Transcript ABC Company

Strategic Forecasting, Inc.
Employee Benefits
2003 - 2004 Plan Year
Gallagher Romine
Table of Contents
•
Gallagher Romine Contact Information
1
•
Benefits and Customer Service Information
2
•
Open Enrollment
3
•
Notice Regarding the Women’s Health & Cancer Act
4
•
HMO Terms & Conditions
5
•
HMO Benefits
•
HMO Prescription Drug Incentive
8
•
PPO Terms & Conditions
9
•
PPO Benefits
•
PPO Prescription Drug Incentive
12
•
Myths & Facts about Generic Drugs
13
•
Dental Benefits
14
•
Vision Benefits
15
•
Group Term Life & AD&D Benefits
16
•
Long Term Disability Benefits
17
6-7
10 - 11
Benefit Specialist
Gallagher Romine:
Contact Information
Gallagher Romine: We’re Here to Help!
The
Insurance
Company
Gallagher
Romine
YOU!
Gallagher Romine is here to act as a liaison in your dealings with insurance carriers.
If you are having problems getting claims paid or have questions regarding your
coverage, let us deal with the insurance company for you! Please contact anyone at
Gallagher Romine with questions regarding your employee benefits package.

Account Manager:
Valerie Seymour

Claims Representatives:
Jeanne Holy
Nikki Lamberty
Cheri Dillard
Lydia Lara
Phone:
Fax:
(512) 499-8005 / (800) 492-8005
(512) 499-0412
E-mail:
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Page 1
Benefits & Customer
Service Information
The following benefits are offered through Blue Cross Blue Shield:

Medical Insurance
Customer Service:
HMO Group #: 08807N
PPO Group #: 08807
800-521-2227
www.bcbstx.com
The following benefits are offered through Jefferson Pilot (formerly Guarantee Life):

Dental Insurance
Customer Service:
Group #: 01-D005425
800-523-2144
www.jpfinancial.com
The following benefits are offered through VSP:

Vision Insurance
Customer Service:
Group #: 12182159
800-216-6248
www.vsp.com
The following benefits are offered through Hartford:


Life Insurance
Long Term Disability Insurance
Customer Service:
Group #: GLT-707173
800-523-2233
www.hartfordlife.com
Page 2
Open Enrollment
The open enrollment period for eligible employees of Strategic Forecasting will be October 1, 2003 to
October 31, 2003. The new benefit plan will be effective November 1, 2003. An eligible employee is
one who works 30 or more hours per week. Employees are encouraged to add dependents or make
any changes to their current level of benefits during this time. Individuals are able to make changes or
add dependents without having to provide evidence of insurability. The open enrollment for this plan
year will apply to Medical coverage. The open enrollment period is the only time employees may enroll
in the above listed coverages or make modifications without the occurrence of a qualifying event (see
definition below). Credit will be given towards the satisfaction of the pre-existing limitation clause, if you
and/or your dependents have maintained continuous coverage for the past 12 months with no more
than a 63 day lapse in coverage. You and/or your dependents will receive a HIPAA certificate at
termination from your previous carrier to provide proof of prior coverage.
Qualifying Event - an event or change in status which allows an individual to make changes to their level of
coverage, outside the open enrollment period, without a penalty. The following are examples of qualifying
events:
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Marriage
Divorce
Death of a spouse or dependent
Birth
Adoption
Commencement or termination of a spouse’s employment
Change from full-time to part-time employment, or vice versa, of employee or spouse
Commencement of unpaid leave of absence by employee or spouse
Substantial change in insurance coverage of employee or spouse due to spouse’s employment
IRS regulations require that for enrollment due to a qualifying event, change forms
must be submitted to your benefits office within 31 days of that qualifying event.
Contact your Human Resources office for these forms.
This summary of benefits is intended only to highlight your benefits and should not be relied upon to fully determine
coverage. Please refer to your Certificate of Coverage for a complete listing of services, limitations and exclusions. The
Certificate of Coverage prevails in the event of discrepancies.
Page 3
Notice Regarding the Women’s
Health & Cancer Rights Act of 1998
Under federal law, group health plans and health insurance issuers providing
benefits for a mastectomy must also provide, in connection with the
mastectomy for which the participant or beneficiary is receiving benefits,
coverage for:
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
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reconstruction of the breast on which the mastectomy has been performed;
surgery and reconstruction of the other breast to produce a symmetrical
appearance; and
prostheses and physical complications of mastectomy, including
lymphedemas;
These benefits must be provided in a manner determined in consultation
between the attending physician and the patient. These benefits may be subject
to annual deductibles and coinsurance provisions that are appropriate and
consistent with other benefits under your plan or coverage.
This summary of benefits is intended only to highlight your benefits and should not be relied upon to
fully determine coverage. Please refer to your Certificate of Coverage for a complete listing of
services, limitations and exclusions. The Certificate of Coverage prevails in the event of
discrepancies.
Page 4
HMO Terms and Conditions
Pre-Existing Condition Limitations: This does not apply to the HMO benefit.
You will receive the full benefit regardless of past medical coverage.
Non-Network Benefits: The HMO does not offer Non-Network benefits except
in the case of life or limb threatening emergencies.
Primary Care Physician (PCP): You must seek care from your selected PCP.
Women may select an OB/GYN as a secondary PCP. Each family member may
utilize a different physician.
Copayments: Deductibles do not apply. You will pay a copayment for services.
Out-of-Pockets: Copayments apply to the Out-of-Pocket Maximum.
Dependent Age Limitation: Your dependent children are eligible for coverage
on your medical plan until the age of twenty-five.
This summary of benefits is intended only to highlight your benefits and should not be
relied upon to fully determine coverage. Please refer to your Summary of Benefits for a
complete listing of services, limitations and exclusions. The Summary of Benefits prevails
in the event of discrepancies.
Page 5
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Page 7
Blue Cross Blue Shield - HMO
Generic Prescription Drug Incentive
The “generic incentive” program requires plan participants and
their doctors to choose a generic equivalent (when available)
over a brand name drug. If a plan participant chooses to
purchase a brand name drug when there is a generic equivalent
available, they will be charged the co-pay for the generic drug
plus the cost difference between the brand and generic drug.
Please note that this program will apply even if the
prescribing doctor writes the prescription “dispense as
written”.
Page 8
PPO Terms and Conditions
Note: Pre-Existing Condition Limitations do not apply to current Strategic Forecasting
employees who have been enrolled on the health plan for 12 months.
Pre-Existing Condition Limitations: Conditions treated or diagnosed 6 months prior to your
hire date will not be covered for 12 months unless you have maintained continuous coverage for
the past 12 months with no more than a 63-day gap in coverage. You should receive a HIPAA
certificate at termination from your current carrier to provide proof of coverage. It is important
that you keep this certificate and/or complete this section on the new carrier’s application
to avoid future claims being denied.
Benefit Payments: For benefits received in the Network, you are responsible only for your
copayment or deductible amount and coinsurance. Your provider will file the claim. Benefits for
Non-Network visits are payable on a reimbursement basis only. You can be subject to additional
charges over the reasonable and customary allowed amount.
Copayment: Copayments for Office visits and Prescription drugs do not count toward the
deductible or out-of-pocket maximum.
Dependent Age Limitation: Your dependent children are eligible for coverage on your medical
plan until the age of twenty-five.
This summary of benefits is intended only to highlight your benefits and should not be relied
upon to fully determine coverage. Please refer to your Summary of Benefits for a complete
listing of services, limitations and exclusions. The Summary of Benefits prevails in the event of
discrepancies.
Page 9
Page 10
Page 11
Blue Cross Blue Shield - PPO
Generic Prescription Drug Incentive
The “generic incentive” program requires plan participants and
their doctors to choose a generic equivalent (when available)
over a brand name drug. If a plan participant chooses to
purchase a brand name drug when there is a generic equivalent
available, they will be charged the co-pay for the brand name
drug plus the cost difference between the brand and generic
drug. Please note that this program will apply even if the
prescribing doctor writes the prescription “dispense as
written”.
Page 12
Myths and Facts about Generic Drugs
Myth: Generics take longer to act in the
body.
Fact: The firm seeking to sell a generic drug
must show that its drug delivers the
same amount of active ingredient in the
same timeframe as the original product.
Myth: Generics are not as potent as brandname drugs.
Fact:: The FDA requires generics to have
the same quality, strength, purity and
stability as brand-name drugs.
Myth: Generics are not as safe as brandname drugs.
Fact: The FDA requires that all drugs be
safe and effective and that their
benefits outweigh their risks. Since
generics use the same active
ingredients and are shown to work the
same way in the body, they have the
same risk-benefit profile as their brandname counterparts.
Myth: Brand-name drugs are made in
modern manufacturing facilities, and
generics are often made in substandard facilities.
Fact: The FDA won’t permit drugs to be
made in substandard facilities. It
conducts about 3,500 inspections a
year in all firms to ensure standards are
met. Generic firms have facilities
comparable to those of brand-name
firms. In fact, brand-name firms account
for an estimated 50% of generic drug
production. They frequently make
copies of their own or other brandname drugs but sell them without the
brand name.
Myth: Generic drugs are likely to cause
more side effects.
Fact: There is no evidence of this. The FDA
monitors reports of adverse drug
reactions and has found no difference
between generic and brand-name
drugs.
FDA Requirements for Brand-Name
and Generic Drugs

For reformulations of a brand-name
drug or generic versions of a drug,

FDA reviews data showing the drug
is bioequivalent to the one used in
the original safety and efficacy
testing.

FDA evaluates the manufacturer’s
adherence to good manufacturing
practices before the drug is
marketed.
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FDA reviews the active and inactive
ingredients used in the formulation
before the drug is marketed.
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FDA reviews the actual drug
product.
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FDA reviews the drug’s labeling.
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Manufacturer must seek FDA
approval before making major
manufacturing changes or
reformulating the drug.
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Manufacturer must report adverse
reactions and serious adverse
health effects.
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FDA periodically inspects
manufacturing plants.

FDA monitors drug quality after
approval.
Page 13
Dental Benefits

Deductible:
$50 (3 per family)
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Preventive Care:
100% (deductible waived)
Diagnostic X-rays
CLeanings and Examinations (limited to 2 per Cal. Year)
Fluoride Treatment (up to age 19; limit 1 per Cal. year)
Space Maintainers

Basic Care:
Emergency Treatment
Fillings
Dental Sealants (up to age 17)
Non-Surgical Extractions
Oral Surgery
Endodontic Services
Periodontic Services
80% after deductible

Major Care:
Prosthodontic Services
Restorative Services
50% after deductible

Calendar Year Maximum:
$1,500

Orthodontia:
(children under age 19)
50% (deductible waived)

Orthodontia Lifetime Maximum:
$1,500
This summary of benefits is intended only to highlight your benefits and should not be relied upon to
fully determine coverage. Please refer to your Certificate of Coverage for a complete listing of
services, limitations and exclusions. The Certificate of Coverage prevails in the event of
discrepancies.
Page 14
Page 15
Group Term Life
and AD&D Benefits
Benefit:
1 x Annual Salary
Benefit Maximum:
$250,000
Guarantee Issue Amount:
$150,000
Age Reductions:
35% at age 65
35% at age 70
35% at age 75
25% at age 80
25% at age 85
Age Reductions - the life benefit will be reduced by the respective percentage
amounts shown above once an individual has attained age 65, 70, 75,80 and
again at 85.
Accidental Death
& Dismemberment:
1 x Annual Salary
This summary of benefits is intended only to highlight your benefits and should not be relied upon
to fully determine coverage. Please refer to your Summary of Benefits for a complete listing of
services, limitations and exclusions. The Summary of Benefits prevails in the event of discrepancies.
Page 16
Long Term Disability Insurance
Monthly Benefit:
60% of income
Maximum Monthly Benefit:
$10,000
Elimination Period:
90 days
Maximum Benefit Duration:
Social Security Normal Retirement Age
Own Occupation:
24 months
Mental / Nervous Limitation:
24 months
Substance Abuse Limitation:
24 months
Benefits Integration:
Full Family Direct
Pre-existing Conditions:
3/3/12
This summary of benefits is intended only to highlight your benefits and should not be relied upon
to fully determine coverage. Please refer to your Summary of Benefits for a complete listing of
services, limitations and exclusions. The Summary of Benefits prevails in the event of
discrepancies.
Page 17