum
Brand Formulary Mail Order - You Pay 15%, up to $120 maximum
Prescription Drug Non-Formulary Mail Order
Non-Formulary Mail Order - You Pay 35%, up to $200 maximum
Non-Formulary Mail Order - You Pay 35%, up to $200 maximum
Non-Formulary Mail Order - You Pay 35%, up to $200 maximum
Non-Formulary Mail Order - You Pay 35%, up to $200 maximum
Brand with Generic Available Prescription Drug Brand for which a Generic equivalent is available - retail or mail order
Plan Pays Cost of Generic Drug- You Pay remainder, no maximum
Plan Pays Cost of Generic Drug- You Pay remainder, no maximum
Plan Pays Cost of Generic Drug- You Pay remainder, no maximum
Plan Pays Cost of Generic Drug- You Pay remainder, no maximum
Annual Prescription Out-of-pocket Maximum
$4,600 per person N / A
$4,600 per person N / A
$2,600 per person N / A
$1,600 per person N / A
$9,200 per family $9,200 per family $4,200 per family $3,200 per family
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Your Summary of Benefits EPO
Anthem Blue Cross and Blue Shield and University of Louisville want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:
• Anthem.com – Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor, hospital and much more.
• 24/7 NurseLine – Always there for you. A nurse is a phone call away as well as other health resources, all available 24-hours a day, 7-days a week to provide you with information that can help you make informed decisions. Call toll free at 888.279.5378.
• Customer Care telephone support – Need more help? Contact your designated member services team at 855.747.1137. Get answers to your benefit questions or receive guidance when looking for a doctor or hospital.
The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Plan Highlights
Types of Coverage Network Benefits
Annual Deductible
Individual Deductible No deductible Family Deductible No deductible
Out of Pocket Maximum (Member copayments (excluding Pharmacy) accumulate toward the OOP maximum)
Individual Out-of-Pocket Maximum $2,000 per year Family Out-of-Pocket Maximum $4,000 per year
Benefit Plan Coinsurance (The amount the Plan pays)
90% coverage
Lifetime Maximum
There is no dollar limit to the amount the Plan will pay for essential No lifetime maximum benefit benefits during the entire period you are enrolled in this Plan.
Prescription Drug Benefits
Prescription drug benefits are shown under separate cover.
Information of Precertification
Precertification is required for certain services. Please refer to your Benefit Plan Document.
Information on Benefit Limits
Out-of-pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. When benefit limits apply, the limit refers to any combination of network and non-
network benefits unless specifically stated in the benefit category.
http:Anthem.com
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Benefits
Types of Coverage Network Benefits
Ambulance Services (Emergency and non emergency)
100% after you pay a $100 copayment per trip
Dental Services (Accident only)
90% coverage
Durable Medical Equipment (DME)
100% coverage
Emergency Health Services Outpatient
100% after you pay a $100 copayment per visit. If you are admitted as an inpatient to a network hospital directly from the emergency
room, you will not have to pay this copayment. The benefits for an inpatient stay in a network hospital will apply instead.
Hearing Aids
One per year every 36 months 100% coverage
Home Health Care
Benefits are limited to 100 visits per year 100% coverage
Hospice Care
100% coverage
Hospital Inpatient Stay
90% coverage
Lab, X Ray and Major Diagnostics Outpatient
Lab 100% coverage X-Ray and Diagnostics 90% coverage
Lab, X Ray and Major Diagnostics (CT, PET, MRI and Nuclear Medicine)
Lab 100% coverage X-Ray and Diagnostics 90% coverage
Mental Health Services
Inpatient - 90% coverage Outpatient - 100% after you pay a $20 copayment per visit
ULP Providers – covered in full
Neurobiological Disorders Mental Health Services for Autism Spectrum Disorders
Inpatient - 90% coverage Outpatient - 100% after you pay a $20 copayment per visit
ULP Providers – covered in full
Pharmaceutical Products Outpatient
This includes medications administered in an outpatient setting, Physician’s office – 100% coverage in the physician’s office and by a home health agency. All other place of service – 100% after you pay a $35 copay
Physician Fees for Surgical and Medical Services
90% coverage
Physician s Office Services Sickness and Injury
100% - copay waived if ULP Provider Primary Physician $20 Copayment per visit for Anthem PCP
Specialist Physician 100% after you pay a $35 Copayment per visit for Anthem PCP
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Types of Coverage
Pregnancy Maternity Services
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each covered Health Service
category in this Benefit Summary.
For services provided in the physician’s office, a copayment will only apply to the initial office visit
Infertility treatment (Limited to $5,000 per lifetime)
Preventive Care Services (Covered health services include but not limited to:)
Primary Physician Office Visit 100% coverage
100% coverage Specialist Physician Office Visit
100% coverage Lab, X-Ray or other preventive tests
Prosthetic Devices
100% coverage
Reconstructive Procedures
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary.
Rehabilitation Services Outpatient Therapy and Manipulative Treatment
Benefits are limited as follows: PT/OT 100% copay waived for ULP Providers
50 visits combined of physical and occupational therapy $20 Copayment per visit for Anthem PCP 25 visits combined of speech and cognitive therapy Manipulative and all other therapies - 100% after you pay a $35
30 visits of manipulative treatment copayment per visit 25 visits combined of respiratory and pulmonary therapy
Scopic Procedures Outpatient Diagnostic and Therapeutic
Diagnostic scopic procedures include, but are not limited to: Colonoscopy; Sigmoidoscopy; Endoscopy.
90% coverage For Preventive Scopic Procedures, refer to the
Preventive Care Services category.
Skilled Nursing Facility / Inpatient Rehabilitation Facility Services
Benefits are limited as follows: 120 days per year 100% coverage
Substance Use Disorder Services
Inpatient - 90% coverage Outpatient - 100% after you pay a $20 copayment per visit
ULP Providers – covered in full
Surgery Outpatient
$100 coverage after you pay $100 copayment
Transplantation Services
90% coverage
For network benefits, services must be received at a Blue Distinction Center for Transplant.
Urgent Care Center Services
100% coverage after you pay a $35 copayment per visit
Vision Examinations
Benefits are limited as follows: 1 routine exam every year 100% coverage after you pay a $20 copayment per visit
Medical Notes
It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
In network deductibles and out of pocket amounts apply to the out of network accumulations. However, out of network deductible and out of pocket amounts are not included in the in network accumulations.
Dependent Age: to the end of the calendar year the child attains age 26. When choosing a non-network provider, the member is responsible for any balance due after the plan
payment.
Benefit Period: Equals calendar year Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with
the Federal Mental Health Parity.
Precertification: Members are encouraged to always obtain prior approval when using non network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services.
Primary Care Physician: Network Provider who is a practitioner that specializes in family and general practice,
internal medicine and pediatrics.
Specialist Physician: Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association.
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and
Blue Shield Association.
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Your Summary of Benefits PPO
Anthem Blue Cross and Blue Shield and University of Louisville want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:
• Anthem.com – Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor, hospital and much more.
• 24/7 NurseLine – Always there for you. A nurse is a phone call away as well as other health resources, all available 24-hours a day, 7-days a week to provide you with information that can help you make informed decisions. Call toll free at 888.279.5378.
• Customer Care telephone support – Need more help? Contact your designated member services team at 855.747.1137. Get answers to your benefit questions or receive guidance when looking for a doctor or hospital.
The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Plan Highlights
Types of Coverage Network Benefits Non Network Benefits
Annual Deductible (Member copayments do not accumulate towards the deductible)
Individual Deductible $250 per year $500 per year Family Deductible $750 per year $1,500 per year
Out of Pocket Maximum (Both deductibles and member copayments (excluding Pharmacy) accumulate towards the OOP maximum)
Individual Out-of-Pocket Maximum $2,250 per year $4,500 per year Family Out-of-Pocket Maximum $4,750 per year $13,500 per year
Benefit Plan Coinsurance (The amount the Plan pays)
90% after deductible has been met 60% after deductible has been met
Lifetime Maximum Benefit
There is no dollar limit to the amount the Plan will pay for essential benefits during the entire No lifetime maximum benefit No lifetime maximum benefit
period you are enrolled in this Plan.
Prescription Drug Benefits
Prescription drug benefits are shown under separate cover.
Information of Precertification
Precertification is required for certain services. Please refer to your Benefit Plan Document.
Information on Benefit Limits
The annual deductible, out-of-pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. When benefit limits apply, the limit refers to any
combination of network and non-network benefits unless specifically stated in the benefit category.
http:Anthem.com
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Benefits
Types of Coverage Network Benefits Non Network Benefits
Ambulance Services (Emergency and non emergency)
100% after you pay a $100 copayment per trip
100% after you pay a $100 copayment per trip
Notification required for non-emergency ambulance services
Dental Services (Accident only)
90% after deductible has been met 90% after network deductible
has been met
Durable Medical Equipment (DME)
90% after deductible has been met 60% after deductible has been met
Emergency Health Services Outpatient
100% after you pay a $100 copayment per visit. If you are admitted as an inpatient to a
network hospital directly from the emergency room, you will not have to pay this
copayment. The benefits for an inpatient stay in a network hospital will apply instead.
100% after you pay a $100 copayment per visit
Hearing Aids
One per ear every 36 months 90% after deductible has been met 60% after deductible has been met
Home Health Care
Benefits are limited to 100 visits per year 90% after deductible has been met 60% after deductible has been met
Hospice Care
100% 60% after deductible has been met
Hospital Inpatient Stay
90% after deductible has been met 60% after deductible has been met
Lab, X Ray and Major Diagnostics Outpatient
Lab 100% X-ray and Diagnostic services 90% after deductible has been met
60% after deductible has been met
Lab, X Ray and Major Diagnostics (CT, PET, MRI and Nuclear Medicine)
90% after deductible has been met 60% after deductible has been met
Mental Health Services
Inpatient - 90% after deductible has been met Outpatient- 100% after you pay a
$15 copayment per visit ULP Providers – covered in full
60% after deductible has been met
Neurobiological Disorders Mental Health Services for Autism Spectrum Disorders
Inpatient - 90% after deductible has been met Outpatient - 100% after you pay a
$15 copayment per visit ULP Providers – covered in full
60% after deductible has been met
Pharmaceutical Products Outpatient
This includes medications administered in an outpatient setting, in the physician’s office and 90% after deductible has been met
by a home health agency. 60% after deductible has been met
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Types of Coverage Network Benefits Non Network Benefits
Physician Fees for Surgical and Medical Services
90% after deductible has been met 60% after deductible has been met
Physician s Office Services Sickness and Injury
University of Louisville Primary Care 100% - copay waived
Primary Physician 100% after you pay a $15 copayment per visit 60% after deductible has been met
Specialist Physician 100% after you pay a $30 Copayment per visit 60% after deductible has been met
Pregnancy Maternity Services
For services provided in the physician’s office, Depending upon where the Covered Health a copayment will only apply to the initial
Service is provided, Benefits will be the same as office visit. those stated under each covered Health Service Infertility treatment (Limited to $5,000 per
category in this Benefit Summary. lifetime)
Precertification is required if inpatient stay exceeds 48 hours following a normal
vaginal delivery or 96 hours following a cesarean section delivery.
Preventive Care Services (Covered health services include but are not limited to:)
Primary Physician Office Visit 100% - deductible does not apply 60% after deductible has been met
Specialist Physician Office Visit 100% - deductible does not apply 60% after deductible has been met
Lab, X-Ray or other preventive tests 100% - deductible does not apply 60% after deductible has been met
Prosthetic Devices
90% after deductible has been met 60% after deductible has been met
Reconstructive Procedures
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service
category in this Benefit Summary.
Precertification is required for certain services
Rehabilitation Services Outpatient Therapy and Manipulative Treatment
Benefits are limited as follows:
50 visits combined of physical and occupational 90% after deductible has been met therapy
25 visits combined of speech and cognitive Chiropractic Treatment - 100% after you pay a therapy
$30 copayment per visit 30 visits of manipulative treatment 25 visits combined of respiratory and pulmonary
therapy
60% after deductible has been met
Scopic Procedures Outpatient Diagnostic and Therapeutic
Diagnostic scopic procedures include, but are not limited to:
Colonoscopy; Sigmoidoscopy; Endoscopy. 90% after deductible has been met
For Preventive Scopic Procedures, refer to the Preventive Care Services category.
60% after deductible has been met
Skilled Nursing Facility / Inpatient Rehabilitation Facility Services
Benefits are limited as follows: 90% after deductible has been met 120 days per year 60% after deductible has been met
Substance Use Disorder Services
Inpatient - 90% after deductible has been met Outpatient - 100% after you pay a
$30 copayment per visit ULP Providers – covered in full
60% after deductible has been met
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Types of Coverage Network Benefits Non Network Benefits
Surgery Outpatient
90% after deductible has been met 60% after deductible has been met
Transplantation Services
For network benefits, services must be received at a Blue Distinction Center for Transplant.
90% after deductible has been met 60% after deductible has been met
Benefits are limited to $35,000 per covered transplant
Urgent Care Center Services
100% after you pay a $30 copayment per visit
60% after deductible has been met
Vision Examinations
Benefits are limited as follows: 1 routine exam every year
100% after you pay a $15 copayment per visit 60% after deductible has been met
Medical Notes
It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
In network deductibles and out of pocket amounts apply to the out of network accumulations. However, out of network deductible and out of pocket amounts are not included in the in network accumulations.
Dependent Age: to the end of the calendar year the child attains age 26. When choosing a non-network provider, the member is responsible for any balance due after the plan
payment.
Benefit Period: Equals calendar year Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with
the Federal Mental Health Parity.
Precertification: Members are encouraged to always obtain prior approval when using non network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services.
Primary Care Physician: Network Provider who is a practitioner that specializes in family and general practice, internal medicine and pediatrics.
Specialist Physician: Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
Preventive Care Services that meet the requirements of federal and state law, including certain screenings,
immunizations and physician visits are covered.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association.
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and
Blue Shield Association.
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Your Summary of Benefits PCA High PPO
(HRA High Medical Plan with HealthEquity) Network includes University of Louisville and Blue Cross Blue Shield PPO Providers
Anthem Blue Cross and Blue Shield and University of Louisville want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:
• Anthem.com – Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor, hospital and much more.
• 24/7 NurseLine – Always there for you. A nurse is a phone call away as well as other health resources, all available 24-hours a day, 7-days a week to provide you with information that can help you make informed decisions. Call toll free at 888.279.5378.
• Customer Care telephone support – Need more help? Contact your designated member services team at 855.747.1137. Get answers to your benefit questions or receive guidance when looking for a doctor or hospital.
The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Plan Highlights
Types of Coverage Network Benefits Non Network Benefits
Annual Deductible (Member copayments do not accumulate towards the deductible)
Individual Deductible $1,000 per year $2,000 per year Family Deductible $3,000 per year $6,000 per year
Out of Pocket Maximum (Member copayments for Pharmacy does not accumulate towards the Out of Pocket Maximum)
Individual Out-of-Pocket Maximum $4,000 per year $8,000 per year Family Out-of-Pocket Maximum $9,000 per year $18,000 per year
Personal Care Account
Annual Allowances that can be applied per year toward the member’s portion of covered medical costs, such as plan deductibles or coinsurance: $500 – Employee $2,000 – Employee + Child(ren) $1,000 – Employee + Spouse $2,000 – Employee + Family
Benefit Plan Coinsurance (The amount the Plan pays)
90% after Deductible has been met 60% after Deductible has been met
Lifetime Maximum Benefit
There is no dollar limit to the amount the Plan will pay for essential benefits during the entire No lifetime maximum benefit No lifetime maximum benefit
period you are enrolled in this Plan.
Prescription Drug Benefits
Prescription drug benefits are shown under separate cover.
Information of Precertification
Precertification is required for certain services. Please refer to Benefit Plan Document.
Information on Benefit Limits
The annual deductible, out-of-pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. In network deductible and out of pocket amounts apply to
the out of network accumulations. However, out of network deductible and out of pocket do not apply to in network.
http:Anthem.com
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Benefits
Types of Coverage Network Benefits Non Network Benefits
Ambulance Services (Emergency and non emergency)
90% after deductible has been met
90% after network deductible has been met
Notification required for non-emergency ambulance services
Dental Services (Accident only)
90% after deductible has been met 90% after network deductible
has been met
Durable Medical Equipment (DME)
90% after deductible has been met 60% after deductible has been met
Emergency Health Services Outpatient
90% after deductible has been met
90% after network deductible has been met for Emergency 60% after network deductible
has been met for Non-Emergency
Hearing Aids
One per ear every 36 months 90% after deductible has been met 60% after deductible has been met
Home Health Care
Benefits are limited to 100 visits per year 90% after deductible has been met 60% after deductible has been met
Hospice Care
90% after deductible has been met 60% after deductible has been met
Hospital Inpatient Stay
90% after deductible has been met 60% after deductible has been met
Lab, X Ray and Major Diagnostics Outpatient
Lab 100% coverage X-Ray and Diagnostics 90% after deductible has been met
60% after deductible has been met
Lab, X Ray and Major Diagnostics Outpatient (CT, PET, MRI and Nuclear Medicine)
90% after deductible has been met 60% after deductible has been met
Mental Health Services
90% after deductible has been met 60% after deductible has been met
Neurobiological Disorders Mental Health Services for Autism Spectrum Disorders
90% after deductible has been met 60% after deductible has been met
Pharmaceutical Products Outpatient
This includes medications administered in an outpatient setting, in the physician’s office and 90% after deductible has been met
by a home health agency. 60% after deductible has been met
Physician Fees for Surgical and Medical Services
90% after deductible has been met 60% after deductible has been met
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Types of Coverage Network Benefits Non Network Benefits
Physician s Office Services Sickness and Injury
90% after deductible has been met; University of Louisville Primary Care
Primary Physician Physicians will apply a $20 discount off the normal network discount
60% after deductible has been met
Specialist Physician 90% after deductible has been met 60% after deductible has been met
Pregnancy Maternity Services
Depending upon where the Covered Health Infertility treatment (Limited to Service is provided, Benefits will be the same as $5,000 per lifetime) those stated under each covered Health Service
category in this Benefit Summary.
Pre-certification is required if inpatient stay exceeds 48 hours following a normal
vaginal delivery or 96 hours following a cesarean section delivery.
Preventive Care Services (Covered health services include but are not limited to:)
Primary Physician Office Visit 100% - deductible does not apply 60% after deductible has been met
Specialist Physician Office Visit 100% - deductible does not apply 60% after deductible has been met
Lab, X-Ray or other preventive tests 100% - deductible does not apply 60% after deductible has been met
Prosthetic Devices
90% after deductible has been met 60% after deductible has been met
Reconstructive Procedures
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service
category in this Benefit Summary.
Precertification is required for certain services
Rehabilitation Services Outpatient Therapy and Manipulative Treatment
Benefits are limited as follows:
50 visits combined of physical and occupational therapy
90% after deductible has been met 25 visits of speech and cognitive therapy
30 visits of manipulative treatment 25 visits combined of respiratory and pulmonary
treatment
60% after deductible has been met
Scopic Procedures Outpatient Diagnostic and Therapeutic
Diagnostic scopic procedures include, but are not limited to:
Colonoscopy; Sigmoidoscopy; Endoscopy. 90% after deductible has been met
For Preventive Scopic Procedures, refer to the Preventive Care Services category.
60% after deductible has been met
Skilled Nursing Facility / Inpatient Rehabilitation Facility Services
Benefits are limited as follows: 90% after deductible has been met 120 days per year 60% after deductible has been met
Substance Use Disorder Services
90% after deductible has been met 60% after deductible has been met
Surgery Outpatient
90% after deductible has been met 60% after deductible has been met
-Types of Coverage Network Benefits Non Network Benefits
Transplantation Services
For network benefits, services must be received at a Blue Distinction Center for Transplant.
90% after deductible has been met 60% after deductible has been met
Urgent Care Center Services
90% after deductible has been met 60% after deductible has been met
Vision Examinations
One Routine Exam per year 90% after deductible has been met; 60% after deductible has been met
Medical Notes
It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
In network deductibles and out of pocket amounts apply to the out of network accumulations. However, out of network deductible and out of pocket amounts are not included in the in network accumulations.
Dependent Age: to the end of the calendar year the child attains age 26. When choosing a non-network provider, the member is responsible for any balance due after the plan
payment.
Benefit Period: Equals calendar year Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with the
Federal Mental Health Parity.
Precertification: Members are encouraged to always obtain prior approval when using non network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services.
Primary Care Physician: Network Provider who is a practitioner that specializes in family and general practice, internal medicine and pediatrics.
Specialist Physician: Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
Preventive Care Services that meet the requirements of federal and state law, including certain screenings,
immunizations and physician visits are covered.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association.
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and
Blue Shield Association.
Anthem Blue Cross and Blue Shield and University of Louisville want to help you take control and make the most of your
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Your Summary of Benefits PCA Low PPO
(HRA Low Medical Plan with HealthEquity) Network includes University of Louisville and Blue Cross and Blue Shield PPO Providers
health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:
• Anthem.com – Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor, hospital and much more.
• 24/7 NurseLine – Always there for you. A nurse is a phone call away as well as other health resources, all available 24-hours a day, 7-days a week to provide you with information that can help you make informed decisions. Call toll free at 888.279.5378.
• Customer Care telephone support – Need more help? Contact your designated member services team at 855.747.1137. Get answers to your benefit questions or receive guidance when looking for a doctor or hospital.
The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Plan Highlights
Types of Coverage Network Benefits Non Network Benefits
Annual Deductible (Member copayments do not accumulate towards the deductible)
Individual Deductible $2,000 per year $4,000 per year Family Deductible $4,000 per year $8,000 per year
Out of Pocket Maximum (Member copayments for Pharmacy do not accumulate towards the Out of Pocket Maximum)
Individual Out-of-Pocket Maximum $5,000 per year $10,000 per year Family Out-of-Pocket Maximum $10,000 per year $20,000 per year
Personal Care Account
Annual Allowances that can be applied per year toward the member’s portion of covered medical costs, such as plan deductibles or coinsurance: $500 – Employee $2,000 – Employee + Child(ren) $1,000 – Employee + Spouse $2,000 – Employee + Family
Benefit Plan Coinsurance (The amount the Plan pays)
80% after Deductible has been met 50% after Deductible has been met
Lifetime Maximum Benefit
There is no dollar limit to the amount the Plan will pay for essential benefits during the entire No lifetime maximum benefit No lifetime maximum benefit
period you are enrolled in this Plan.
Prescription Drug Benefits
Prescription drug benefits are shown under separate cover.
Information of Precertification
Precertification is required for certain services. Please refer to your Benefit Plan Document.
Information on Benefit Limits
The annual deductible, out-of-pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. In network deductible and out of pocket amounts apply to
the out of network accumulations. However, out of network deductible and out of pocket do not apply to in network.
http:Anthem.com
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Benefits
Types of Coverage Network Benefits Non Network Benefits
Ambulance Services (Emergency and non emergency)
80% after deductible has been met
80% after network deductible has been met
Notification required for non-emergency ambulance services
Dental Services (Accident only)
80% after deductible has been met 80% after network deductible
has been met
Durable Medical Equipment (DME)
80% after deductible has been met 50% after deductible has been met
Emergency Health Services Outpatient
80% after deductible has been met
80% after network deductible has been met Emergency
50% after deductible has been met for Non-Emergency
Hearing Aids
One per ear every 36 months 80% after deductible has been met 50% after deductible has been met
Home Health Care
Benefits are limited to 100 visits per year 80% after deductible has been met 50% after deductible has been met
Hospice Care
80% after deductible has been met 50% after deductible has been met
Hospital Inpatient Stay
80% after deductible has been met 50% after deductible has been met
Lab, X Ray and Major Diagnostics Outpatient
Lab 100% coverage X-Ray and Diagnostics 80% after deductible has been met
50% after deductible has been met
Lab, X Ray and Major Diagnostics Outpatient (CT, PET, MRI and Nuclear Medicine)
80% after deductible has been met 50% after deductible has been met
Mental Health Services
80% after deductible has been met 50% after deductible has been met
Neurobiological Disorders Mental Health Services for Autism Spectrum Disorders
80% after deductible has been met 50% after deductible has been met
Pharmaceutical Products Outpatient
This includes medications administered in an outpatient setting, in the physician’s office and 80% after deductible has been met
by a home health agency. 50% after deductible has been met
Physician Fees for Surgical and Medical Services
80% after deductible has been met 50% after deductible has been met
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Types of Coverage Network Benefits Non Network Benefits
Physician s Office Services Sickness and Injury
80% after deductible has been met; University of Louisville Primary Care
Primary Physician Physicians will apply a $20 discount off the normal network discount
50% after deductible has been met
Specialist Physician 80% after deductible has been met 50% after deductible has been met
Pregnancy Maternity Services
Depending upon where the Covered Health Infertility treatment (Limited to $5,000 per
Service is provided, Benefits will be the same as lifetime)
those stated under each covered Health Service category in this Benefit Summary.
Precertification is required if inpatient stay exceeds 48 hours following a normal
vaginal delivery or 96 hours following a cesarean section delivery.
Preventive Care Services (Covered health services include but are not limited to:)
Primary Physician Office Visit 100% - deductible does not apply 50% after deductible has been met
Specialist Physician Office Visit 100% - deductible does not apply 50% after deductible has been met
Lab, X-Ray or other preventive tests 100% - deductible does not apply 50% after deductible has been met
Prosthetic Devices
80% after deductible has been met 50% after deductible has been met
Reconstructive Procedures
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service
category in this Benefit Summary.
Precertification is required for certain services
Rehabilitation Services Outpatient Therapy and Manipulative Treatment
Benefits are limited as follows:
50 visits combined of physical and occupational therapy
80% after deductible has been met 25 visits of speech and cognitive therapy 30 visits of manipulative treatment
25 visits combined of respiratory and pulmonary treatment
50% after deductible has been met
Scopic Procedures Outpatient Diagnostic and Therapeutic
Diagnostic scopic procedures include, but are not limited to:
Colonoscopy; Sigmoidoscopy; Endoscopy. 80% after deductible has been met
For Preventive Scopic Procedures, refer to the Preventive Care Services category.
50% after deductible has been met
Skilled Nursing Facility / Inpatient Rehabilitation Facility Services
Benefits are limited as follows: 80% after deductible has been met 120 days per year
50% after deductible has been met
Substance Use Disorder Services
80% after deductible has been met 50% after deductible has been met
Surgery Outpatient
80% after deductible has been met 50% after deductible has been met
-Types of Coverage Network Benefits Non Network Benefits
Transplantation Services
For network benefits, services must be received at a Blue Distinction Center for Transplant.
80% after deductible has been met 50% after deductible has been met
Urgent Care Center Services
80% after deductible has been met 50% after deductible has been met
Vision Examinations
Benefits are limited as follows: 1 routine exam every year
80% after deductible has been met 50% after deductible has been met
Medical Notes
It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
In network deductibles and out of pocket amounts apply to the out of network accumulations. However, out of network deductible and out of pocket amounts are not included in the in network accumulations.
Dependent Age: to the end of the calendar year the child attains age 26. When choosing a non-network provider, the member is responsible for any balance due after the plan
payment.
Benefit Period: Equals calendar year Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with
the Federal Mental Health Parity.
Precertification: Members are encouraged to always obtain prior approval when using non network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services.
Primary Care Physician: Network Provider who is a practitioner that specializes in family and general practice, internal medicine and pediatrics.
Specialist Physician: Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
Preventive Care Services that meet the requirements of federal and state law, including certain screenings,
immunizations and physician visits are covered.
solution for your insurance needs
Dental Insurance
Now offering 2 Dental Plan Options.
Routine dental exams do more than protect your teeth. They can help protect your health by catching serious problems, such as diabetes and heart disease. In fact, more than 90% of all diseases produce oral signs and symptoms.
1 And without dental coverage,
out-of-pocket costs for cleanings, exams, and dental procedures can really add up.
Network: PDP Plus
PLAN OPTION 1 BASIC PLAN
PLAN OPTION 2 ENHANCED PLAN
Coverage Type In-Network % of Negotiated Fee*
Out-of-Network % of R&C Fee**
In-Network % of Negotiated Fee*
Out-of-Network % of R&C Fee**
Type A: Preventive (cleanings, exams, X-rays)
100% 75% 100% 75%
Type B: Basic Restorative (filings, extractions)
80% 60% 80% 60%
Type C: Major Restorative (bridges, dentures)
60% 40% 60% 40%
Type D: Orthodontia 50% 50% 50% 50%
Deductible
Individual $25 $25 $25 $25
Family $75 $75 $75 $75
Annual Maximum Benefit
Per Person $1,000 $1,000 $3,000 $3,000
Orthodontia Lifetime Maximum
Per Person $1,000 Child(ren) Only
$1,000 Child(ren) Only
$1,500 Adult & Child(ren)
$1,500 Adult &
Child(ren)
Child(ren)’s eligibility for dental coverage is from birth up to age 26. * Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefit maximums. Negotiated fees are subject to change ** R&C fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of the most dentists in the same geographic area for the same or similar services as determined by MetLife
Applies to Type B & C Services
Don’t worry, you’re covered.
You have the flexibility to go to any licensed dentist. Just remember you usually save more when you stay in-network. That’s because participating dentists accept negotiated fees for covered services that are typically 15 to 45% less than average charges in the same community.
2 Services standardly include:
Preventative care (exams, sealants, x-rays)
Fillings
Crowns, dentures and bridges
Root canals and extractions
General anesthesia
Oral surgery
Adult and child orthodontics (Enhanced Plan) Child orthodontics (Basic Plan)
To locate a participating dentist visit at www.metlife.com/mybenefits. You can also call MetLife at 1-866-832-5756 for more information.
Metropolitan Life Insurance Company
200 Park Avenue
New York, NY 10166
www.metlife.com
1 Academy of General Dentistry. The Importance of Oral Health to Overall Health.
http://www.knowyourteeth.com/infobites/abc/article/?abc=T&iid=320&aid=1289 (last accessed November 4, 2014). 2 Based on internal analysis. Savings from enrolling in a dental benefits plan will depend on various factors,
including the cost of the plan, how often participants visit the dentist and the costs of services received. Negotiated
fees are subject to any deductibles, copayments, cost sharing and benefit maximums and are subject to change.
Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions,
exceptions, waiting periods, reductions, limitations and terms for keeping them in force. Please contact MetLife or
your plan administrator for complete details.
1405-1414 L1015441552[exp1016][All States][DC,GU,MP,PR,VI]
© 2015 METLIFE, INC. PEANUTS © 2015 Peanuts Worldwide LLC
http://www.metlife.com/mybenefitshttp://www.knowyourteeth.com/infobites/abc/article/?abc=T&iid=320&aid=1289http:www.metlife.com
Healthy eyes and clear vision are an important part of your overall health and quality of life. Your vision plan helps you care for your eyes while saving you money by offering:
Paid-in-full eye examinations, eyeglasses and contacts, after applicable copayments!
Frame Collection: Your plan includes a selection of designer, name brand frames that are completely covered in full./1
Contact Lens Collection: Select from the most popular contact lenses on the market today with Davis Vision’s Contact Lens Collection./1
One-year eyeglass breakage warranty included on plan eyewear at no additional cost!
How to locate a Network Provider... Just log on to the Member site at davisvision.com and click “Find a Provider” to locate a provider near you including:
IN-NETWORK BENEFITS
Eye Examination Every January 1, Covered in full after $10 copayment
Eyeglasses
Spectacle Lenses Every January 1, Covered in full For standard single-vision, lined bifocal, or trifocal lenses after $20 copayment
Frames
Every other January 1, Covered in full Any Fashion or Designer frame from Davis Vision’s Collection/1 (value up to $160)
OR $120 retail allowance toward any frame from provider, plus 20% off balance/3
OR $170 allowance, plus 20% off balance/3 to go toward any frame from a Visionworks store locations./5
Contact Lenses
Contact Lens Evaluation, Fitting & Follow Up Care
Every January 1 Collection Contacts: Covered in full
Non Collection Contacts: 15% discount/3
Contact Lenses
Every January 1, Covered in full Any contact lenses from Davis Vision’s Contact Lens Collection/1
OR $120 retail allowance toward provider supplied contact lenses, plus 15% off balance/3
ADDITIONAL DISCOUNTED LENS OPTIONS & COATINGS
MOST POPULAR OPTIONS Savings based on in-network usage and average retail values.
Without Davis Vision
With Davis Vision
Scratch-Resistant Coating $25 $0 Polycarbonate Lenses $66 $0/2-$30 Standard Anti-Reflective (AR) Coating $83 $35 Standard Progressives (no-line bifocal) $198 $50 Photochromic Lenses (i.e. Transitions®, etc.)/4 $110 $65
Designer Vision Plan
For more details about the plan, just log on to davisvision.com or call 1.877.923.2847 and enter Client Code 7631
Lower costs and more benefits! See the savings!
Employee Contributions Monthly Annually Employee $3.70 $44.40 Employee plus Spouse $6.71 $80.52 Employee plus Child(ren) $7.11 $85.32 Employee plus Family $10.21 $122.52
Service Estimated
Cost Without Davis Vision
With Davis Vision
Eye Examination $103 $10 Lenses
Bifocals $116 $20 Scratch-Resistant Coating $25 $0 Transitions®/5 $110 $65
Frame $160 $0
Total $514 $95
Savings up to:
$419 1/ The Davis Vision Collection is available at most participating independent provider locations. 2/ For dependent children, monocular patients and patients with prescriptions of 6.00 diopters or greater. 3/ Additional discounts not applicable at Walmart, Sam’s Club or Costco locations.. 4/ Transitions® is a registered trademark of Transitions Optical Inc. 5/ Allowance is available at all Visionworks store locations.
Davis Vision has made every effort to correctly summarize your vision plan features. In the event of a conflict between this information and your organization’s contract with Davis Vision, the terms of
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