Polk County Public Schools

Annual Open Enrollment Benefits Guide

2015 Plan Year

Wise The smart way to elect benefits!

The Annual Benefits Guide and personalized form will be available on the Staff Portal. Open Enrollment forms and booklets will not be mailed to all employees.

All forms must be returned to the Risk Management & Employee Benefits Department by October 20, 2014. Send forms to the Risk Management Department by: Courier: Benefits Department District Office, Route E Mail: Polk County School Board Attn: Benefits Department P.O. Box 391 Bartow, FL 33831

Reminder Deductions for January coverage will be taken from your December paycheck. Be sure to check both your December & January paychecks to ensure 2015 elections are correct.

For additional assistance please contact the Risk Management and Employee Benefits Department at: Phone: 863-519-3858 Email: [email protected]

Atención Personas que hablan español: Si usted desea una copia de su Guía de Beneficios e información sobre sus derechos en español, favor de comunicarse con el Departamento de Gestión de Riesgos y Beneficios al Empleado (Risk Management Department/ Employee Benefits) al 863-519-3858 ó por correo electrónico a: [email protected].

Welcome from Risk Management Greetings Fellow Polk County Public Schools Employees: It is our pleasure to welcome you to the 2015 Open Enrollment. At Polk County Public Schools, we recognize our success depends on dedicated, hard-working employees. Your daily contributions make a difference in the lives of students and your fellow employees. Your benefits program is an important part of your overall compensation and through collaboration with the School Board, Superintendent, PEA and AFSCME unions; the District is pleased to provide a comprehensive benefits package. This year we are continuing our focus is on Ongoing Well Living (OWL) for all employees and dependents! Our goal is to create WISE employee benefit consumers because Wise Individuals Stay Engaged! As the cost of healthcare continues to rise, it is more important than ever for each of us to take an active part in our health. The 2015 Benefits Guide includes a summary of your benefit plans, the eligibility requirements and instructions on how to enroll. This year, as a cost saving effort, your individualized enrollment form will be available on the Staff Portal. The 2015 Benefits Guide will be available through the PCSB website at www.polk-fl.net (Keyword: INSURANCE). Please read the information contained in this guide carefully before making your decisions. The Annual Open Enrollment period is your once-a-year opportunity to make changes to your current benefit election and to review which family members you are including on your benefit plans. The plan year begins on January 1 and continues through December 31. Benefit elections made during Open Enrollment are generally binding for the entire plan year. You may not make any changes until next year’s Open Enrollment period unless you have experienced a qualifying change in status event (e.g., marriage, birth, adoption, etc.) and notify Risk Management and Employee Benefits of such a change within 31 days from the date of the qualifying event. The Risk Management staff strives to deliver prompt, current and accurate information to enable you to make informed choices. If you have any questions or need any assistance, please call us, email us, or stop by to see us. We are here to assist you. Sincerely, Risk Management and Employee Benefits Department

WHAT SHOULD I DO?   

Accessing the Staff Portal Submitting the Enrollment Form How to Waive Insurance Page 2

ELIGIBILITY  

Who is Eligible? Required Documentation

Page 3

HEALTH PLAN PREMIUM  

Pre-Tax Deductions Monthly Premiums

Page 4

EMPLOYEE HEALTH CLINICS  

Who Can Use Clinics Services Provided

Page 5

FLORIDA BLUE   

Benefit Summary PCSB Florida Blue Team Quick Reference Guide

Page 6

WELLDYNERX   

Registering On-line Copays & Formulary Mail Order Service

Page 11

THE STANDARD     

Basic & Additional Life Dependent Life Accidental Death & Dismemberment Short Term Disability Long Term Disability Page 13

DELTA DENTAL  

Why Choose Dental? Benefit Summary

Page 18

UNTIED HEALTHCARE VISION  

Benefit Summary Laser Vision Benefit

Page 20

TASC – FLEXIBLE SAVINGS ACCOUNTS  

Health Care Reimbursement Child Care Reimbursement

Page 23

AETNA – EMPLOYEE ASSISTANCE PROGRAM 

Aetna Resources for Living

Page 25

PCSB EMPLOYEE WELLNESS  

ABCs of Diabetes Prenatal Programs

Page 26

TAX SHELTERED ANNUITIES  

Authorize Providers BENCOR

Page 27

KNOW YOUR RIGHTS 

Very Important Information & Legal Notices Page 28

1 2 3

What Should I Do? Review this Booklet Open Enrollment is your one-time opportunity to review your current benefit elections and make any changes that may be needed for you and your family. Please take the time to familiarize yourself with the guide’s contents. We hope that after you review this guide you will have a clear understanding of the changes that will be effective January 1, 2015, and how they may impact you and your covered dependents. At PCSB, you are important! That’s why we work hard to provide you with affordable benefit options for you and your family.

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Print & Submit your Form Forms must be returned to the Risk Management and Employee Benefits Department by October 20, 2014. If you do not complete your enrollment form via the Staff Portal, your benefits will remain the same for 2015 with the exception of Flexible Spending Accounts, which will be discontinued without a new enrollment.

Access the Staff Portal Accessing the Staff Portal is easy. All you have to do is visit our website at www.polk-fl.net, click the “Staff” tab at the top and then click on “Staff Home” in the drop-down menu. Next, click on the orange “Staff Portal” button. Enter your username (firstname.lastname) and your password (your email/network password) then click the “Log In” button.

Make 2015 Elections There are no changes to benefits or premium for 2015. If you do not wish to make any changes, you do not need to do anything. However, if you are enrolled in a Flexible Spending Account, you must re-enroll if you want to continue participating in 2015. The IRS requires that FSA elections be made each year.

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Employees without regular access to computers will be permitted to use PCSB computers at school locations. Each location will also have a person designated to help print personalized forms for those without computers. You may also visit the Risk Management and Employee Benefits Department for assistance. Forms received after the due date cannot be accepted. ORIGINALS ONLY – NO FAXES PLEASE.

What if I want to waive the health insurance? If you are covered by another health plan and do not wish to enroll in the PCSB Health Plan, please check the box to waive coverage and return it to the Risk Management & Employee Benefits Department. Important note: If you are covered under another group health plan, failure to waive the PCSB Health Plan means that the PCSB Health Plan is considered your primary insurance and your other plan will be your secondary insurance.

Open Enrollment Ends Oct 20th!

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Open Enrollment for 2015

Who Is Eligible? Employees Employees who work at least 30 hours per week and have completed the necessary waiting period, including those active employees eligible for coverage under Medicare, are eligible for benefits. All employees are automatically enrolled in the Group Health Plan unless they submit the appropriate waiver.

Spouses Spouses are eligible for coverage when they met all requirements of a legal marriage in the state of Florida. An ex-spouse does not meet eligibility criteria even if insurance coverage is specified by a judge in a divorce decree. An employee who is eligible for coverage cannot be covered as a spouse. If you and your spouse are both employees and eligible for coverage, you must select the “Board Spouse” option. This will ensure you both receive the full board contribution for your coverage.

Children A covered employee’s children are eligible for coverage until the end of the calendar month in which they turn 26. An eligible child includes the employee’s natural, newborn, adopted, foster, or step child(ren), and a child for whom the Covered Employee has been court-appointed as legal guardian or legal custodian. There are provisions for continuing coverage for disabled dependent children beyond the age of 26. If you feel you have a dependent who may meet this criteria and have not already submitted documentation to Risk Management, please contact our office at 863-519-3858 so that we can assist you with this process. Grandchildren can only be covered up to 18 months of age and are only eligible if the parent remains covered.

Eligibility Documentation It is your responsibility to show that your dependent meets the eligibility requirements and to remove them when eligibility ends. Eligibility ends on the last day of the month in which the requirements are no longer met. The premium will be deducted for the Dependent Relationship Spouse Natural Child Stepchild Adopted Child Legal Custody or Guardianship Disabled Dependents Over Age 26 Adult Child (ages 19-26) Grandchildren (EE’s child must be listed as parent on birth cert. & remain covered)

entire plan year; however, dependents will not be covered until the documentation is received. You must provide the following documentation to the Risk Management & Employee Benefits Department for any dependents being added during Open Enrollment:

Documentation Requirements* Copy of Marriage License Copy of Birth Certificate (must list employee as a parent) Copy of Birth Certificate (must list employee’s spouse as a parent) and Marriage Certificate Adoption Certificate Court Order establishing legal guardianship Social Security Disability Documentation. Disabled dependents are eligible only if covered by the PCSB Health Plan prior to age 26. Copy of Birth Certificate OVER 18 MONTHS OLD UNDER 18 MONTHS OLD Legal Custody or Guardianship documentation Copy of Birth Certificate

*The previous year’s U.S. Tax Return showing you claimed the dependent can also be used to establish eligibility.

POLK COUNTY PUBLIC SCHOOLS |

Open Enrollment for 2015

IMPORTANT Section 125 of the IRS code allows employees to use pretax dollars to pay the premiums on certain group insurance products. These deductions are taken prior to Social Security and Federal Income Taxes being deducted from your paycheck, which can lead to significant savings. Benefits elections must remain in effect until the next Open Enrollment Period unless you experience a qualifying event.

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Premium Information What do you receive? There is no cost to the employee for health insurance. Health insurance includes medical coverage administered by Florida Blue and prescription coverage through WellDyneRx. This also includes access to the Polk County School Board Employee Health Clinic and the Better Now Health Center at no cost to the covered member. The School Board also provides each benefitseligible employee with $20,000 of Group Term Life and $10,000 of Accidental Death and Dismemberment.

A qualifying event is a change in status to your life that meets IRS approved definitions. Examples are marriage, divorce, birth, death, adoption, legal guardianship, gain or loss of stepchildren, gain or loss of coverage. If you need to make a change to your coverage due to a Qualifying Event, you must submit the Change of Status Form along with required documentation no more than 31 days after the qualifying event has taken place. Change of Status Forms are available on the Risk Management and Employee Benefits page of the Polk County School Board website: www.polk-fl.net keyword “Insurance” or by contacting Risk Management at:

What will you pay?

[email protected].

When will your insurance end?

TIER Employee Spouse 1 Child 2 Children 3 + Children

Monthly Rate $0 $423 $95 $190 $215

Payroll Deductions Premiums are due in advance; therefore deductions begin one month before coverage is effective. Please view your December paycheck to ensure your 2014 elections are correct.

For 10 and 11 month employees: If you resign prior to the end of the school year your benefits will end the last day of the month in which you paid for coverage from your last paycheck. If you work to the end of the contract year, your benefits will end on August 31st.

The Board contributes $594 per month for health insurance for each eligible employee.

For 12 month employees: Your benefits will end the last day of the month in which you pay for coverage from your last paycheck.

POLK COUNTY PUBLIC SCHOOLS |

Open Enrollment for 2015

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Polk County School Board Employee Health Clinic and the Better Now Health Center The health and wellness of our employees, retirees and their families is an important focus of the Polk County School Board. To support this focus, PCSB provides access to 2 physician-led health clinics: The Polk County School Board Employee Health Clinic in Haines City and the Better Now Health Center in Winter Haven. The primary goal of the clinics is to provide high quality family practice healthcare to members of the PCSB and their covered dependents at NO COST. Employees, Retirees and dependents

age 2 and up covered by the PCSB health plan can get primary healthcare services at either clinic. Not covered under the PCSB health plan? Not to worry! All PCSB Employees are eligible to utilize the PCSB Employee Health Clinic in Haines City at no cost from their date-of-hire regardless of health plan coverage. Both clinics provide access to primary care lab work and can dispense certain generic medications as prescribed by one of the clinic

providers. You may (depending on the prescription) be able to get your medication at no cost from the clinics as well. You can also stop by the Florida Blue Retail Center in Winter Haven where you’ll be able to get in-person support for your health and wellness goals, plus answers to questions about claims or benefits. If you are already established with a physician, you are not required to use the PCSB Employee Health Clinic. You will continue to receive the benefits of your health plan.

395 Cypress Gardens Blvd. Winter Haven, FL 33880 Appointments: 863-837-5739

641 US Highway 17-92 West, #631B Haines City, FL 33844 Appointments: 863-419-3322

Clinical Care Consultants are available at both locations.

X-Ray room available at the Florida Blue Clinic

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Open Enrollment for 2015

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Benefit Summary – 2015 Plan Year BlueOptions – Plan 03566

In-Network

Out-of-Network

$750

$1,500

$1,500

$3,000

Deductible (DED) Per Person Per Family Aggregate Coinsurance (Member Responsibility) Out of Pocket Maximum Per Person Per Family Aggregate Lifetime Maximum

20%

40%

Includes DED, Coins, Copays and Rx

N/A

$5,000

Unlimited

$9,000

Unlimited

No Maximum

No Maximum

EMPLOYEE CLINICS Polk County School Board Employee Health Clinic Office Visit, Labs, On-site Prescriptions Better Now Health Center Operated by Watson Clinic Office Visit, Labs, X-rays, On-site Prescriptions

$0

N/A

$0

N/A

Allergy Injections - Family Physician or Specialist

$10

DED + 40%

E-Office Visit Services - Family Physician or Specialist

$10

DED + 40% DED + 40%

Provider Services at Hospital and ER

$40 $40 for Initial OB Prenatal Visit only DED + 20%

In-Ntwk DED + 20%

Provider Services at Other Locations

DED + 20%

DED + 40%

DED + 20%

In-Ntwk DED + 20%

PROFESSIONAL PROVIDER SERVICES

Office Services Family Physician or Specialist Specialist Maternity Care

DED + 40%

Radiology, Pathology and Anesthesiology Provider Svcs Ambulatory Surgical Center Hospital

DED + 20%

In-Ntwk DED + 20%

Included in Office Visit Copay

DED + 40%

Adult Wellness Office Svcs - Family Physician or Specialist

$0

DED + 40%

Colonoscopies (Routine) Age 50+ then Frequency Schedule Applies

$0

$0

Mammograms (Routine and Dx)

$0

$0

Well Child Office Visits - Family Physician or Specialist

$0

$0

20% of billed charges

20% of billed charges

Medical Pharmacy (Provider-Administered Rx in the Office) PREVENTIVE CARE

EMERGENCY/URGENT/CONVENIENT CARE

Ambulance (ground, air and water - per day) Convenient Care Centers (CCC) Emergency Room Facility Services Urgent Care Centers (UCC)

$40

DED + 40%

DED + 20%

OON DED + 20%

$40

DED + 40%

FACILITY SERVICES - HOSP/SURG/ICL/IDTF Unless otherwise noted, physician services are in addition to facility services. See Professional Provider Services. Ambulatory Surgical Center DED + 20% DED + 40% Independent Clinical Lab

$0

DED + 40%

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Open Enrollment for 2015

Benefit Summary – 2015 Plan Year BlueOptions – Plan 03566 Independent Diagnostic Testing Facility Xrays and AIS (Includes Physician Services) Advanced Imaging Services (AIS) Other Diagnostic Services Inpatient Hospital (per admit)

In-Network

Out-of-Network

DED + 20%

DED + 40%

DED + 20% Option 1 - DED + 20% Option 2 - DED + 25%

DED + 40%

Inpatient Rehab Maximum

DED + 40% 21 Days

Option 1 - DED + 20% Option 2 - DED + 25% Option 1 - DED + 20% Option 2 - DED + 25%

DED + 40%

Inpatient Hospitalization

Option 1 or 2: DED + 20%

DED + 40%

Outpatient Hospitalization (per visit)

Option 1 or 2: DED + 20%

DED + 40%

Provider Services at Hospital and ER

DED + 20%

DED + 20%

$40

DED + 40%

Emergency Room Facility Services (per visit)

DED + 20%

INN DED + 20%

Provider Svcs - Locations other than Hospital, ER & Office

DED + 20%

DED + 40%

DED + 20%

DED + 40%

$0 Option 1 – 20% (DED Waived) Option 2 – 25% (DED Waived)

DED + 40%

DED + 20%

DED + 40%

DED + 20%

DED + 40%

Hospice

DED + 20%

DED + 40%

Outpatient Therapy and Spinal Manipulations BPM

35 Visits (Includes up to 26 Spinal Manipulations)

Skilled Nursing Facility BPM - 60 Days per Benefit Period

DED + 20%

Outpatient Hospital (per visit) Therapy at Outpatient Hospital

DED + 40%

MENTAL HEALTH AND SUBSTANCE ABUSE

Physician Office Visit - Family Physician or Specialist

OTHER SPECIAL SERVICES AND LOCATIONS Advanced Imaging Services in Physician's Office Colonoscopies (Diagnostic) Ambulatory Surgical Center Outpatient Hospital Durable Medical Equipment, Prosthetics, Orthotics BPM Enteral Formulas:$2,500 All Other: No Maximum Home Health Care - 20 Visits per Benefit Period

DED + 40%

DED + 40%

This is not an insurance contract or Benefit Booklet. The above Benefit Summary is only a partial description of the many benefits and services covered by your Health Plan. For a complete description of benefits and exclusions, please refer to the Summary Plan Description (SPD). The written terms of the SPD prevail.

Staying healthy just got less expensive Great discounts and valuable information you can use all year long—Blue365 You can save BIG on a wide variety of healthy products and services through our members-only discount program— Blue365*. Take advantage of exclusive discounts at select local companies and leading, national brands for your everyday health and wellness or family care—even healthy vacation destinations! Save up to 60% on fitness clubs, exercise equipment, contact lenses or glasses, nutrition and weight management programs and so much more! All included as part of your Blue membership. It’s easy to find details for these exclusive savings—the information is available online 24/7 for your convenience. Simply log in at bcbsfl.com. Under the Discounts & Rewards tab, choose Discount Programs. New discounted products and services are being added all the time—so check back often for new savings opportunities.

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Open Enrollment for 2015

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The PCSB Florida Blue Team Florida Blue provides many resources to help you get the most benefit from your health plan. Some of the most important resources they provide are people who are dedicated to serving Polk County School Board members. Many employees are familiar with Connie Ashley. Connie is a life-long resident of Polk County and has served the employees of Polk County School Board for over 25 years. Her office is located at the PCSB District Office in Bartow. Connie is the Florida Blue on-site Customer Service Representative. She is here to assist our members with benefit issues including plan design questions and claim inquiries. Connie can be reached at 863-519-8799. Another resource available to you is Tammie Thompson. Tammie is the PCSB dedicated Case Manager. She has been a nurse for 18 years with experience in a variety of areas. She has been a Case Manager for the last 8 years and does a wonderful job helping members manage their health care needs beyond the hospital setting. She can assist with personalized information based on your health care needs such as educational materials and community resources. If you have an unexpected illness or even a long-term health condition, it helps to know what actions to take to manage your health for a better quality of life. Tammie is here to help you understand what you may experience with your condition, helping you prevent complications and provide you with extra peace of mind. Tammie can be reached at 1-800-262-2166 x59264. The third member of our team is Joyce Smith. She is the Florida Blue Clinical Health Care Advocate located at the Polk County School Board Employee Health Clinic in Haines City. Joyce is a registered nurse with over 25 years of experience in a variety of specialties including the emergency room, intensive care units, cardiovascular thoracic trauma, orthopedic trauma, and care in acute care settings. Joyce is no stranger to Polk County; she has lived here for over 20 years and is excited to be part of the PCSB family. In her free time, she is a tireless volunteer for organizations such as: Polk County’s Habitat for Humanity, American Heart Walk, Diabetes Association, Breast Cancer Association, and various other community organizations. She currently holds an MBA with concentration in Health Care Management and a Master’s of Nursing degree with a specialization in Nursing Informatics from Walden University. Contact Joyce anytime you would like assistance making important health care decisions such as: prior to scheduling advanced imaging tests, when you need specialized medical equipment, before you schedule outpatient surgery at the hospital or when you have questions about a new or chronic condition. She will be able to help you navigate the system and be sure you are receiving your care in the most appropriate setting – helping you save time and money! Joyce can be reached at 863-419-3322 ext. 223 or by email at [email protected]. Please be sure to take advantage of the resources available to you. The Florida Blue staff is here to help you in your pursuit of health!

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Open Enrollment for 2015

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Quick Reference Guide Questions

Planning surgery or have questions about a condition?

Have a complex health condition?

Why pay more?

Questions about your treatment options?

Resources

How to Access

Health Care Advocate

Joyce Smith, RN

Florida Blue provides an on-site Health Care Advocate to assist members with Clinical Issues including treatment choices, cost saving options, community resources and more.

Located at the Polk County School Board Employee Health Clinic

(863) 419-3322 ext. 223 [email protected]

Nurse Case Manager

Tammie Thompson, RN

Florida Blue provides a dedicated Nurse Case Manager who can answer questions about your treatment plan and help you coordinate with your physicians and other service providers.

Toll Free: 800-262-2166 ext. 59264 Direct Line: 850-505-9264 [email protected]

Know Before You Go

Go to www.floridablue.com and log into your Member Account

Use our online Medical Cost Comparison Tool to shop around for health care services. You can save money and still get the quality care you deserve.

select Tools and Medical Care Comparison

Care Consultants

Toll Free at 1-888-476-2227

Our team of Care Consultants is standing by to answer questions about your benefits, treatment choices and cost saving options.

Monday through Friday, 8 AM to 9 PM

Florida Blue Center

385 Cypress Gardens Blvd Winter Haven

The Florida Blue Center in Winter Haven provides great customer service, in person.

Open 10am - 8pm, Mon. – Sat. No appointment needed. 1-877-352-5830

Want help face-to-face?

Health Dialog 24-hour Nurse Line ER or doctor’s office?

Questions about health can come up at anytime, including times when doctors’ offices are closed. Our 24-hour nurse line can help you make informed health care choices.

Toll Free at 1-877-789-2583

On-Site Customer Service

Connie Ashley Located in Bartow at the District Office

Plan benefits or claim question?

Need help with a claim or have other questions?

The Florida Blue on-site Customer Service Representative is available to assist members with Benefit Issues including plan design questions and claim inquiries. Customer Service Ask your customer service representative how to: Find out what’s covered and how much you’ll pay Shop for the best value on upcoming medical procedures Maximize your health plan benefits to save money Access online tools and resources to help you better manage your health Receive support for a health condition (like diabetes or asthma)

(863) 519-8799 [email protected]

Toll Free at 1-855-600-6701 Monday – Thursday 8 a.m. – 8 p.m. Friday 9 a.m. – 8 p.m.

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Open Enrollment for 2015

Quick Reference Guide Prefer online help?

www.floridablue.com

Go to www.floridablue.com and register.

Register your online Member Account to: Review your plan benefits See your deductible Find a participating doctor or hospital View claim activity, status and history Use your personalized WebMD site Understand your upfront medical costs Find tools to improve your health Access our exclusive discount program

All you need to register is a valid email address, your SSN and your Member Number (located on your BCBSF Member ID card).

It pays to stay in-network When you travel, you’re still covered Our coverage includes a strong network of quality providers located in the communities where you live and work. We’ve negotiated lower rates with our in-network providers to keep your out of-pocket low and help you get the most value for every health care dollar. No referrals are required, so you’ll find it convenient to access specialists for the care you need, while saving money, too. Plus, in-network providers usually obtain the prior authorizations for certain services and help protect you from balance billing.

®

Wherever you go, through our BlueCard program, your health care coverage goes with you. You’ll get access to the participating providers of independent Blue Cross and/or Blue Shield organizations across the country and worldwide – and you shouldn’t have to pay more than the rates they have negotiated with doctors and hospitals in their areas. To find participating doctors and hospitals outside of Florida, call 1-800-810-BLUE (2583) or visit bcbs.com and click on “Find a Doctor or Hospital”.

If your doctor sends you for an X-Ray, CT scan, or MRI, it will generally cost you less to have that test done at an Independent Diagnostic Testing Center (IDTF) – rather than outpatient at the hospital. You can locate a participating IDTF through the Florida Blue online provider directory at www.floridablue.com.

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Open Enrollment for 2015

Prescription Drug Coverage Accessing Services Please read the following information carefully to help you understand your benefits and maximize the advantage of the mail service and retail prescription benefits available to you through WellDyneRx.

WellDyneRx has over 64,000 innetwork pharmacies across the US which includes all major chains & most independent pharmacies. To locate a pharmacy near you go to http://pcsb.welldynerx.com. As we move into our second year with WellDyneRx, we would like to remind everyone how important it to register on WellDyneRx’s website. You will be pleasantly surprised at how easy it is to manage all aspects of your prescription benefit program.

To

begin,

go

to http://pcsb.welldynerx.com and follow these three simple steps for Secure Registration:

more. If you have questions about your prescription benefits, please visit http://pcsb.welldynerx.com or call WellDyneRx toll-free at 1-855748-2661.

Secure Registration Step 1: Register Online

On-line Services

Register now to access online refills, transferred prescriptions, view your mail order history, and more.



Access your personal profile



Locate in-network pharmacies



Refill a mail order prescription



Check your order status



Print a temporary ID card for you and your covered dependents Obtain a complete prescription history Print your prescription expense record for tax purposes See what drugs are on the Formulary Compare the cost of similar medications

Step 2: Enroll for Mail Order Provide us your mailing address and phone number and tell us if you have any known drug allergies to enroll for mail order prescriptions delivered right to your door.

 

Step 3: Set Up Express Pay

 Set up express pay by providing a major credit card. The number will be stored securely in our database and can be used to quickly and conveniently pay for prescriptions.



Registering will allow you to access benefit information, order refills, check your order status, and

Member Costs Your plan will require a copay or coinsurance for covered prescription drugs. Your copay may depend on whether the drug is a brand or a generic and if applicable, whether it is a formulary (preferred) or a non- formulary (non-preferred) status. There is a $25.00 per person annual deductible at retail for brand name medications only. If you purchase a brand-name medication when a generic medication is available or if your doctor requests a brand-name when a generic is available,



Use the Co-pay Calculator



Access and print forms



Access drug and health information

you will pay the generic co-payment, plus the difference in cost between the brand and the generic.

Generic

Preferred Brand

NON – preferred Brand

Retail 30

$8

$30+10%* (max $60)

$50+10%* (max $100)

Retail 90

$8

$90+10%* (max $180)

$150+10%* (max $300)

Mail 90

$8

$75

$125

*10% of the cost of the prescription minus the deductible.

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Open Enrollment for 2015

Prescription Drug Coverage Generic Drugs Generic drugs are approved by the Food and Drug Administration (FDA) as safe and effective. Generics contain the same active ingredients in the same amounts as brand drugs, although they may differ in color, size or shape.

Formulary Drugs A formulary is a list of preferred drugs that have been shown to be safe, effective and have the best cost value. WellDyneRx’s formulary only includes drugs that have been approved by the FDA. For the most up-to-date formulary, visit our website at http://pcsb.welldynerx.com.

Mail Order Mail order provides an easy and cost-effective way to order medications for delivery to your home. To get started: go to

http://pcsb.welldynerx.com,

complete and send in a Mail Order form or call Member Services at 1855-748-2661. If you have new prescriptions, send all original prescriptions with your copay for each drug directly to: WellDyneRx PO Box 90369 Lakeland, FL 33804-0369 For your safety, always review your prescription for accuracy and completeness. Orders will process and ship once the prescriptions are received, unless noted otherwise. For a quicker turnaround, physicians may call-in the prescription to 1-855-748-2661 or fax it to 1-877-221-1259.

Transferring your existing prescriptions to mail order is also easy! After signing up for the Mail Order Program, simply complete an ExpressSwitch™ form, which can be found online at http://pcsb.welldynerx.com, and follow the instructions on the form or contact customer service at 1855-748-2661. Be sure to order refills about three weeks before you run out of your medication. Refills can be ordered anytime on our website at http://pcsb.welldynerx.com, by calling our automated prescription line at 1-855-748-2661 (selection option 2), or by completing and returning the reorder form sent with your previous order.

WellDyneRx cannot legally accept called or faxed prescriptions from patients.

Specialty drugs are usually high cost medications which require special handling and close supervision. Specialty drugs are available through WellDyneRx as part of your pharmacy benefit. Contact WellDyneRx at 1-855-748-2661

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Open Enrollment for 2015

Term Life Insurance Basic Life The time you spend with your family is priceless, full of fun times and precious memories. But what would happen to them if you suddenly died? Would those memories be enough to sustain them through this difficult period? It’s not pleasant to think about, but your death could potentially leave your family unable to meet existing and unexpected financial obligations. In addition to paying the everyday bills, there may be the unexpected expenses of final medical treatment and funeral costs. To help you prepare for the unexpected, the Polk County School Board provides each benefit-eligible employee with $20,000 of life insurance coverage. This coverage includes $10,000 of Accidental Death and Dismemberment (AD&D).

Additional Life You may also request additional coverage up to 5 times your annual earnings. You may elect one of the following Additional Life coverage options: Option 1: Option 2: Option 3: Option 4: Option 5:

1 2 3 4 5

X X X X X

Annual Earnings Annual Earnings Annual Earnings Annual Earnings Annual Earnings

Life insurance is rounded to the next higher multiple of $1,000, if not already a multiple of $1,000. The maximum amount is $300,000. Any increase in benefits or new enrollment requested during Open Enrollment will be subject to medical underwriting. Once we receive your form requesting enrollment or additional coverage, we will send you an Evidence of Insurability form to complete and submit directly to The Standard for approval.

Rates There are no benefit changes or premium changes for any of the plans available through The Standard for 2015; however, these products have age-banded rates. If you have moved from one ageband to the next, you may see an increase in your premium. Rates are based on your age as of January 1, 2015 and do not change mid-year. AGE as of 01/01/15

RATE: PER $1,000

≤ 29

$0.051

30-34

$0.061

35-39

$0.081

40-44

$0.116

45-49

$0.167

50-54

$0.230

55-59

$0.243

60-64

$0.263

65+

$0.298

*$0.02 is for AD&D coverage

Age Reductions Under this plan, coverage reduces by 35% at age 65, by 50% at age 70, and by 65% at age 75. After an age reduction, the amount of your Additional Life and AD&D Insurance will be rounded up to the next higher multiple of $1,000, if not already a multiple of $1,000. Age Reduction does not apply to Basic Life.

The Pre-tax benefit for Group Term Life is available for amounts up to $50,000 in coverage. This total includes the $20,000 paid for by the School Board of Polk County for each benefit-eligible employee. Employees may elect additional coverage; however deductions for amounts over the total of $50,000 will be taken on a post-tax basis.

POLK COUNTY PUBLIC SCHOOLS |

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Open Enrollment for 2015

Term Life Insurance Waiver of Premium Provision The Standard may continue your Life insurance without premium payments if you: Become totally disabled while insured under the group policy Are under the age of 65 Complete the waiting period of 180 days Give us satisfactory proof of loss Waiver of Premium does not apply to AD&D insurance.

Eligibility

open enrollment applications will be subject to medical underwriting approval. “Child” means your unmarried child from live birth through age 20 (through age 24 if a registered student in full-time attendance at an accredited educational institution). If both spouses work for PCSB, only one may elect dependent life and only the child(ren) will be covered. Employees cannot cover each other as dependent spouses. Also, your spouse or children must not be full-time member(s) of the armed forces.

To be eligible for this plan: You must be insured for Basic Life You must be an active employee of The School Board of Polk County, Florida, excluding Superintendent, Retirees, temporary and seasonal employees, full-time members of the armed forces, leased employees and independent contractors You must be regularly working at least 3.75 hours per day and 18.75 hours per week.

Group Insurance Certificate If you become insured, you can obtain a group insurance certificate containing a detailed description of the insurance coverage at www.polk-fl.net key word “Insurance”. The information presented above is controlled by the group policy and does not modify it in any way. The controlling provisions are in the group policy issued by Standard Insurance Company.

Dependent Life You may elect Dependent Life insurance for your spouse and eligible child(ren) at a flat amount of $10,000 for your spouse and $5,000 for your eligible child(ren). All

When Dependent Life Coverage Ends Dependent Life coverage for your spouse and child(ren) will automatically end on the earliest of the following: Five months after the date you die The date your Life insurance ends The date Dependents Life insurance terminates under the group policy The date your employer’s coverage under the group policy for Dependent Life insurance terminates The date the last period ends for which a premium was paid for your Dependent Life insurance When the dependent ceases to be an eligible dependent For your spouse, the date of your divorce or legal separation For a child who is disabled, 90 days after we mail you a proof of disability request, if proof is not given

POLK COUNTY PUBLIC SCHOOLS |

15

Open Enrollment for 2015

Accidental Death & Dismemberment Accidental Death and Dismemberment (AD&D) With Additional AD&D insurance from Standard Insurance Company, you or your beneficiaries may be eligible to receive an additional amount in the event of death or dismemberment as a result of an accident. The amount of this AD&D Insurance Benefit for loss of life is equal to the amount payable for Additional Life insurance coverage on the date of the accident. The amount of this AD&D Insurance Benefit for other covered losses is a percentage of the amount payable for Additional AD&D insurance coverage on the date of the accident, as shown in the following table:

Type of Loss

Percentage Payable

One hand or one foot

50%

Sight in one eye, (speech, or hearing in both ears)

50%

Two or more of the losses listed above

100%

Thumb and index finger of the same hand1

25%

Quadriplegia

100%

Hemiplegia

50%

Paraplegia

50%

When Coverage Ends AD&D insurance will automatically end on the earliest of the following: The date your Life insurance ends The date your Waiver of Premium begins The date AD&D insurance terminates under the group policy The date the last period ends for which a premium was paid for your AD&D insurance The date your employer’s coverage under the group policy for AD&D insurance terminates The date your employment terminates

Additional Features The following are brief descriptions of features included in this plan. These features offer additional benefits when an AD&D Insurance Benefit is payable. The Seat Belt Benefit provision provides an additional benefit in the event of a covered automobile accident. The Air Bag Benefit provision provides an additional benefit in the event of a covered automobile accident for which a Seat Belt Benefit is payable. With the Family Benefits Package provision, your eligible family members may be entitled to receive additional financial help for child care, college or career training. Included are the Child Care Benefit, Higher Education Benefit and Career Adjustment Benefit. The Occupational Assault provision provides an additional benefit if you suffer death or dismemberment as a result of an act of workplace physical violence that is punishable by law.

1

This benefit is not payable if an AD&D Insurance Benefit is payable for the loss of the entire hand.

The Public Transportation provision provides an additional benefit in the event of death as a result of an accident that occurs while you are riding as a farepaying passenger on public transportation.

POLK COUNTY PUBLIC SCHOOLS |

Open Enrollment for 2015

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Short Term Disability Coverage Options Chances are you may already own home, auto and life insurance to protect yourself against the threat of loss. And you probably have health insurance to guard against costly medical bills. But what steps have you taken to help shield yourself and those who count on you from an unexpected loss of income? To help you plan for the unexpected, the Polk County School Board offers both Short and Long Term Disability coverage through The Standard. You can elect one of three short-term disability coverage options. The options have varying benefit waiting periods and maximum benefit periods as show below:

Option A

Benefit Waiting Period 7 days

Maximum Benefit Period up to 25 weeks

Option B

14 days

up to 24 weeks

Option C

30 days

up to 22 weeks

Option

The benefit waiting period is the period of time that you must be continuously disabled before benefits become payable. The Maximum Benefit Period is the maximum amount of time can receive benefits. You must exhaust all of your accumulated sick leave before collecting Short Term Disability payments.

Benefit Amount The weekly benefit is up to 60% of your insured predisability earnings. The maximum weekly benefit is $1,750 and the minimum weekly benefit is $15. This amount is then reduced by other income you receive or are eligible to receive while STD benefits are payable. This other income is referred to as deductible income. Deductible income is income you receive or are eligible to receive while STD benefits are payable. It includes but is not limited to the following:

Benefits under any state disability income benefit law or similar law. Earnings from work activity while disabled. Any amount you receive by compromise, settlement or other method as a result of a claim for any of the above.

Premium You can estimate your monthly payroll deduction by using the worksheet below: Enter average weekly earnings, not to exceed $1,750 on Line 1.

1: _____________

Multiply Line 1 by 0.60 and enter on Line 2.

2: _____________

Select your rate from the table below and enter on Line 3.

3: _____________

Multiply Line 2 by the amount entered on Line 3.

4: _____________

Divide the amount on Line 4 by 10 and enter on Line 5.

5: _____________

The amount shown on Line 5 is your estimated monthly payroll deduction.

STD Rate Table Waiting Period Age as of 01/01/15

Option A 7 day

Option B 14 day

Option C 30 day

≤29 30-34 35-39 40-44 45-49 50-54 55-59 60+

$1.31 $1.45 $0.94 $0.70 $0.76 $0.80 $1.03 $1.31

$0.92 $1.00 $0.62 $0.44 $0.47 $0.50 $0.64 $0.81

$0.64 $0.70 $0.43 $0.29 $0.31 $0.33 $0.42 $0.53

POLK COUNTY PUBLIC SCHOOLS |

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Open Enrollment for 2015

Long Term Disability Premium

Coverage Group Long Term Disability (LTD) insurance is designed to pay a monthly benefit to you in the event you cannot work because of a covered illness or injury. This benefit replaces a portion of your income, thus helping you to meet your financial commitments in a time of need. The Long Term Disability (LTD) benefit level is up to 60% of pre-disability earnings. The maximum monthly benefit is $7,500 and the minimum monthly benefit is $100. If your claim for Long Term Disability benefits is approved by The Standard, benefits become payable after you have been continuously disabled for 180 days and remain continuously disabled. Benefits are not payable during the benefit waiting period. You must exhaust all of your accumulated sick leave. After 180 days of continuous disability the LTD benefit amount is determined by multiplying your insured monthly pre-disability earnings by 60%. This amount is then reduced by other income you receive or are eligible to receive while LTD benefits are payable. This other income is referred to as deductible income.

Maximum Benefit Period If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins: Age 62 63 64 65 66 67 68 69+

Maximum Benefit Period 3 years 6 months 3 years 2 years 6 months 2 years 1 year 9 months 1 year 6 months 1 year 3 months 1 year

You can estimate your monthly payroll deduction by using the worksheet below: Enter average weekly earnings, not to exceed $1,750 on Line 1.

1: _____________

Multiply Line 1 by 0.60 and enter on Line 2.

2: _____________

Select your rate from the table below and enter on Line 3.

3: _____________

Multiply Line 2 by the amount entered on Line 3.

4: _____________

Divide the amount on Line 4 by 10 and enter on Line 5.

5: _____________

The amount shown on Line 5 is your estimated monthly payroll deduction.

LTD Rate Table Age as of 01/01/15