Medical/Rx, Vision, Dental, Flexible Spending & BuyOut / BuyDown
IRS Forms 1095-B and 1095-C for the 2019 Tax Year
As an employer, the District is required to mail IRS Form 1095-C to all employees who had an offer of health insurance coverage
as an active employee for at least one month during the calendar year 2019.
Part III of this form is left blank because member and dependent enrollment is tracked and reported by Excellus, via a separate IRS form, the 1095-B.
In the past Excellus has mailed out the Form 1095-B to members. This has changed for the 2019 tax year. The IRS no longer
requires insurance companies, like Excellus, to mail the 1095-B forms to members. If needed, the forms are available
to download on the Excellus website at www.ExcellusBCBS.com. Website instructions
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: www.ExcellusBCBS.com/cnycoop
♦ MEMBER PORTAL: www.ExcellusBCBS.com/cnycoop
♦ Register online - Online Account tip sheet
♦ View plan benefits, request ID cards, check claim status, view authorizations, and more
Medical Provider Search 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 of CNY.
♦ 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 Rate Sheets: 1920 Rates for Active Employees hired prior to 10/01/2018
1920 Rates for Active Employees hired on and after 10/01/2018
|MEDICAL PLAN FORMS||Enrollment Form Use this form for initial enrollments and changes to current enrollment. 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.
Medical Plan Summaries (SBC):
♦ BESPA - Rx $5/20/40 ♦ BESPA - Rx $5/10/25 ♦ BESPA - Rx $1/1/1 ♦ BESPA - Rx $1/5/5 ♦ BESPA - Rx $5/5/5
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 under the group Lifetime Benefit Solutions.
♦ All medical plan participants are automatically enrolled in the Davis Vision plan.
♦ Members receive a separate identification card for the Davis Vision coverage from Lifetime Benefit Solutions.
♦ 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 - 1-800-553-2942
♦ CLAIMS: Vision Care Unit, PO Box 1525, Latham, NY 12110.
♦ WEBSITE: www.davisvision.com
♦ MEMBER PORTAL: davisvision.com/member
- View benefit information, print ID cards, participating providers, and more
|VISION PLAN FORMS||♦ Davis Vision Claim Form Direct Reimbursement Claim Form - for visits to an out of network provider|
|Dental Enrollment Form - For initial dental enrollments
Dental Change Form - Add dependents, switch plans, change address, etc
Dental Cancel Form - Cancel a subscriber and/or dependent(s)
Claim Form - Use to manually submit a dental claim
Privacy Authorization Form - For access to claims of spouse and dependents age 18 and older.
|LIFETIME BENEFIT SOLUTIONS
♦ PHONE: Customer Service - 1-888-800-0922 or 315-671-9812
♦ CLAIMS: Lifetime Benefit Solutions, Dental TPA, P.O. Box 21951, Eagan, MN 55121
♦ WEBSITE / PORTAL: http://www.lifetimebenefitsolutions.com
- Create an account, available 24/7
- View plan benefits, explanation of benefits form, claim status, and payment status, request ID cards, etc.
|Plan Summaries (one-page):
♦ 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)
|Dental Provider Search - Direct link http://providers.lifetimebenefitsolutions.com/pages/search.aspx
- Scroll down to the Dental Solutions provider network.
|STUDENT CERTIFICATION||Student Certification: - Dependents Age 19 to 25 must be certified, full time students to be eligible for dental.
Student FAQ's - Summary of requirements for dependents age 19 to 25
Student Certification Form - Form required by dental carrier
|DENTAL PLAN RATES||Employee premium cost, per pay period, for dental coverage
♦ 2019-20 School Year Rates 1920 Dental Rates
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 & 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.
♦ 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.
| 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.
♦ Medical Reimbursement Form ♦ Dependent Care Reimbursement Form
| Enrollment Kit - For Flexible Spending Accounts (FSA) in calendar year 2020
Enrollment Form Only - For enrollment in 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 DOWN ELECTION FORMS
♦ Buy Out / Buy Down election forms must be submitted to the Human Resources Office for approval.