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Health, Rx, Dental, Flexible Spending & Buy Out / Buy Down Elections
Contact:  Karen DelPriore    Phone:  315-635-4545     Email:

Open enrollment for the Flexible Spending Account (FSA) will be during the month of November for a January 1, 2019 start date.
 Cooperative Health Insurance Fund:  
Power Point PresentationPresentation for Informational Meetings
VISION PLAN As of October 1, 2018 vision coverage is provided by Davis Vison through 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. 

Vision Plan Description: Davis Vision Summary
Phone: Customer Service - 1-877-923-2847
Website: - Set up a Member Account
Print a temporary card for Davis Vision at this linkDavis Vision ID cards.
Plan Information
Deduction Rates
As of October 1, 2018 all medical plans automatically converted to a new plan, Excellus Classic Blue, as offerred through the Cooperative Health Insurance Fund.  New Excellus identification cards (with a new subscriber ID number) have been mailed.  Prescription drug coverage will continue to be provided through Excellus under the new Classic Plan.  

    ♦ PHONE: 1-877-253-4797
    ♦ CLAIMS: EXCELLUS, P.O. BOX 21146, EAGAN, MN 55121

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 documentation includes copies of social security cards and birth certificates for ALL enrollees; as well as marriage licenses and court orders and child support orders, if appropriate.

Privacy Authorization Form - For access to claims of spouse and dependents age 18 and older.

Medical Self Service Web Account (Excellus)
    ♦ First time users can register online -  Online Account tip sheet
    ♦ View your plan benefits, request ID cards, check claim status, view authorizations, and more
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 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 Summaries (SBC):  Please note, the individual "out of pocket limit" shown on page 1 of the SBC is comprised of 1) the annual coinsurance maximum ($400.00), 2) the annual deductible ($50.00) and 3) the prescription maximum ($1,000 or $2,000 - dependent upon your contractual Rx benefit).

  ♦ BTA    ♦ BESPA    ♦ BAPIS    ♦ CSEA     ♦ Non Aligned     ♦ Administrators    ♦ BTSSA    ♦ Public Library 

Medical Insurance Rates1819 Rates for Active Employees hired prior to 10/01/2018
Retired Members
Medical Plan Summaries (SBC):  Please note, the individual "out of pocket limit" shown on page 1 of the SBC is comprised of 1) the annual coinsurance maximum ($400.00), 2) the annual deductible ($50.00) and 3) the prescription maximum ($1,000 or $2,000 - dependent upon your contractual Rx benefit).
BTA    ♦ BAPIS    ♦ CSEA     ♦ Non Aligned     ♦ Administrators    ♦ BTSSA    ♦ Public Library
BESPA - Rx $5/20/40   BESPA - Rx $5/10/15 (changes to $5/10/25 10/1/18)   
BESPA - Rx $1/1/1     BESPA - Rx $1/5/5      BESPA - Rx $5/5/5   
Vision Plan Description: Summary
Medical Insurance Rates:  1819 Rates for Retirees     
PRESCRIPTION INFORMATIONEnrollment in pharmacy benefit is concurrent with medical plan participation.
♦ As of October 1, 2018, prescription purchases at a local retail pharmacy are now limited to a 30 day supply.  Three month (90 day) maintenance prescriptions are only available by mailorder - through Express Scripts and Wegmans Home Delivery. 
♦ Initial fills of new prescriptions are limited to a 30 day supply.
♦ Use your Excellus Member ID card for prescription purchases.
RETAIL (local in-store) PRESCRIPTIONS - must use a participating pharmacy.  For a listing of pharmacies in your area, visit or contact customer service.

Pharmacy Customer Service: 1-877-253-4797
Pharmacist Inquiry Line: 1-800-922-1557

To manually submit a pharmacy claim, complete and submit the Pharmacy Claim Form.
MAIL ORDER PRESCRIPTIONS - available through Express Scripts and Wegmans Home Delivery

Express Scripts -  Member Services: 1-855-315-5220  

ExpressScripts Info Sheet Set up a Mail Order Member Acccount online at or by calling Member Services at 1-855-315-5220. 
Express Scripts Forms: Rx Mail Order form  Mail Order Doctor FAX 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

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 Medical section. 

DENTAL INSURANCE INFORMATION:  Open enrollment for Dental Insurance is in September for an effective date of October 1.
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)
Student Certification Form - Dependents Age 19 to 25 must be full time students
Claim Form - Use to manually submit a dental claim (contains old address, pending update)
Privacy Authorization Form - For access to claims of spouse and dependents age 18 and older.
CUSTOMER SERVICE - Lifetime Benefit Solutions - Dental TPA  (formerly EBS-RMSCO)
    ♦ PHONE: 1-888-800-0922 or 315-671-9812
    ♦ PAPER CLAIMS:  Lifetime Benefit Solutions, Dental TPA, P.O. Box 21951, Eagan, MN 55121

    ♦ 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- Dependents Age 19 to 25 must be certified, full time students to be eligible for dental.
Student Certification Form - Form required by dental carrier
STUDENT Information - Summary of requirements for dependents age 19 to 25 
Employee premium cost, per pay period, for dental coverage
    ♦ 2018-19 School Year Rates - Dental Rate Sheet
DENTAL LINKS     ♦ Website
    ♦ Direct link to Dental Web Portal
          - Log on or create an account, available 24/7
          - View your plan benefits, claim status, and payment status, request ID cards, etc.
          - View and download your Explanation of Benefits (EOB) forms
   ♦ Dental Provider Search
          - Direct link
          - Scroll down to Dental Solutions
            As of January 1, 2018 the provider network is Dental Solutions; replacing Dental Prime SCH31.
FLEXIBLE SPENDING ACCOUNT (FSA) INFORMATION:  Open enrollment for FSA is in November for an effective date of January 1.

Enrollment Kit  - For Flexible Spending Accounts (FSA) in calendar year 2018
Enrollment Form
- For FSA Open Enrollments - medical and dependent care. 
REIMBURSEMENT FORMS:  Use to manually (fax or mail in) submit claims.
    ♦ Medical Reimbursement Form 
    ♦ Dependent Care Reimbursement Form 
    ♦ Claim Terms & Conditions
Data Change Form - Use to update your address, name changes, etc.
Direct Deposit Form - Use to have reimbursements directly deposited into your bank account.
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


    1.  FSA Health Spending Visa CardUse 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 
FSA Summary Plan Description
    ♦ FSA Listing of Eligible Expenses 
    ♦ Website
    ♦ FSA Web Portal   
         - Log on or create an account, available 24/7
         - View your account summary, track contributions and and payment status   
    ♦ FSA Store -
         - Use your flexible spending account and discover surprisingly FSA eligible products
         - Quickly determine FSA eligible products - with and without a doctor's prescription.
         - Competitive pricing and discounts, free shipping over $50 and a quick turnaround. 
         - Pay with your FSA debit card as well as all major credit cards. 
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