Health, Rx, Dental, Flexible Spending & Buy Out / Buy Down Elections
Contact: Karen DelPriore Phone: 315-635-4545 Email: firstname.lastname@example.org
Dental Provider Network change
On January 1, 2018 the District's network of Dental Providers changes to Dental Solutions.
Dental Solutions replaces the Prime 31 Dental Network. New dental identification cards were mailed to
your home address from Lifetime Benefit Solutions in December 2017.
MEDICAL INSURANCE INFORMATION:
Open enrollment for Medical Insurance is in September for an effective date of October 1.
Enrollment & Change Form - Updates must be done within 30 days of date of eligibility or status change (birth, divorce, medicare eligibility, loss of coverage, etc.)
Claim Form - Medical - Use to manually submit a medical claim
Claim Form - BlueCard Worldwide - Use to submit claims incurred outside the U.S.
Medicare Eligibility Form - Use to notify of an insured's medicare eligibility for any reason (Age, Disability or ESRD). Copy of medicare card required.
Privacy Authorization Form - For access to claims of spouse and dependents age 18 and older.
Student Certification - Currently not required for medical coverage.
CUSTOMER SERVICE - EXCELLUS (BlueCross BlueShield)
♦ PHONE: 1-800-499-1275
♦ CLAIMS: EXCELLUS, P.O. BOX 22999, ROCHESTER, NY 14692-2999
|COVERAGE WHEN TRAVELING ABROAD :
♦ BlueCard Worldwide Information - How your healthcare benefits work outside of the United States. Requires use of BlueCard Worldwide claim form.
AGE 26 LAW:
♦ Age 26 Information - Federal Health Care Law that allows for the enrollment of eligible young adults to age 26 as a dependent on a parent's medical coverage. Use the enrollment and change form above.
AGE 29 LAW:
♦ Age 29 Information - NYS law that allows for the enrollment of eligible young adults to age 29 on their own individual plan at 100% of the premium cost.
♦ Age 29 Enrollment Form - Mail form & payment directly to Excellus
COORDINATION OF BENEFITS (COB):
♦ COB Information ♦ COB Questionaire Form
MARKETPLACE - Notice to Employees of Health Insurance Marketplace
|Buy Out / Buy Down Election Forms: Election forms must be submitted to the Human Resources Office for approval. Requests for changes to medical coverage must be submitted to the Benefits Office before payroll deductions and coverages can be updated.
♦ BTA ♦ BESPA ♦ CSEA
PRESCRIPTION INSURANCE INFORMATION:
Enrollment in pharmacy benefit is concurrent with medical plan participation.
DENTAL INSURANCE INFORMATION:
Open enrollment for Dental Insurance is in September for an effective date of October 1.
|Prescription Information: Use your Excellus Member ID card for prescription purchases.
Express Scripts - Retail (in-store) pharmacy management service under contract with Excellus as of 1/1/2017.
Pharmacy Customer Service: 1-800-499-1275 Option 2
Pharmacist Inquiry Line: 1-800-922-1557
For a list of participating pharmacies in your area, visit www.ExcellusBCBS.com or contact customer service.
To manually submit a pharmacy claim, complete and submit the Pharmacy Claim Form.
|Home Delivery - Prescriptions by mail:
Express Scripts - Mail Order pharmacy management service under contract with Excellus as of 1/1/2016.
Mail Order Member Services: 1-855-315-5220
How to get started? Set up a Mail Order Member Acccount online at www.Express-Scripts.com or by calling Member Services at 1-855-315-5220. Express Scripts Mail Order Welcome letter.
How to send in a new mail order prescription:
By Mail - Send in paper scripts from your doctor along with a completed Rx Mail Order form to the address provided on the mail order form.
By Fax - Bring the Mail Order Doctor Fax form to your next doctor visit. Doctor must complete and fax the form.
By e-Prescribe - Ask your doctor to electronically submit a script to Express Scripts.
|Formulary Guide: Use the Excellus Formulary Guide (drug list) to determine the tier level of your medication. The specific copayments of drug tiers is contractually determined and is available in the Plan Comparisons / Documents in the green Medical section above. The formulary also lists medications that are subject to prior authorization and step therapy requirements.
|CUSTOMER SERVICE - Lifetime Benefit Solutions - Dental TPA (formerly EBS-RMSCO)
♦ PHONE: 1-888-800-0922 or 315-671-9812
♦ CLAIMS: Lifetime Benefit Solutions, Dental TPA, P.O. Box 780, Liverpool, NY 13088-0780
♦ Plan 1 - Premium plan
♦ Plan 2 - With orthodontic coverage - 50% & $1,500 lifetime maximum (children and adults)
♦ Plan 1 - Premium plan (100/100/80% and $2,000 calendar year maximum) No orthodontics.
♦ Plan 2 - Orthodontic plan (100/80/60/50% and $1,250 calendar year maximum)
STUDENT CERTIFICATION - Requirements for dependents age 19 to 25
Employee premium cost, per pay period, for dental coverage
♦ 2017-18 School Year Rates - Dental Rate Sheet
FLEXIBLE SPENDING ACCOUNT (FSA) INFORMATION:
Open enrollment for Flexible Spending is in November for an effective date of January 1.
1. FSA Health Spending Visa Card - Use card to directly debit from your account at point of service. No claim forms needed, but all receipts must be maintained.
2. FSA Website - Submit form & receipts on line.
3. Fax - Submit form & receipts by fax at 1-877-256-7228.
4. Mail - Submit form & receipts by mail to: Lifetime Benefit Solutions, FSA Claims Dept,
P.O. BOX 680, Liverpool, NY 13088
|FSA CUSTOMER SERVICE - Lifetime Benefit Solutions
♦ PHONE: 1-800-327-7130