This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official plan and insurance documents govern your right and benefits under each plan. For more details about your benefits, including a complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Web site under “Employee Benefits.” www.leusd.k12.ca.us 2016-17 Employee Benefits Booklet Confidential Management/ Admin. Lake Elsinore Unified School District
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This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official
plan and insurance documents govern your right and benefits under each plan. For more details about your benefits, including a
complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under
This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official
plan and insurance documents govern your right and benefits under each plan. For more details about your benefits, including a
complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under
“Employee Benefits.” www.leusd.k12.ca.us
Important Information About Your Benefits
This section includes some important notices about your right and responsibilities as a
participant in the District’s plans. If you have any additional questions about this
information, feel free to contact the Safety & Risk Services department at (951) 253-
7000, ext. 5380.
Important Notice About Your Rights and Benefits Under Each Plan This booklet is intended to provide only highlights of your benefits; it is not an Evidence
of Coverage (EOC) plan document. Official plan and insurance documents govern your
rights and benefits under each plan. For more details about your benefits, including a
complete list of exclusions and limitations, please refer to each carrier’s EOC. A copy of
the EOC can be obtained from the Lake Elsinore Unified School District website:
www.leusd.k12.ca.us.
Notice of Health Insurance Portability and
Accountability Act of 1996 (HIPAA) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal
law that affects your rights to obtain health benefits and to safeguard your privacy
regarding Protected Health Information (PHI). Specifically, HIPAA includes, but is not
limited to, the following:
Limitations on pre-existing condition exclusions;
Prohibitions against discriminating against individual participants and
beneficiaries based on health status;
Special enrollment periods under certain conditions for qualified individuals; or
Privacy standards
COBRA Rights Once an employee and/or dependent lose coverage, SISC prepares and mails the
COBRA 14-day notification to the qualified beneficiary’s last known address. It
includes information and rates on all of the products the qualified beneficiary is enrolled
in through SISC immediately preceding the qualifying event (loss of coverage).
In this incentive plan, Delta Dental pays 70% of the contract allowance for covered basic services and major services during the first year of eligibility. The coinsurance percentage will increase by 10% each year (to a maximum of 100%) for each enrollee if that person visits the dentist at least once during the year. If an enrollee does not use the plan during the calendar year, the percentage remains at the level attained the previous year. If an enrollee becomes ineligible for benefits and later regains eligibility, the percentage will drop back to 70%.
Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26
Deductibles N/A
Deductibles waived for D & P? N/A
Maximums The maximum benefit paid per calendar year is $1,200* per person in-network (this amount includes the additional $200 for using a PPO dentist. See note above under Network)
The maximum benefit paid per calendar year is $1,000 per person out-of-network
Waiting Period(s) Basic Benefits
None
Major Benefits None
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for out-of-network dentists.
Delta Dental of California 100 First St. San Francisco, CA 94105
Customer Service 866-499-3001
Claims Address P.O. Box 997330 Sacramento, CA 95899-7330
deltadentalins.com This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.
Plan Benefit Highlights for: PPO Incentive ($1,200/$1,000) no Orthodontic
Group No: Active, Retirees, and Cobra
Network: PPO/Premier *The plan provides an additional $200 toward the calendar year maximum when you visit a PPO dentist. Look for this information for the dentist of your choice on the Delta find a provider website to take advantage of this additional amount: (Other network affiliations: Delta Dental PPO)
Endodontics (root canals) Covered Under Basic Services
70-100 % 70-100% UCR
Periodontics (gum treatment) Covered
Under Basic Services 70-100 % 70-100% UCR
Oral Surgery Covered Under Basic Services
70-100 % 70-100% UCR
Major Services Crowns, inlays, onlays, and cast restorations
70-100 % 70-100% UCR
Prosthodontics Bridges, dentures, implants
50 % 50% UCR
Dental Accident Benefits 100% (separate $1,000 maximum per person per calendar year)
Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26
Deductibles In-Network: N/A
Out-of-Network: $25 per person, $75 per family, per plan year
Deductibles waived for D & P? In-Network: N/A
Out-of-Network: No
Maximums The maximum benefit paid per calendar year is $2,000 per person in-network
The maximum benefit paid per calendar year is $1,000 per person out-of-network
Waiting Period(s) Basic Benefits
None
Major Benefits None
Orthodontics None
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists.
Delta Dental of California 100 First St. San Francisco, CA 94105
Customer Service 866-499-3001
Claims Address P.O. Box 997330 Sacramento, CA 95899-7330
deltadentalins.com
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.
Plan Benefit Highlights for: PPO $2,000 with Orthodontic
Group No: Active and Cobra, (Retirees - exclude Orthodontic)
Endodontics (root canals) Covered Under Basic Services
100 % 50 %
Periodontics (gum treatment) Covered Under Basic Services
100 % 50 %
Oral Surgery Covered Under Basic Services
100 % 50 %
Major Services Crowns, inlays, onlays and cast restorations
100 % 50 %
Prosthodontics Bridges, dentures, implants
50 % 50 %
Orthodontic Benefits Adults and dependent children
100% 100%
Orthodontic Maximums Separate $3,000 Lifetime maximum per person
Dental Accident Benefits 100% (separate $1,000 maximum per person per calendar year)
50%
SISC and VSP provide you an affordable eyecare plan.
Signature Plan C $20
Your Coverage from a VSP Doctor
WellVision Exam® focuses on your eye health and
overall wellness .......................... every calendar year Prescription Glasses Lenses ........................................ every calendar year • Single vision, lined bifocal, lined trifocal lenses
and tints.• Polycarbonate lenses for dependent children.
Frame ......................................... every calendar year • $150.00 allowance for frame of your choice• $170.00 featured frame brands• 20% off the amount over your allowance• $80 allowance at Costco
~OR~Contact Lens Allowance .......... every calendar year$105.00 allowance for contacts and the contact lens exam (fitting and evaluation). .
Extra Discounts and Savings
Glasses and Sunglasses
• Average 35 - 40% savings on all non-covered lensoptions
• 30% off additional glasses and sunglasses, includinglens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam
Contacts
• 15% off cost of contact lens exam (fitting andevaluation)
Laser Vision Correction
• Average 15% off the regular price or 5% off thepromotional price. Discounts only available from contracted facilities.
• After surgery, use your frame allowance (if eligible)for sunglasses from any VSP doctor
Co-Payments
Exam and Prescription Glasses Co-payment varies, contact VSP for additional information.
If you see a non-VSP provider, you’ll receive a lesser benefit. Before seeing a non-VSP provider, call us at 800.877.7195 for more details.
Out-of-Network Reimbursement Amounts: Exam ....................................................... Up to $35.00 Single vision lenses ................................. Up to $25.00 Lined bifocal lenses ................................. Up to $40.00 Lined trifocal lenses ................................. Up to $50.00 Frame ...................................................... Up to $30.00 Contacts .................................................. Up to $90.00
VSP guarantees service from VSP doctors only. In the event of a conflict between this information and your organization's contract with VSP, the terms of the contract will prevail.
Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. MDLIVE phone consultations are available 24/7/365, while video consultations are available during the hours of 7 am to 9 pm 7 days a week or by scheduled availability. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit www.mdlive.com/pages/terms.html 010113
24/7/365 on-demand access to affordable, quality healthcare. Anytime, Anywhere.
With MDLIVE, you can visit with a doctor 24/7 from your home, office or on the go. Our network of Board Certified doctors is available by phone or secure video to assist with non-emergency medical conditions.
Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today.
Download the App
When should I use MDLIVE?
Instead of going to the ER or an urgent care center for a non-emergency issue
During or after normal business hours, nights, weekends and even holidays
If your primary care doctor is not available
To request prescription refills (when appropriate)
If traveling and in need of medical care
How much does it cost?Your copay for this service is:
Who are our doctors?
MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.
MDLIVE.com/SISC 1-888-632-2738
$5*All enrolled SISC PPO members and Anthem HMO members.
Common Conditions We Treat■ Allergies■ Asthma■ Bronchitis■ Cold & Flu■ Diarrhea■ Ear Infections■ Fever■ Headache■ Infections
Use Grand Rounds to receive second opinions and schedule office visits with top doctors. Whether you want to learn about a new diagnosis, confirm a course of treatment, or find a great specialist in your insurance network, we can help. It’s a free new benefit for you and your family, 100% covered by SISC.
Grand Rounds connects you with world-class doctors for expert medical guidance. And we handle all the legwork:• Matching you to a top physician for your exact medical needs
• Scheduling appointments for you and your family
• Collecting health records from previous doctors
• Providing support and guidance throughout the process
Get the medical care you deserve.
*In accordance with federal and state law, and professional ethical standards.
Have there been a few bumps in the road?
Have questions about home, work or family?
How we can help
When you or a household member contacts us, we’ll work with you to figure out the next steps. If you need counseling, we can arrange several free visits with a licensed professional. If you have money or legal questions, we can put you in touch with a financial advisor or a lawyer.
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Employee Assistance Program
Maybe you’re a few months behind on bills and want to getback on track. Or you’re new to town and looking for a daycarecenter. Whatever your concern, a call to the EmployeeAssistance Program (EAP) can help you through it.
What is EAP anyway?
You may have heard about EAP but aren’t sure what it is. EAPis a service available to you and members of your householdat no extra cost. It’s designed to help you with everydayproblems and questions, big or small. No need to fill outpaperwork or make an appointment to speak with an EAP staffmember. Just call 800-999-7222 or visit anthemEAP.com.You’ll be connected in an instant, and we’re here 24 hours aday, every day, to help you.
If online help is more your style, visit anthemEAP.com. You’llfind articles, checklists, quizzes and other helpful tools. Youcan browse resources, attend a webinar or take an onlineclass—right at your own desk. Here are just some of the topicscovered:
Remember, EAP is here for you 24/7, so you can call at the time and place that are right for you. Your privacy is important tous. No one will know you’ve called EAP unless you give them permission in writing.*
EAP can help smooth it out. Call 800-999-7222
or go to anthemEAP.com and enter SISC.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name andsymbol are registered marks of the Blue Cross Association.
MCASH3151ABC 2/12
CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | 1025 West Navitus Drive | Appleton, Wisconsin 54913
Share a Clear Viewnavitus.com
Have questions about your pharmacy benefi ts with Navitus Health Solutions? Visit
www.navitus.com for answers!
For information specifi c to your plan, visit Navi-Gate® for Members. Activate your
account online using the Member Login link and an activation email will be sent
to you. The site provides a wealth of information and is available 24 hours a day,
seven days a week. Navi-Gate for Members allows you to access personalized
pharmacy benefi t information online.
Some of the features offered include:
MY PRESCRIPTION BENEFITS
View general information about your pharmacy benefi t.
PHARMACY SEARCH
Find a participating pharmacy in your local area — search
for 24-hour pharmacies, and it provides a map to help you
fi nd a pharmacy.
DRUG SEARCH
Learn about prescription and over-the-counter drugs, how
they are used, warnings and more.
HEALTH INFO
Keep on top of important health news and information.
MAIL ORDER
Learn about available mail order options, if applicable to your pharmacy benefi t.
WHAT’S MY COPAY?
Determine your estimated cost for specifi c prescriptions.
NAVI-GATE® FOR MEMBERSPharmacy Benefi t Information at Your Fingertips
Navi-Gate for
Members Offers
Easier Access
to Your
Prescription
Benefi t
Information
N1045-1213
CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | 1025 West Navitus Drive | Appleton, Wisconsin 54913
Share a Clear Viewnavitus.com
MEDICATION HISTORY
Medication history is displayed for enrollees and dependents in the form of a table for a
specifi ed date range.
DRUG INTERACTIONS
Understand how the effect of a particular drug is altered when taken with another
drug or food. Contains thousands of drug interactions between prescriptions, over-the-
counter drugs, as well as herbal, vitamin and nutritional products. Includes severity
rankings so steps can be taken to lessen harmful effects.
Please contact Navitus Customer Care if you have any additional questions or concerns.
We hope you fi nd Navi-Gate for Members informative and useful.
TO ACCESS, GO TO: WWW.NAVITUS.COM > MEMBERS > MEMBER LOGIN
This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official plan and insurance
documents govern your right and benefits under each plan. For more details about your benefits, including a complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under “Employee Benefits.” www.leusd.k12.ca.us