BENEFITS
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Medical/Rx, Vision, Dental, Flexible Spending & BuyOut / BuyDown |
MEDICAL INSURANCE INFORMATION:
| MEDICAL PLAN CONTACT INFORMATION |
EXCELLUS (Blue Cross Blue Shield) ♦ PHONE: Customer Service 1-877-253-4797 ♦ CLAIMS: EXCELLUS, P.O. BOX 21146, EAGAN, MN 55121 ♦ WEBSITE & MEMBER PORTAL: www.ExcellusBCBS.com (You can see all your Excellus plans in one portal) ♦ Create an online member account - Online Member Account Guide ♦ View plan benefits, request ID cards, check claim status, view authorizations, and more Medical Provider Search - Direct link https://www.excellusbcbs.com/find-a-doctor/provider. Search the Excellus national Blue Card network to find a participating doctor, hospital, urgent care, etc. The prefix for Classic Blue is VYW. |
| MEDICAL PLAN INFORMATION |
The District's medical offering is the Classic Blue Traditional plan that is administered by Excellus BCBS.
♦ as offerred through the Cooperative Health Insurance Fund. ♦ Calendar year deductible is $50 per individual with a $150 family maximum. ♦ After deductible, the annual co-insurance maximum is $400 per individual with a $1,200 family maximum. ♦ Prescription drugs are subject to a separate co-payment schedule and out-of-pocket maximum. Medical Plan Summaries (SBC): ♦ BTA ♦ BESPA ♦ BAPIS ♦ CSEA ♦ Non Aligned ♦ Administrators ♦ BTSSA ♦ Public Library International Travel: Coverage available under Blue Cross Blue Shield Global Core (formerly BlueCard Worldwide®) • Global Core brochure • Visit www.bcbsglobalcore.com. • Call the Service Center at 1.800.810.2583 |
| PRESCRIPTION DRUG INFORMATION: |
EXCELLUS Pharmacy Customer Service
♦ PHONE: 1-877-253-4797 ♦ Enrollment in pharmacy benefit is concurrent with medical plan participation. RETAIL (local in-store) PRESCRIPTIONS ♦ Use your Excellus Member ID card for prescription purchases. ♦ Prescription purchases at a local retail pharmacy are limited to a 30 day supply. ♦ To manually submit a pharmacy claim, complete and submit the Pharmacy Claim Form. 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 SBC's. MAIL ORDER PRESCRIPTIONS: ♦ Maintenance prescriptions (90 day supply) are only available by mail order. ♦ Initial fills of new prescriptions are limited to a 30 day supply. Express Scripts - Member Services: 1-855-315-5220 Set up a Mail Order Acccount at www.Express-Scripts.com ExpressScripts Info Sheet Express Scripts Forms: Rx Mail Order form Wegmans Home Delivery - Member Services: 1-800-586-6910 Set up a Home Delivery Account Wegmans Home Delivery Info Sheet Wegmans Home Delivery Form: Wegmans Home Delivery form |
| MEDICAL PLAN RATES | Medical Insurance Rates for Active Employees : 2022-23 Medical Rates effective 9/1/2022 through 8/31/2023 |
| MEDICAL PLAN FORMS | Enrollment Form Use this form for initial enrollments and changes to current enrollment. Extra Dependents Form Use this form if you have more than 3 dependents to enroll or update. Updates must be done within 30 days of date of eligibility or status change (birth, divorce, medicare eligibility, loss of coverage, etc.). Support documentation must be included with enrollment forms. Required documents include copies of birth certificates and social security cards for all enrollees; as well as marriage licenses, financial proof (tax return), court orders and child support orders, if appropriate. Privacy Authorization Form - For access to claims of spouse and dependents age 18 and older. Additional information is available on the Excellus website - under Manage Your Privacy. Claim Form - Medical - Use to manually submit a medical claim. Medicare Eligibility Form - Use to notify of an insured's medicare eligibility for any reason (Age, Disability or ESRD). Copy of medicare card required. |
| RETIRED MEMBERS |
Medical Plan Summaries (SBC):
♦ BESPA - Rx $5/20/40 ♦ BESPA - Rx $5/10/25 ♦ BESPA - Rx $1/5/5
Medicare Eligibility form: Medicare Eligibility Form - Use to notify of an insured's medicare eligibility for any reason (Age, Disability or ESRD). Copy of medicare card required. AutoPay Authorization form: AutoPay form |
VISION INSURANCE INFORMATION:
| VISION PLAN INFORMATION | The District's vision benefit is provided by Davis Vison and andministered by Excellus as of 9/1/2022. ♦ All medical plan participants are automatically enrolled in the Davis Vision plan. ♦ Members receive a separate identification card from Excellus/Davis Vision. ♦ Benefit provides coverage for routine eye exams and eyeglasses or contacts. Vision Plan Description: Davis Vision Summary |
| VISION PLAN CONTACT INFORMATION | DAVIS VISION ♦ PHONE: Customer Service - 1-888-921-1194 ♦ CLAIMS: Vision Care Unit, PO Box 1525, Latham, NY 12110. ♦ MEMBER PORTAL: www.ExcellusBCBS.com Login & Select 'Simply Vision Gold' from drop down at top of page. - View benefit information, print ID cards, find participating providers, and more |
| VISION PLAN FORMS | ♦ Davis Vision Claim Form Claim Form for direct reimbursement; for visits to an out-of-network provider |
DENTAL INSURANCE INFORMATION:
| DENTAL FORMS |
Enrollment Form - Excellus Dental - For dental enrollments effective 9/1/2020. Extra Dependents Form Use this form if you have more than 3 dependents to enroll or update. Claim Form - Excellus Dental - Use to manually submit a dental claims. Privacy Authorization Form - For access to claims of spouse and dependents age 18 and older. |
| DENTAL CONTACT INFORMATION |
EXCELLUS BLUE CROSS BLUE SHIELD as of 9/1/2020 ♦ PHONE: Excellus Dental Customer Service - 1-800-724-1675 ♦ CLAIMS: Excellus Dental Claims, P.O. Box 21146, Eagan, MN 55121 ♦ WEBSITE & MEMBER PORTAL: www.excellusbcbs.com Create an online member account - Online Member Account Guide View plan benefits, request ID cards, check claim status, view authorizations, and more |
DENTAL PLAN INFORMATION |
Plan Summaries: ♦ Plan 1 - Excellus Premium plan ♦ Plan 2 - Excellus Orthodontic plan |
| Plan Descriptions: ♦ 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; $1,500 lifetime ortho maximum) |
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| Dental Provider Search - Direct link https://www.excellusbcbs.com/find-a-doctor/provider - The provider networks include Dental Blue Options and National Dental GRID+ DenteMax effective 9/1/22. |
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| STUDENT CERTIFICATION | Student Certification: - Dependents Age 19 to 25 must be certified, full time students to be eligible for dental. Student Certification Form - Form required by Excellus to certify students. Must be mailed directly to Excellus. |
| DENTAL PLAN RATES | Dental Insurance Rates for active employees: 2022-23 Dental Rates effective 9/1/2022 through 8/31/2023 |
FLEXIBLE SPENDING ACCOUNT (FSA) INFORMATION:
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FLEXIBLE SPENDING ACCOUNT |
Flexible Spending Accounts (FSA)
FSA is a calendar year benefit (January through December) and deductions are withheld over 20 pay periods. Open enrollment for FSA is in September for an effective date of January 1. You may elect one or both of the following: ♦ Health Care Account (HCA) for out-of-pocket medical expenses such as copays, prescription drugs, orthodontics, vision care, hearing aids, dental services and eligible over-the-counter (OTC) items, and more. ♦ Dependent Care Account (DCA) for daycare expenses for dependent children under age 13, who are claimed on your federal tax return, a disabled spouse or other dependent on your tax return who resides with you and is physically or mentally disabled. ♦ Website Portal Instructions ♦ FSA Summary Plan Description |
| FSA CONTACT INFORMATION |
LIFETIME BENEFIT SOLUTIONS
♦ PHONE: Customer Service 1-800-327-7130 ♦ WEBSITE / PORTAL: www.lifetimebenefitsolutions.com
- Create an online account to view your account summary, track contributions and and payment status ♦ FSA Store - https://fsastore.com// - Use your flexible spending account and discover surprisingly FSA eligible products - Quickly determine FSA eligible products - with and without a doctor's prescription.
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| FSA CLAIMS |
Reimbursement Methods: ♦ FSA Health Spending Visa Card - Use card to directly debit from your account. No claim forms needed, but all receipts must be maintained and are subject to verification. ♦ FSA Website - Submit form & receipts on line. ♦ Fax - Submit form & receipts by fax at 1-877-256-7228. ♦ Mail - Submit form & receipts by mail to: Lifetime Benefit Solutions, FSA Claims Dept, P.O. BOX 211126, Eagan, MN 55121 ♦ FSA Claiming Terms & Conditions. Reimbursement Forms: ♦ Medical Reimbursement Form ♦ Dependent Care Reimbursement Form |
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FSA
FORMS
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Enrollment Kit - For Flexible Spending Accounts (FSA) in calendar year 2023 Enrollment Form Only - For enrollment in 2023 medical reimbursement and/or dependent care accounts. Medical Necessity Form - Some services and products are only eligible for reimbursement when certified medically neccessary by a doctor or other provider. Privacy Authorization Form - Use to allow access to account information to a spouse, etc. |
| BUY OUT BUY DOWN ELECTION FORMS |
♦ Buy Out / Buy Down election forms must be submitted to the Human Resources Office for approval.
♦ Written requests to cancel coverage and/or dependents from your policy must be submitted to the Benefits Office before payroll deductions and coverages can be updated.
♦ BTA ♦ BESPA ♦ CSEA ♦ Benefit Verification Form |
