Shelton School District Benefit Handbook 2016-2017
Shelton School District #309 A Summary of Health and Welfare Benefits 2016-17 Open Enrollment August 22 September 30 Benefit Fair August 30, 9:00 a.m. 1:00 p.m. Olympic Middle School
BENEFIT/HEALTH FAIR Back To School News 2016-17 Insurance Update The Shelton School District is pleased to announce the annual Shelton Benefits Fair, Tuesday, August 30, 2016. All benefits vendors have been invited to attend the Benefits Fair to provide up-to-date information and answer questions from employees and their family members. The Benefits Fair will be held from 9:00 a.m. to 1:00 p.m. at Olympic Middle School. DISTRICT CONTRIBUTIONS The District contribution toward your insurance premium amount is driven by the amount of money the District receives from the state. This year the state monthly contribution for a full time employee is $780.00 per month. The specific amount of contribution received by each employee is based on hours worked and is set by bargaining agreements. Due to state legislation that requires every school district employee to pay a portion of the premium charge for medical coverage, every district employee will pay a minimum of 3% of the medical insurance premium as an out-of-pocket cost. INSURANCE POOL When employees do not utilize their full District contribution, the amount is placed in a district pool (pooled by bargaining group) and distributed to those who are paying out of pocket. After open enrollment is complete (September 30), Payroll adjusts the pool beginning with the October pay warrant based on 2016-17 usage. OPEN ENROLLMENT Employees have an opportunity to change their benefit programs, drop coverage or enroll in new programs during the Open Enrollment Period, which is August 22, 2016 through September 30, 2016. All changes must be submitted by September 30 and will effective November 1, 2016. The open enrollment period to add, delete, or change your medical, vision or dental insurance coverage is August 22, 2016 through September 30, 2016. Please complete the enrollment information carefully. New enrollment and enrollment changes for Premera Medical, and all vision and dental coverage must be done on-line at http://resources.hewitt.com/wea. Group Health enrollment and changes will need to be done on a paper form. Please check your October payroll stub for the correct medical deduction. All Open Enrollments/changes must be done by September 30, 2016.
The benefit pool will be calculated in October, after the open enrollment period. Your October 31, 2016 pay warrant will reflect the 2016-17 pooling amount. CHANGES IN MEDICAL INSURANCE COVERAGE It is important that you review the premium comparison sheets found in the insurance information included in this packet. Medical insurance representatives for Group Health, and Premera Blue Cross will be at the Benefits Fair on August 30,, 2016 to answer your questions. ASSISTANCE Remember, if you ever have questions or wish to provide input to the insurance committee, you can do so by contacting any of the following: ESP SEA SEOP Teamsters Admin District Sheila Iversen, Choice High School Ron Goodale, Shelton High School Jamie Dobson, Shelton High School Anne Chappell, MCTC Pat Cusack, Shelton School District Tami Ford, Payroll & Benefits Coordinator Tracey Burnfield, Payroll Assistant Brenda Trogstad, Director of Finances Linda Arnold, Director of Human Resources
Enrollment changes for insurance need to be completed by September 30, 2016 in order to be effective November 1, 2016. The information contained in this brochure is only an outline and highlights of benefits offered. This information is not a contract. Each plan described herein excludes certain conditions and types of treatment from coverage or payment. To fully understand and use your benefits, you will need more details than these brief descriptions can provide. All features are subject to general and contract benefit provisions, limitations, and exclusions. If you have questions regarding your benefits please contact the district office. You may also contact our insurance agent Jeff McHargue or John Lester with Arnold Smith Insurance at 426-3317. District office contacts: 426-1687 Tami Ford Tracey Burnfield Payroll & Benefits Coordinator Payroll Assistant Dental, Vision, and Orthodontia are mandatory for all eligible employees to enroll in. Medical coverage is optional.
Group: SHELTON SCHOOL DISTRICT #309 Group#: 1234500, 1234300 Reference ID#: RQ-102387 For Attachment to Group Medical Coverage Agreement INSIDE THE NETWORK: MANAGED CARE PROVIDERS Group Health Cooperative Benefit Description $0 100% $2,000 2x $20 $20 $15/$30/M2X $100/3 $100 Deductible Coinsurance Out of Pocket Family Ded & OOP Max. Office Visit Copay Outpatient Surgery Copay Prescription Drug Copay Hospital Inpatient Copay Emergency Room Copay No PEC wait Group Offering: Dual Choice MONTHLY HEALTH CARE PREMIUM This schedule reflects monthly premium effective: 11/1/2016-10/31/2017 Subscriber $ 955.01 Subscriber & Spouse $1,858.29 Subscriber & Child(ren) $1,337.48 Subscriber, Spouse & Child(ren) $2,240.67
Benefit Summary Shelton School District #309 Group Number: 1234500 Effective Date 11/1/2016 Health Plan Group Health Ref RQ-102387 This is a brief summary of benefits. THIS IS NOT A CONTRACT OR CERTIFICATE OF COVERAGE. All benefit descriptions, including alternative care, are for medically necessary services. The Member will be charged the lesser of the cost share for the covered service or the actual charge for that service. For full coverage provisions, including limitations, please refer to your certificate of coverage. In accordance with the Patient Protection and Affordable Care Act of 2010, The lifetime maximum on the dollar value of covered essential health benefits no longer applies. Members whose coverage ended by reason of reaching a lifetime limit under this plan are eligible to enroll in this plan, and Dependent children who are under the age of twenty-six (26) are eligible to enroll in this plan. Benefits Plan deductible Individual deductible carryover Plan coinsurance Out-of-pocket limit Inside Network No annual deductible Not applicable No plan coinsurance Individual out-of-pocket limit: $2,000 Family out-of-pocket limit: $4,000 Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit: Pre-existing condition (PEC) waiting period Lifetime maximum Outpatient services (Office visits) Hospital services Prescription drugs (some injectable drugs may be covered under Outpatient services) Prescription mail order Acupuncture All cost shares for covered services No PEC Unlimited $20 copay Inpatient services: $100 copay, per day for up to 3 days per admit Outpatient surgery: $20 copay Preferred generic/preferred brand $15/$30 copay per 30 day supply 2 x prescription cost share per 90 day supply Ambulance services Plan pays 80%, you pay 20% Chemical dependency Devices, equipment and supplies Durable medical equipment Orthopedic appliances Post-mastectomy bras limited to two (2) every six (6) months Ostomy supplies Prosthetic devices Covered up to 8 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by the plan $20 copay Inpatient: $100 copay, per day for up to 3 days per admit Outpatient: $20 copay Covered in full Diabetic supplies Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.
Diagnostic lab and X-ray services Emergency services (copay waived if admitted) Hearing exams (routine) Hearing hardware Home health services Hospice services Infertility services Manipulative therapy Massage services Maternity services Mental Health Naturopathy Newborn Services Obesity-related surgery (bariatric) Organ transplants Inpatient: Covered under Hospital services Outpatient: Covered in full High end radiology imaging services such as CT, MR and PET must be determined Medically Necessary and require prior authorization except when associated with Emergency care or inpatient services. $100 copay at a designated facility $100 copay at a non designated facility $20 copay Not covered Covered in full. No visit limit. Covered in full Not covered Covered up to 10 visits per calendar year without prior authorization $20 copay See Rehabilitation services Inpatient: $100 copay, per day for up to 3 days per admit Outpatient: $20 copay. Routine care not subject to outpatient services copay. Inpatient: $100 copay, per day for up to 3 days per admit Outpatient: $20 copay Covered up to 3 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by the plan $20 copay Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother. Not covered Unlimited, no waiting period Inpatient: $100 copay, per day for up to 3 days per admit Preventive care Well-care physicals, immunizations, Pap smear exams, mammograms Rehabilitation services Rehabilitation visits are a total of combined therapy visits per calendar year Skilled nursing facility Sterilization (vasectomy, tubal ligation) Temporomandibular Joint (TMJ) services Tobacco cessation counseling Routine vision care (1 visit every 12 months) Optical hardware Lenses, including contact lenses and frames Outpatient: $20 copay Covered in full Women's preventive care services (including contraceptive drugs and devices and sterilization) are covered in full. Inpatient: 30 days per calendar year $100 copay, per day for up to 3 days per admit Outpatient:45 visits per calendar year $20 copay Covered in full up to 60 days per calendar year Inpatient: $100 copay, per day for up to 3 days per admit Outpatient: $20 copay Women's sterilization procedures are covered in full. Inpatient: $100 copay, per day for up to 3 days per admit Outpatient: $20 copay Quit for Life Program - covered in full $20 copay Not covered Coverage provided by Group Health Cooperative RQ-102387
WEA Select Health Plans Monthly Rates Effective November 1, 2016 Premera Blue Cross Plan 5/Foundation Employee Only $1,133.45 Employee & Spouse $2,178.35 Employee, Spouse & Child(ren) $2,624.25 Employee & Child(ren) $1,546.60 Plan 2 Employee Only $979.90 Employee & Spouse $1,793.75 Employee, Spouse & Child(ren) $2,150.55 Employee & Child(ren) $1,308.40 Plan 3 Employee Only $895.85 Employee & Spouse $1,640.10 Employee, Spouse & Child(ren) $1,966.50 Employee & Child(ren) $1,196.30 EasyChoice Plan Employee Only $659.70 Employee & Spouse $1,198.70 Employee, Spouse & Child(ren) $1,436.35 Employee & Child(ren) $875.30 Basic Plan Employee Only $532.55 Employee & Spouse $966.80 Employee, Spouse & Child(ren) $1,158.20 Employee & Child(ren) $706.25 QHDHP Employee Only $516.80 Employee & Spouse $938.05 Employee, Spouse & Child(ren) $1,108.40 Employee & Child(ren) $685.30
WEA Select Medical Plans Effective November 1, 2016 Plan 5 Plan 2 Plan 3 Provider Network Foundation Heritage Heritage Copayments, Deductible & Coinsurance In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Copayments Non-specialist Copay $20* 30% $25* $30* $30* $40* Specialist Copay $30* 30% $35* $40* $40* $50* Inpatient Copay (per person) $150 per day, $450 Max PCY None $150 per day, $450 Max PCY $300 per day, $900 Max PCY Outpatient Surgery Copay None $100 $150 ER Copay (waived if admitted) $50 $75 $100 Deductible Deductible PCY Individual $200 $350 $300 $500 Family $600 $350/family member $900 $1,500 Coinsurance Coinsurance 10% 30% 20% 40% 20% 40% Out-of-Pocket Maximum PCY** Individual $1,000 No limit $2,000 $3,400 $3,000 $5,900 includes copays, deductible and coinsurance Family $3,000 No limit $6,000 $10,200 $9,000 $17,700 Covered Services In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Office Visits Professional Care Medical and Naturopathic Office Visits unlimited Spinal and Other Manipulations unlimited visits (chiropractic) Acupuncture 12 visits PCY (Plan 5 unlimited visits) Preventive Care Exams/Immunizations Preventive Screenings (includes mammography and colon health screenings) Diagnostic Services $20* 30% $25* $30* $30* $40* $0* Not covered $0* 20%* $0* 20%* Diagnostic Imaging/Laboratory Ded + Coin Ded + Coin Ded + Coin Hospital/Facility Care Outpatient Ded + Coin Outpatient Surgery Copay+Ded+Coin Outpatient Surgery Copay+Ded+Coin Inpatient Inpatient Copay + Ded + Coin Inpatient Copay + Ded + Coin Inpatient Copay + Ded + Coin Ded + Coin Maternity Prenatal/Postnatal Care Ded + Coin Ded + Coin Ded + Coin Ded + Coin Maternity Delivery (newborns have their own copays, deductibles, and coinsurance) Emergency Care Inpatient Copay + Ded + Coin Ded + Coin See Outpatient or Inpatient Hospital / Facility Care See Outpatient or Inpatient Hospital / Facility Care Professional / Facility ER Copay + Ded + Coin ER Copay + Ded + Coin ER Copay + Ded + Coin Ambulance (air and ground) Deductible +$50 Ded + Coin Ded + Coin Other Services Mental Health Outpatient unlimited visits $20* 30% $25* $30* $30* $40* Inpatient Copay + Mental Health Inpatient unlimited days Ded + Coin Inpatient Copay + Ded + Coin Inpatient Copay + Ded + Coin Ded + Coin Rehabilitation Outpatient 45 visits PCY (PT, Massage, Speech, OT) (2 & 3: PT unlimited) Rehabilitation Inpatient 5&3: 30 days PCY, 2: 120 days PCY Prescription Drugs (participating pharmacies) $30* 30% $35* PT Ded + Coin $40* PT Ded + Coin $40* PT Ded + Coin $50* PT Ded + Coin Inpatient Copay + Ded + Coin Inpatient Copay + Ded + Coin Inpatient Copay + Ded + Coin Ded + Coin Generic / Preferred brand-name / Non-preferred brand-name Rx Deductible None None None Rx Out-of-Pocket Maximum** includes Rx copays and Rx deductible $2,000 individual $4,000 family $2,000 individual $4,000 family $2,000 individual $4,000 family Retail Cost Share $10 / $15 / $30 (up to 30-day supply) $10 / $20 / $35 (up to 34-day supply) $15 / $25 / $40 (up to 34-day supply) Mail Order Cost Share $20 / $30 / $60 (up to 90-day supply) $20/ $40 / $65 (up to 100-day supply) $30 / $50 / $70 (up to 100-day supply) Specialty Drug Cost Share up to 30-day supply $50 copay $50 copay $60 copay Drug List (use Rx Search tool at premera.com/wea to find your drug tier) Unum Life and AD&D Insurance Benefits that have changed are highlighted in orange PCY = Per Calendar Year OT = Occupational Therapy PT = Physical Therapy Rx = Prescription Drugs B-4 B-4 B-4 $12,500 Term Life and AD&D for employee only * Not subject to the calendar year deductible ** Once the out-of-pocket maximum is met, covered in-network services are paid at 100% of allowable charges for the remainder of the calendar year. There is no out-of-pocket maximum for Plans 5, EasyChoice A, B and Basic for out-of-network services. Please see the benefit modifications portion of your summary for more information on prior authorization for rehabilitation services. 020683 (07-2016)
WEA Select Medical Plans Effective November 1, 2016 PT = Physical Therapy Rx = Prescription Drugs EasyChoice A EasyChoice B Basic Provider Network Heritage Heritage Prime Heritage Prime Copayments, Deductible & Coinsurance In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Copayments Non-specialist Copay $25* 50% $30* 50% $35* 50% Specialist Copay $35* 50% $40* 50% $50* 50% Inpatient Copay (per person) None None None Outpatient Surgery Copay None None None ER Copay (waived if admitted) $100 $150 $200 Deductible Deductible PCY Individual $1,250 $2,000 $750 $1,500 $2,100 $2,500 Family $3,750 $6,000 $2,250 $4,500 $4,200 $5,000 Coinsurance Coinsurance 20% 50% 25% 50% 30% 50% Out-of-Pocket Maximum PCY** Individual $4,000 No limit $3,500 No limit $6,600 No limit includes copays, deductible and coinsurance (Basic only: shared with Rx OOPM) Family $8,000 No limit $7,000 No limit $13,200 No limit Covered Services In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Office Visits Professional Care Medical and Naturopathic Office Visits unlimited Spinal and Other Manipulations 12 visits PCY (chiropractic) Acupuncture 12 visits PCY Preventive Care $25* 50% $30* 50% $35* 50% Exams/Immunizations $0* Not covered $0* Not covered Not covered Preventive Screenings (includes mammography $0* $0* 50% $0* 50% 50% and colon health screenings) Diagnostic Services Diagnostic Imaging/Laboratory Coin to $250* PCY, then Ded + Coin Ded + Coin Ded + Coin Hospital/Facility Care Outpatient Inpatient Maternity Prenatal/Postnatal Care Maternity Delivery (newborns have their own deductibles and coinsurance) Emergency Care Ded + Coin Ded + Coin Ded + Coin Professional / Facility ER Copay + Ded + Coin ER Copay + Ded + Coin ER Copay + Ded + Coin Ambulance (air and ground) Ded + Coin Ded + Coin Ded + Coin Other Services Mental Health Outpatient unlimited visits $25* 50% $30* 50% $35* 50% Mental Health Inpatient unlimited days Ded + Coin Ded + Coin 30% 50% Rehabilitation Outpatient A and Basic: 30 visits PCY; B: 45 visits PCY (PT, Massage, Speech, OT) Rehabilitation Inpatient A and Basic: 30 days PCY; B: 45 days PCY Prescription Drugs (participating pharmacies) $35* 50% $40* 50% $50* 50% Ded + Coin Ded + Coin 30% 50% Generic / Preferred brand-name / Non-preferred brand-name Rx Deductible (waived for generics) per person PCY $500 $250 $750 individual $1,500 family Rx Out-of-Pocket Maximum** includes Rx copays, Rx deductible and Rx coinsurance $2,500 individual $5,000 family $2,500 individual $5,000 family Shared with medical OOPM Retail Cost Share up to 30-day supply $10 / 30% / 30% $5 / $30 / $45 $15 / $30 / $50 Mail Order Cost Share up to 90-day supply $20 / 30% / 30% $10 / $75 / $112 $30 / $60 / $100 Specialty Drug Cost Share up to 30-day supply 30% 30% 30% Drug List (use Rx Search tool at premera.com/wea to find your drug tier) Unum Life and AD&D Insurance Benefits that have changed are highlighted in orange PCY = Per Calendar Year OT = Occupational Therapy A-2 B-4 B-4 $12,500 Term Life and AD&D for employee only Not covered * Not subject to the calendar year deductible ** Once the out-of-pocket maximum is met, covered in-network services are paid at 100% of allowable charges for the remainder of the calendar year. There is no out-of-pocket maximum for Plans 5, EasyChoice A, B and Basic for out-of-network services. Please see the benefit modifications portion of your summary for more information on prior authorization for rehabilitation services. 037550 (07-2016)
WEA Select Qualified High Deductible Health Plan Effective November 1, 2016 Cost share amounts represent what you pay. All services are subject to the deductible except as noted. Dual WEA coverage is not allowed if you are enrolled in QHDHP. Before enrolling in QHDHP, consider the following: Are you able to pay 100% of your healthcare costs until your deductible is met? If you cover any dependent(s), benefits do not begin until your family deductible is met. There is no deductible carryover. To enroll in this plan, you cannot have any other active coverage, or be a dependent on any other coverage. What are your annual healthcare expenses? Review your claims information and Spending Activity Report from the previous calendar year. Log in to premera.com/wea. Include any elective services planned in the next calendar year, such as surgeries or maternity care. Designed to work with a Health Savings Account (HSA). An HSA is an account you fund to pay for current health expenses not covered by your medical plan, such as deductible and out-of-pocket expenses. For more detailed information, refer to IRS Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans, available at www.irs.gov. Consult your tax advisor to determine tax implications of participating in an HSA. Benefits that have changed are highlighted in orange PCY = Per Calendar Year OT = Occupational Therapy PT = Physical Therapy Rx = Prescription Drugs Provider Network QHDHP Foundation Cost Shares In-Network Out-of-Network Deductible Deductible PCY Individual $1,750 $3,000 Family $3,500 $6,000 Deductible Carryover Not Available Not Available Coinsurance Coinsurance 20% 50% Out-of-Pocket Maximum PCY* Individual $5,000 includes deductible and coinsurance No limit (medical and Rx) Family $10,000 Covered Services In-Network Out-of-Network Preventive Care Exams/Immunizations Not covered Preventive Screenings $0 ** 50% Professional Care Office Visit Outpatient Professional Services Inpatient Professional Services Alternative Care Manipulations (Spinal & Other) 12 visits PCY Acupuncture 12 visits PCY Naturopathic Services Diagnostic Services Mammography (Non-preventive) Outpatient Diagnostic Imaging & Laboratory Services Emergency Care Emergency Care Ambulance (Air or ground) Facility Care Inpatient Care Outpatient Facility Care Maternity Maternity Prenatal Care/Postnatal Care/Delivery (newborns have their own deductibles and coinsurance) Other Services Mental Health Care (Inpatient/outpatient) Rehabilitation Outpatient: 15 visits PCY; Inpatient: 30 days PCY (PT, Massage, Speech, OT) Prescription Drugs *** (subject to medical deductible) Retail Pharmacy up to 30-day supply Mail Order Pharmacy up to 90-day supply Specialty Drugs up to 30-day supply Drug List (use Rx Search tool at premera.com/wea to find your drug tier) Unum Life and AD&D Insurance 20% 50% 20% 50% 20% 50% 20% 20% 20% 50% 20% 50% 20% 50% 20% 20% A-1 $12,500 Term Life and AD&D for employee only * There is no out-of-pocket maximum for out-of-network services. ** Not subject to the calendar year deductible. *** A few generic prescription drugs are not subject to deductible and are covered in full. Note: This summary of benefits and rates is intended to assist you in decision making. Details of covered benefits, limitations, and exclusions are provided in the WEA Select Medical Plan benefit booklets. This summary of benefits and rates is not a contract. 025317 (07-2016)
Shelton School District Certificated, SEOP Group # 00186 Delta Dental PPO - WEA Select Dental Plan A Ortho A Benefit Summary Effective Date November 1, 2016 Benefit Period November 1, 2016 October 31, 2017 Benefit Period Deductible $0 Benefit Period Maximum (Per Person) Delta Dental PPO Delta Dental Premier Non-Participating TMJ Annual Maximum (Per Person) Lifetime Maximum (Per Person) $2,000 $1,750 $1,750 $1,000 $5,000 Orthodontia A Adults & Children Lifetime Maximum (Per Person) $1,000 Monthly Composite Rate $118.35 aa Provider Network Delta Dental Delta Dental PPO Dentist Premier Dentist Class I Diagnostic & Preventive Exams 70% 100% Cleaning (2x per Benefit Period) 70% 100% Fluoride (2x per Benefit Period) 70% 100% X-Rays 70% 100% Sealants 70% 100% Class II Restorative Fillings 70% 100% *Composite Fillings (on any tooth) 70% 100% Endodontics (Root Canal) 70% 100% Periodontics 70% 100% Oral Surgery 70% 100% Crowns & Onlays 70% 100% Class III Major Dentures including Partials 50% Implants 50% Bridges 50% TMJ TMJ 50% Orthodontia Orthodontia 50% Non-Participating Dentist This is a brief summary of your dental benefits and does not include all covered benefits, limitations and exclusions. Please refer to your benefits booklet for a complete list of benefits covered by your plan. *New Benefit - Effective 11/1/2016 Composite fillings are covered on any tooth. Delta Dental of Washington PO Box 75983 Seattle WA 98175-0983 800.554.1907 DeltaDentalWA.com/WEA WEABenefitSummary00186A 0716
Here s some important information to help you use your benefits: Your WEA Select Dental Plan A encourages you to use your benefits every benefit period. When you use your benefits in the current benefit period, your benefits will increase by 10% in the next benefit period, up to a maximum of 100%. If you don t use your benefits during any benefit period, the benefit level will decrease by 10% in the next benefit period, but will not drop below 70%. Here s how it works: Current benefit period coverage level Use benefit Next benefit period coverage goes up 10% Use benefit Next benefit period coverage goes up 10% Finding a participating dentist Under your plan, you can choose dentists from two networks: Delta Dental PPO or Delta Dental Premier. You can find a participating, in-network, dentist in your area by visiting DeltaDentalWA.com/WEA and using our Find a Dentist tool. We recommend you select the Delta Dental PPO network to filter your search results. The advantages of seeing a Delta Dental PPO or Delta Dental Premier dentist We encourage you to see a Delta Dental network dentist because they provide treatments at discounted rates and file all claims paperwork for you. We will pay our portion and you re only responsible for your stated deductibles, coinsurance and/or amounts in excess of the plan maximums. In most cases, you will experience the greatest out-of-pocket savings if you choose a dentist from the Delta Dental PPO network. Visiting your participating, in-network, dentist Be sure to tell your dentist you re covered by Delta Dental of Washington and give them your member identification number, plan name and group number. Visiting a non-participating, out-of-network, dentist You are not limited to using a Delta Dental network dentist. You may use any licensed dentist. If you choose a non-participating dentist, you will be responsible for ensuring the dentist completes your claim forms and that the claims are sent to us. Claim payments will be based on actual charges or our maximum allowable fees for nonparticipating dentists, whichever is less. You re then responsible for any balance remaining after we pay. Unlike our participating dentists, we have no control over non-participating dentists charges or billing procedures. Confirmation of Treatment and Cost (Formerly called Predeterminations) If you are considering extensive treatments such as crowns, oral surgery, periodontics or prosthodontics, we recommend you ask your dentist to request a predetermination from us. We will process the request and provide you and your dentist with a Confirmation of Treatment and Cost (Confirmation). The confirmation will show you what procedures will be covered, an estimate of what Delta Dental of Washington will pay and your expected financial responsibility. Confirmations are based on the treatment plan submitted by your dentist and the covered dental benefits available to you at the time the Confirmation is issued. Confirmations are estimates, not guarantees of payment. Have a question? Give us a call at 800.554.1907, Monday Friday from 7 am to 5 pm, Pacific Time. We re happy to help. Delta Dental of Washington PO Box 75983 Seattle WA 98175-0983 800.554.1907 DeltaDentalWA.com/WEA WEABenefitSummary00186A 0716
Shelton School District Administrators, ESP, Non-represented Group # 00186 Delta Dental PPO - WEA Select Dental Plan A Ortho B Benefit Summary Effective Date November 1, 2016 Benefit Period November 1, 2016 October 31, 2017 Benefit Period Deductible $0 Benefit Period Maximum (Per Person) Delta Dental PPO Delta Dental Premier Non-Participating TMJ Annual Maximum (Per Person) Lifetime Maximum (Per Person) $2,000 $1,750 $1,750 $1,000 $5,000 Orthodontia B Children Only Lifetime Maximum (Per Person) $1,000 Monthly Composite Rate $113.60 aa Provider Network Delta Dental Delta Dental PPO Dentist Premier Dentist Class I Diagnostic & Preventive Exams 70% 100% Cleaning (2x per Benefit Period) 70% 100% Fluoride (2x per Benefit Period) 70% 100% X-Rays 70% 100% Sealants 70% 100% Class II Restorative Fillings 70% 100% *Composite Fillings (on any tooth) 70% 100% Endodontics (Root Canal) 70% 100% Periodontics 70% 100% Oral Surgery 70% 100% Crowns & Onlays 70% 100% Class III Major Dentures including Partials 50% Implants 50% Bridges 50% TMJ TMJ 50% Orthodontia Orthodontia 50% Non-Participating Dentist This is a brief summary of your dental benefits and does not include all covered benefits, limitations and exclusions. Please refer to your benefits booklet for a complete list of benefits covered by your plan. *New Benefit - Effective 11/1/2016 Composite fillings are covered on any tooth. Delta Dental of Washington PO Box 75983 Seattle WA 98175-0983 800.554.1907 DeltaDentalWA.com/WEA WEABenefitSummary00186A 0716
Here s some important information to help you use your benefits: Your WEA Select Dental Plan A encourages you to use your benefits every benefit period. When you use your benefits in the current benefit period, your benefits will increase by 10% in the next benefit period, up to a maximum of 100%. If you don t use your benefits during any benefit period, the benefit level will decrease by 10% in the next benefit period, but will not drop below 70%. Here s how it works: Current benefit period coverage level Use benefit Next benefit period coverage goes up 10% Use benefit Next benefit period coverage goes up 10% Finding a participating dentist Under your plan, you can choose dentists from two networks: Delta Dental PPO or Delta Dental Premier. You can find a participating, in-network, dentist in your area by visiting DeltaDentalWA.com/WEA and using our Find a Dentist tool. We recommend you select the Delta Dental PPO network to filter your search results. The advantages of seeing a Delta Dental PPO or Delta Dental Premier dentist We encourage you to see a Delta Dental network dentist because they provide treatments at discounted rates and file all claims paperwork for you. We will pay our portion and you re only responsible for your stated deductibles, coinsurance and/or amounts in excess of the plan maximums. In most cases, you will experience the greatest out-of-pocket savings if you choose a dentist from the Delta Dental PPO network. Visiting your participating, in-network, dentist Be sure to tell your dentist you re covered by Delta Dental of Washington and give them your member identification number, plan name and group number. Visiting a non-participating, out-of-network, dentist You are not limited to using a Delta Dental network dentist. You may use any licensed dentist. If you choose a non-participating dentist, you will be responsible for ensuring the dentist completes your claim forms and that the claims are sent to us. Claim payments will be based on actual charges or our maximum allowable fees for nonparticipating dentists, whichever is less. You re then responsible for any balance remaining after we pay. Unlike our participating dentists, we have no control over non-participating dentists charges or billing procedures. Confirmation of Treatment and Cost (Formerly called Predeterminations) If you are considering extensive treatments such as crowns, oral surgery, periodontics or prosthodontics, we recommend you ask your dentist to request a predetermination from us. We will process the request and provide you and your dentist with a Confirmation of Treatment and Cost (Confirmation). The confirmation will show you what procedures will be covered, an estimate of what Delta Dental of Washington will pay and your expected financial responsibility. Confirmations are based on the treatment plan submitted by your dentist and the covered dental benefits available to you at the time the Confirmation is issued. Confirmations are estimates, not guarantees of payment. Have a question? Give us a call at 800.554.1907, Monday Friday from 7 am to 5 pm, Pacific Time. We re happy to help. Delta Dental of Washington PO Box 75983 Seattle WA 98175-0983 800.554.1907 DeltaDentalWA.com/WEA WEABenefitSummary00186A 0716
Shelton School District Certificated, SEOP Group # 00188 Ortho A DeltaCare - WEA Select Dental Plan Benefit Summary Effective Date November 1, 2016 Benefit Period November 1, 2016 October 31, 2017 Benefit Period Deductible No Deductible Benefit Period Maximum No Maximum Orthodontia A Adults & Children Lifetime Maximum (Per Person) $1,000 Monthly Rate Monthly Composite Rate $70.85 Your Share of Costs Diagnostic and Preventive Exams (Including Periodontal Exams) $0 Cleanings (Prophylaxis) $0 Fluoride Treatments $0 X-Rays (Bitewing & Panoramic) $0 Sealants (per tooth) $5 Restorative Fillings $0 Root Canal $0 Crowns Crowns $47-238 Endodontics Endodontics $0 Periodontics Periodontal Cleaning $0 Periodontics (Services on your Gums) $0 Prosthodontics, removable Dentures $305-530 Partial Dentures $202-530 Prosthodontics, fixed Bridges $202-238 Oral Surgery Oral Surgery $0 Adjunctive General Services Palliative Treatment (Emergency) $0 Specialty Services Molar Root Canal $0 Orthodontia Orthodontia (Braces) 50% This is a brief summary of your dental benefits and does not include all covered benefits, limitations and exclusions. Please refer to your benefits booklet for a complete list of benefits covered by your plan. Delta Dental of Washington PO Box 75983 Seattle WA 98175-0983 800.650.1583 DeltaDentalWA.com/WEA WEA00188DeltaCare - 0716
Here s some important information to help you use your benefits: Your DeltaCare managed dental plan, administered by Delta Dental of Washington, makes taking care of your smile easy and predictable. Your Primary Care Dentist (PCD) manages all of your care and you have fixed copays for covered treatments. Start using your benefits in 3 easy steps: Step 1 Select your PCD Visit DeltaDentalWA.com/WEA and use our Find a Dentist Tool to find a DeltaCare network dentist near you. Be sure to select the DeltaCare network to filter your search results. You can select a different PCD for each member of your family. You must have a PCD; if you don t select one, we will assign a PCD for you. Step 2 Enroll in your DeltaCare plan Complete the enrollment process used by your employer. Be sure to indicate your PCD and the PCD for your dependents. Step 3 Schedule your appointment After you ve enrolled, you will receive the address and phone number of your PCD along with your ID cards. Contact your PCD to make an appointment. It s important that you receive all your dental care from your PCD or a PCD-referred specialist. Your DeltaCare plan only covers services provided by your PCD or a PCD-referred specialist. Visiting your PCD Your PCD manages all of your dental care needs. If you need specialty care, your PCD needs to coordinate the referral. Visiting non-deltacare dentists You re responsible for any costs related to services provided by non-deltacare dentists. Delta Dental of Washington will reimburse up to $100 for out-of-area emergency care received from licensed dentists for procedures to alleviate pain. Changing your PCD You can change your Primary Care Dentist whenever you want. First, be sure to confirm your new dentist is a DeltaCare PCD by checking the DeltaCare network listings at DeltaDentalWA.com. Then you must call us in advance of the change to tell us the name of your new PCD. If you make the request before the 20 th of the month, you can start seeing your new dentist on the 1 st of the next month. Dental Emergencies Your PCD will help you access emergency care, 24 hours a day, every day of the year. Have a question? Give us a call at 800.650.1583, Monday Friday from 7 am to 5 pm, Pacific Time. We re happy to help. Delta Dental of Washington PO Box 75983 Seattle WA 98175-0983 800.650.1583 DeltaDentalWA.com/WEA WEA00188DeltaCare - 0716
Shelton School District Administrators, ESP, Non-represented Group # 00188 Ortho B DeltaCare - WEA Select Dental Plan Benefit Summary Effective Date November 1, 2016 Benefit Period November 1, 2016 October 31, 2017 Benefit Period Deductible No Deductible Benefit Period Maximum No Maximum Orthodontia B Children Only Lifetime Maximum (Per Person) $1,000 Monthly Rate Monthly Composite Rate $66.10 Your Share of Costs Diagnostic and Preventive Exams (Including Periodontal Exams) $0 Cleanings (Prophylaxis) $0 Fluoride Treatments $0 X-Rays (Bitewing & Panoramic) $0 Sealants (per tooth) $5 Restorative Fillings $0 Root Canal $0 Crowns Crowns $47-238 Endodontics Endodontics $0 Periodontics Periodontal Cleaning $0 Periodontics (Services on your Gums) $0 Prosthodontics, removable Dentures $305-530 Partial Dentures $202-530 Prosthodontics, fixed Bridges $202-238 Oral Surgery Oral Surgery $0 Adjunctive General Services Palliative Treatment (Emergency) $0 Specialty Services Molar Root Canal $0 Orthodontia Orthodontia (Braces) 50% This is a brief summary of your dental benefits and does not include all covered benefits, limitations and exclusions. Please refer to your benefits booklet for a complete list of benefits covered by your plan. Delta Dental of Washington PO Box 75983 Seattle WA 98175-0983 800.650.1583 DeltaDentalWA.com/WEA WEA00188DeltaCare - 0716
Here s some important information to help you use your benefits: Your DeltaCare managed dental plan, administered by Delta Dental of Washington, makes taking care of your smile easy and predictable. Your Primary Care Dentist (PCD) manages all of your care and you have fixed copays for covered treatments. Start using your benefits in 3 easy steps: Step 1 Select your PCD Visit DeltaDentalWA.com/WEA and use our Find a Dentist Tool to find a DeltaCare network dentist near you. Be sure to select the DeltaCare network to filter your search results. You can select a different PCD for each member of your family. You must have a PCD; if you don t select one, we will assign a PCD for you. Step 2 Enroll in your DeltaCare plan Complete the enrollment process used by your employer. Be sure to indicate your PCD and the PCD for your dependents. Step 3 Schedule your appointment After you ve enrolled, you will receive the address and phone number of your PCD along with your ID cards. Contact your PCD to make an appointment. It s important that you receive all your dental care from your PCD or a PCD-referred specialist. Your DeltaCare plan only covers services provided by your PCD or a PCD-referred specialist. Visiting your PCD Your PCD manages all of your dental care needs. If you need specialty care, your PCD needs to coordinate the referral. Visiting non-deltacare dentists You re responsible for any costs related to services provided by non-deltacare dentists. Delta Dental of Washington will reimburse up to $100 for out-of-area emergency care received from licensed dentists for procedures to alleviate pain. Changing your PCD You can change your Primary Care Dentist whenever you want. First, be sure to confirm your new dentist is a DeltaCare PCD by checking the DeltaCare network listings at DeltaDentalWA.com. Then you must call us in advance of the change to tell us the name of your new PCD. If you make the request before the 20 th of the month, you can start seeing your new dentist on the 1 st of the next month. Dental Emergencies Your PCD will help you access emergency care, 24 hours a day, every day of the year. Have a question? Give us a call at 800.650.1583, Monday Friday from 7 am to 5 pm, Pacific Time. We re happy to help. Delta Dental of Washington PO Box 75983 Seattle WA 98175-0983 800.650.1583 DeltaDentalWA.com/WEA WEA00188DeltaCare - 0716
Shelton School District #309 Certificated/SEOP Employees Benefit Summary WEA Plan 1 Benefits Copayment Annual Maximum No Annual Maximum* Deductible No Deductible General Office Visit $15 per visit Diagnostic & Preventive Services Routine & Emergency Exams All X-rays Teeth Cleaning Fluoride Treatment Sealants (per tooth) Periodontal Evaluation Restorative Dentistry & Prosthodontics Fillings (Amalgam) Stainless Steel Crown Porcelain-Metal Crowns $50 Complete Upper or Lower Denture $50 Bridge (per tooth) $50 Endodontics & Periodontics Root Canal Therapy Root Planing (per quadrant) Oral Surgery Routine Extraction Surgical Extraction Orthodontic Services Pre-Orthodontic Service $150** Orthodontia Plan 4: Family $1,500 Miscellaneous Nitrous Oxide (per visit) Out of Area Emergency Care is Reimbursed Up to $500 Composite Rate: $89.45 *Orthognathic Surgery has a benefit maximum. TMJ has a $1000 annual maximum/ $5000 lifetime maximum. **Fee credited towards orthodontic copayment if patient accepts treatment plan. 5 Reasons Willamette Dental Group is the Plan For You & Your Family No Annual Maximum, No Deductibles With no annual maximum and no deductibles, you will never exhaust your dental coverage and you don t need to satisfy a deductible before you can receive benefits. Predictable, Low Out-of-Pocket Costs Out-of-pocket costs for covered dental services are predictable, low copays. Combined with the low premium, you and your family won t be surprised by any unknown costs. Simple Scheduling All of our 54 office locations practice our Simple Scheduling method. Through this model, every appointment type is offered everyday so you can be seen when it fits your schedule! Exceptional Patient Satisfaction We are dedicated to creating the best patient experience possible. With an average score over 90% on our patient satisfaction survey, our patients tell us we are doing something right. Proactive Dental Care Through dentist-patient partnerships, we focus on promoting your long-term health rather than merely correcting what is bothering you today. Effective Date: 11/1/2016 Underwritten by Willamette Dental Insurance, Inc. Please refer to your Member Handbook for limitations and exclusions. www.willamettedental.com www.fb.com/mywillamettedentalgroup @WDGDental
Shelton School District #309 Admin/ESP/Non-Rep Employees Benefit Summary WEA Plan 1 Benefits Copayment Annual Maximum No Annual Maximum* Deductible No Deductible General Office Visit $15 per visit Diagnostic & Preventive Services Routine & Emergency Exams All X-rays Teeth Cleaning Fluoride Treatment Sealants (per tooth) Periodontal Evaluation Restorative Dentistry & Prosthodontics Fillings (Amalgam) Stainless Steel Crown Porcelain-Metal Crowns $50 Complete Upper or Lower Denture $50 Bridge (per tooth) $50 Endodontics & Periodontics Root Canal Therapy Root Planing (per quadrant) Oral Surgery Routine Extraction Surgical Extraction Orthodontic Services Pre-Orthodontic Service $150** Orthodontia Plan 1: Children Only $1,500 Miscellaneous Nitrous Oxide (per visit) Out of Area Emergency Care is Reimbursed Up to $500 5 Reasons Willamette Dental Group is the Plan For You & Your Family No Annual Maximum, No Deductibles With no annual maximum and no deductibles, you will never exhaust your dental coverage and you don t need to satisfy a deductible before you can receive benefits. Predictable, Low Out-of-Pocket Costs Out-of-pocket costs for covered dental services are predictable, low copays. Combined with the low premium, you and your family won t be surprised by any unknown costs. Simple Scheduling All of our 54 office locations practice our Simple Scheduling method. Through this model, every appointment type is offered everyday so you can be seen when it fits your schedule! Exceptional Patient Satisfaction We are dedicated to creating the best patient experience possible. With an average score over 90% on our patient satisfaction survey, our patients tell us we are doing something right. Composite Rate: $87.85 *Orthognathic Surgery has a benefit maximum. TMJ has a $1000 annual maximum/ $5000 lifetime maximum. **Fee credited towards orthodontic copayment if patient accepts treatment plan. Proactive Dental Care Through dentist-patient partnerships, we focus on promoting your long-term health rather than merely correcting what is bothering you today. Effective Date: 11/1/2016 Underwritten by Willamette Dental Insurance, Inc. Please refer to your Member Handbook for limitations and exclusions. www.willamettedental.com www.fb.com/mywillamettedentalgroup @WDGDental
Benefits and rates WEA Select Vision Plan A NOVEMBER 1, 2016 OCTOBER 31, 2017 2016-2017 All benefit-eligible employees, as defined by the bargaining unit or group, must participate in the plan. This is a brief comparison of benefits. For details of benefit limitations and exclusions, please refer to the benefit book on the vision page available online at premera.com/wea. Plan A Network PBC Other Copay amounts Exam $5 $0 Materials $0 $0 Exam Once every calendar year after copay Paid in full $48 Eyeglass lenses (pair) Once every calendar year Single vision Paid in full $45 Bifocal Paid in full $74 Trifocal Paid in full $87 Lenticular Paid in full $122 Progressive lenses $125 $125 Lens tinting and coating N/C N/C Oversize lenses N/C N/C Frames Once every 2 calendar years $80 $45 Contact lenses (in lieu of frames and eyeglass lenses) Once every 2 calendar years $130 Vision rates Each eligible employee pays the monthly composite rate, which covers the employee and all eligible dependents. An employee may be enrolled as a subscriber on the WEA Select Vision Plan through only one school district. Enrollee pays: Copay amounts as noted All charges exceeding any allowed amounts or benefit maximums All charges for non-covered benefits Premera Blue Cross WEA Select Customer Service 800-932-9221 800-842-5357 (Hearing impaired TTY) Go to premera.com/wea for: Benefit books Claim forms Provider directory* First time users will need their Premera ID number to create a new account. *Select Vision in the Network section. Monthly composite rate $17.75 N/C = Not covered WEA Select Vision Plan A benefits and rates are underwritten and administered by Premera Blue Cross. Benefits are subject to Premera Blue Cross allowable charges. Premera Blue Cross network providers agree not to bill for amounts over the allowable charge. WEA Plan Consultant: 206-467-4646 Aon Hewitt, an independent provider of plan consultation and administration services, does not provide Premera Blue Cross products or services. Aon Hewitt is solely responsible for their own services. 012916 (07-2016)
Benefits and rates WEA Select Vision Plan C NOVEMBER 1, 2016 OCTOBER 31, 2017 2016-2017 All benefit-eligible employees, as defined by the bargaining unit or group, must participate in the plan. This is a brief comparison of benefits. For details of benefit limitations and exclusions, please refer to the benefit book on the vision page available online at premera.com/wea or by calling VSP Customer Service. Plan C Network VSP Other Copay amounts Exam $5 Materials $15 Exam Once every calendar year after copay Paid in full $60 Eyeglass lenses (pair) Once every calendar year after copay Single vision Paid in full $76 Bifocal Paid in full $112 Trifocal Paid in full $142 Lenticular Paid in full $148 Progressive lenses Paid in full $140 Lens tinting and coating Paid in full N/C Oversize lenses* Paid in full N/C Frames Once every 2 calendar years after copay $110 $60 Contact lenses (in lieu of frames and eyeglass lenses) Once every 2 calendar years after copay $200 Medically necessary contact lenses (in lieu of frames and eyeglass lenses) Covered in Please contact VSP at 800-877-7195 full after prior approval $316 Vision rates Each eligible employee pays the monthly composite rate, which covers the employee and all eligible dependents. An employee may be enrolled as a subscriber on the WEA Select Vision Plan through only one school district. Enrollee pays: Copay amounts as noted All charges exceeding any allowed amounts or benefit maximums All charges for non-covered benefits VSP Customer Service 800-877-7195 Go to vsp.com for: Benefits Claims Provider directory First time users will need their Premera ID number to create a new account. Monthly composite rate $33.00 N/C = Not covered * Includes polycarbonates and photochromic lenses. WEA Select Vision Plan benefits and rates are underwritten by Premera Blue Cross. Plan C is administered by VSP (Vision Service Plan). Benefits are subject to VSP allowable charges. VSP network providers agree not to bill for amounts over the allowable charge. Some VSP provider network discounts may apply. WEA Plan Consultant: VSP, an independent provider of vision benefit services, does not provide Premera Blue Cross products or services. VSP is solely responsible for its products and services. 206-467-4646 Aon Hewitt, an independent provider of plan consultation and administration services, does not provide Premera Blue Cross products or services. Aon Hewitt is solely responsible for their own services. 012918 (07-2016)
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Product Lump Sum Critical Illness Dental products offered by ARNOLD SMITH INSURANCE features Up to $100,000 coverage available Benefit amounts for spouse and dependents are equal to primary insured Major Critical Illness Benefit may become eligible again after five years - NO lifetime max $5,000 Subsequent Critical Illness Event Benefit Covered critical illness events are heart attack,stroke, end-stage renal failure, coma, paralysis, and major human organ transplant No networks Portable Guaranteed-renewable at same payroll rates No deductible Optional Cosmetic Benefit Rider Optional Orthodontic Benefit Rider Hospital Confinement Sickness Indemnity Physician Visits Benefit Major Diagnostic Exams Benefit Surgical Benefit Hospital Confinement Benefit Hospital Confinement Indemnity Annual Hospitalization Confinement Benefit Daily Hospital Confinement Benefit Rehabilitation Unit Benefit HSA-Compatible Option