Health, Rx, Dental, Flexible Spending & Buy Out / Buy Down Elections
Contact: Karen DelPriore Phone: 315-635-4545 Email: email@example.com
O P E N E N R O L L M E N T for Flexible Spending Accounts (FSA)
Open Enrollment for the 2018 Flexible Spending Account (FSA) has begun and will end at the close of business on Thursday, November 16, 2017.
A FSA is an IRS Section 125 Cafeteria Plan that allows employees to withhold pre-tax payroll deductions and use the funds
to pay for qualifying unreimbursed medical, dental, vision expenses and dependent care.
This is a calendar year benefit and deductions are withheld over 20 pay periods.
All full time and part time employees who work a minimum of 20 hours per week are eligible to participate in the plan.
Health Care Account for out-of-pocket medical expenses such as office visit copays, prescription drug copays,
orthodontics, vision care, hearing aids, dental services and eligible over-the-counter (OTC) items, and more.
The 2018 maximum annual contribution to a Health Care FSA is $2,650.
Dependent Care Account for daycare expenses for dependent children under age 13 or a disabled spouse
or other dependent who resides with you and is claimed on your federal tax return.
The 2018 maximum annual contribution to a Dependent Care FSA is $5,000 (per couple).
Completed forms should be returned to Karen DelPriore / Benefits Office in the District Office no later than Thursday, November 16, 2017.
Please note: A separate enrollment form must be completed for each calendar year of participation in the plan.
Enrollment in this benefit does not automatically rollover to the next calendar year.
For returning participants: All direct deposit information on file will continue into the new plan year unless you
update your account by completing the ‘Direct Deposit’ form. The Health Spending Cards should continue
to be used in the new plan year. New cards are not re-issued each calendar year. Cards are reissued only when they expire.
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.
NOTE: On January 1, 2017 Excellus contracted Express Scripts as the new provider of retail pharmacy benefit
management services, replacing MedImpact/FLRx. This change affects all retail (in-store) prescription claims processing.
As a result of this change, all subscribers were issued new Excellus Identification Cards in November 2016. The new ID cards
list the new pharmacy information of RxGRP: EXLHPRX, RxBIN: 003858, RxPCN: A4. Subsciber ID numbers remain unchanged.
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