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BENEFITS


Medical/Rx, Vision, Dental, Flexible Spending & BuyOut / BuyDown 
Contact:  Karen DelPriore    Phone:  315-635-4545     Email:  kdelpriore@bville.org

The Benefit's Office is now located in the transportation building at 2810 West Entry Drive, B'ville.
 
Information regarding WellNow Urgent Care's decision to leave the Excellus participating provider network effective January 1, 2024.  
Excellus has created a microsite to help members find options for care; visit ExcellusBCBS.com/CareOptions
The website includes information on:
  • How to find a primary care doctor if you don’t have one
  • Accessing telehealth services
  • A list of alternative in-network urgent care providers by county
Our plan does allow you to use an out-of-network provider, but you most likely will have a higher out of pocket cost (the difference between what the provider charges and what the plan will pay).  Excellus will reimburse the member the allowable costs.*   You may need to pay up front and submit the claim to Excellus yourself.  You need to check with the out-of-network provider on their billing and payment process for out-of-network services.  
*Please note, this is not a guarantee of benefits and benefit eligibility will be determined by Excellus based upon the date of service and benefit plan in place at the time of service.
 

TELEMEDICINE INFORMATION:
Excellus has partnered with MDLIVE for telemedicine services.
FLYER - What is Telemedicine?  
FLYER - TeleHealth vs. TeleMedicine 
GUIDE - TeleMed Frequently Asked Questions
YOUTUBE - How to Register for MDLIVE®   https://youtu.be/AHsTshf2fbM
YOUTUBE - How to Use MDLIVE®  https://youtu.be/i6podzKJm4Q
 

MEDICAL INSURANCE INFORMATION:
Enrollment booklets - for medical, vision and dental plans along with an enrollment form:  BESPA    BTA    CSEA    BAPIS    NonAligned    BTSSA    Public Library
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 ID cards are issued all enrolled members, with each dependents' name listed on the front.  Dental and vision ID cards with only list the name of the subscriber.

Medical Plan Summaries (SBC): 
  ♦ BTA    ♦ BESPA    ♦ BAPIS    ♦ CSEA     ♦ Non Aligned     ♦ Administrators    ♦ BTSSA    ♦ Public Library 

International TravelCoverage 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
RATES for MEDICAL PLAN 
Medical Insurance Rates for Active Employees :   2023-24 Medical Rates   effective 9/1/2023 through 8/31/2024
                                                         
MEDICAL PLAN FORMS Enrollment booklets - for medical, vision and dental plans along with an enrollment form:
  BESPA    BTA    CSEA    BAPIS    NonAligned    BTSSA    Public Library


Enrollment Form  Use this form for initial enrollments and changes to current enrollment.  

Extra Dependents Form  Use this form as an additional page to the enrollment 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) 
BTA    ♦ BAPIS    ♦ CSEA     ♦ Non Aligned     ♦ Administrators   ♦ BTSSA    
BESPA - Rx $5/20/40   ♦ BESPA - Rx $5/10/25            

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   - To update your banking information used to pay for retiree premiums. 
 

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. 
    ♦ 
Vision ID cards will only display the name of the subscriber (dependents are not named on the card).
    ♦ Benefit provides coverage for routine eye exams and eyeglasses or contacts.

Vision Plan Description: Davis Vision Summary
VISION PLAN CONTACT INFORMATION DAVIS VISION
    ♦ PHONE: Davis Vision 
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 the 'Multiple Polices' drop down at top center of the page.  Next, click the secure link to the Davis Vison portal (blue button on the bottom right) to 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.  NOTE: You must a 'Davis Vision' claim form, not an 'Excellus' Vision claim form to submit a manual claim.
 
DENTAL INSURANCE INFORMATION:  
DENTAL
FORMS
Enrollment Form - Excellus Dental - For dental enrollments.
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
    ♦ 
Dental ID cards will only display the name of the subscriber (dependents are not named on the card).
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)
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.
STUDENT CERTIFICATION Student Certification: - Unmarried dependents between the ages of 19 and 25 are eligible for dental coverage only if they are certified as full time students.
Student Certification Form - Form required by Excellus to certify students.  Must be mailed directly to Excellus.
RATES for DENTAL PLAN  Dental Insurance Rates for active employees:  2023-24 Dental Rates   effective 9/1/2023 through 8/31/2024
 

 
FLEXIBLE SPENDING ACCOUNT (FSA) INFORMATION:
 
 

FLEXIBLE SPENDING ACCOUNT
INFORMATION

 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 November 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.
FSA  
CLAIMS
 Reimbursement Methods:
    ♦ FSA Health Spending Visa CardUse 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 
FSA
FORMS
  Enrollment Kit - For Flexible Spending Accounts (FSA) in calendar year 2024
  Enrollment Form Only - For enrollment in 2024 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 elections require 3 items to be submitted for approval:
  1. Buy Out / Buy Down Election Form:   ♦ BTA          ♦ BESPA           CSEA         
  2. Benefit Verification Form:   Benefit Verification Form 
  3. 'Proof of Other Coverage' - a letter from the employer or insurance carrier confirming coverage and listing all insured dependents, a dated screenshot from an insurance portal, etc.  Insurance ID cards alone are not sufficient proof.