Employee Benefits Plan Information Packet

Transcription

Employee Benefits Plan
Information Packet
for Health Benefits
2016
July 1, 2016
To:
Benefits Eligible Employees
Welcome to the Reta Employee Benefits program for The Archdiocese of Portland. This
program gives you the freedom to mix and match your health care, life insurance, disability, and
other benefits. It is up to you to choose the coverage you want at the price you want to pay.
Please read through your options carefully before you complete the online enrollment process.
Be sure to complete the enrollment process within 30 calendar days after starting work in a
benefits eligible position. If you don’t enroll by the deadline, you will receive the default
coverage.
The materials enclosed in this package are intended to provide you with detailed information on
each benefit plan and guide you through the steps of enrollment.
The contents of this package are:
1. A formal “Welcome to Health Benefits Enrollment for the Reta Trust”. This document is an
introduction to the Reta Benefits Center and includes information regarding the online
enrollment process. You will find the website is very interactive and user friendly.
2. A Health Benefits Selection Worksheet. You may want to use this to draft and make your
selections before entering this information electronically. This worksheet is NOT an
enrollment form.
3. Frequently Asked Questions
4. A Table of Contents listing all materials in this package: Benefits Plan Summaries, a Contact
List and a sample Dependent Validation Instruction Sheet. We provided hard copies of the
plan summaries to assist you through the electronic enrollment. As you access the Reta
Benefits Center, you will be able to review all plan summaries and selections.
We are committed to a successful enrollment process for all employees. Please refer to the
Contact List to identify experts who are ready to support you.
Sincerely,
Mary McPartland
Employee Benefits Analyst
mmcpartland@archdpdx.org
Welcome to your Health Benefits Enrollment for the Reta Trust
The Enrollment period for the Archdiocese of Portland in Oregon employees is:
30 days from date of hire in a benefit eligible position.
Reta Benefits Center
Before making any benefits decisions, be sure to visit the Reta Benefits Center, the interactive resource to help
you better understand your choices and to make the most of your options. You can log in to see the
personalized lobby that works like an online virtual benefit fair. Professional representatives from Reta’s
benefits partners provide information and answers to your questions.
Visit www.retatrust.org anytime beginning and select Reta Benefits Center.
RetaEnroll
The date your coverage begins will depend on the date you are hired. The elections you make during your
initial enrollment will be effective the 1st day of the month following your hire date to a benefit eligible position. If
you are hired on the 1st day of the month, your benefits are effective on your first day of work. The initial
enrollment period is your opportunity to select your health benefit elections and coverage level. You will NOT
be permitted to make any changes to your benefit elections until the next annual open enrollment, unless you
experience a Qualified Life Event Change as defined by the IRS Section 125 Guidelines.
All benefit eligible employees are required to enroll online.
If you do not complete the process, your 2015-2016 benefit elections will default to employee-only coverage
with UHC medical, Delta Dental and VSP vision.
With RetaEnroll you will be able to view your insurance benefits and update your information, including:




Personal Data (home address, birth date, etc.)
Dependents (names, birth dates, Social Security Numbers student status, etc.)
Benefit Elections (medical, dental, life, disability, etc.)
Beneficiaries (life insurance beneficiaries)
Page 1 of 4 Obtaining a User ID and Password
To get started a user ID and Password is required to access the site.
You may obtain your unique User ID and Password for the first time, or have it re-sent to you if you are a
returning user, by going to the Reta Trust home page (www.retatrust.org) and clicking on the help button on
the right. Enter your email address; provided that your email address has been previously entered into the
RetaEnroll system and validated. Otherwise, to view your User ID and Password on-screen, select Option 3:
View User ID & Password on Your Screen and you will be prompted to enter:




Last Name
Date of Birth
5-digit Zip Code
Last 4-Digits of your Social Security Number
RetaEnroll will immediately verify your information and ask you to enter an email address, if available. If you do
not have an email address, select the option button indicating such, and then click on Continue. For additional
security, you will be asked to verify at least two pieces of identification (last four of SSN and zip code). Your
User ID and Password will be displayed onscreen for 45 seconds. The password issued by RetaEnroll will be
good for 12 hours. If you do not log on and create your own password within 12 hours, you will need to request
another password.
Please save your confidential User ID and Password in a secure place. Neither your HR department nor BAS
can provide you with your User ID or Password. You must use the self-service “Help” link at www.retatrust.org
to obtain this information.
Making your Online Elections
The enrollment site is available 24 hours a day, 7 days a week during the Open Enrollment period. When
you’re ready to make your elections, follow these five steps:
1.
2.
3.
4.
5.
Go to www.retatrust.org and enter your User ID and Password in the upper right hand corner.
Choose your destination – RetaEnroll.
Follow the easy enrollment steps in the Open Enrollment Wizard.
Review and confirm your elections, making changes as necessary.
Print your benefits statement.
You may go back and make changes as many times as you like during the enrollment period.
Page 2 of 4 Dependent Validation Process
For new dependents, the request for validation will be part of the electronic enrollment process.
Employees will be required to provide documentation of dependent eligibility in order for all newly added
dependent’s coverage to be approved. (Spouse –Marriage certificate, Child – Birth certificate,
Adoption/Legal Guardianship - Court documents)
Reta Trust Dependent Validation Approved Documents
Dependent Type
Spouse
Approved Documents Requirement
Marriage certificate plus one piece of documentation dated
within the past 60 days to establish a common residence or
financial interdependence – Examples of secondary
documentation:
 Jointly filed Form 1040
 Separately filed Form 1040 with the same address
 Financial documents in both parties name
 Utility bill in both parties name
Child to age 26
Birth certificate listing the employee's name
Hospital Birth Record (newborns only)
Stepchild
Birth certificate naming spouse as the child’s biological
parent
and Marriage Certificate
and Jointly filed 1040*
Separately filed 1040 with same address*
Financial document in both names
Utility bill in both names
Disabled Dependent
Birth certificate and a copy of the employee's recent Form
1040 claiming the individual as a dependent OR the
dependent's Form 1040 filed from the employee's address
OR SSDI documentation
Adoption/placed for adoption
Appropriate court document
Legal Guardianship/Foster
Child
Court document establishing employee or the employee's
spouse is the legal guardian
*Not required of marriage less than 90 days Page 3 of 4 If You Need More Detailed Information or Assistance
Detailed information about your benefits plan is available in the Reta Benefits Center through the RetaTrust.org
website. For assistance with accessing your account, call the Reta Enroll Client Services Department at
1.877.303.7382 from 5:30 AM to 5:00 PM PST, Monday through Friday, or send an e-mail to
Service@RetaEnroll.org. The Reta Client Services team will either directly assist you or connect you with the
best resource for help.
If you need further assistance regarding your individual benefit plan options, contact your location’s Benefits
Administrator. Don’t forget—Benefits for 2016-17 begin on July 1, 2016 and will end on June 30, 2017. Do not wait until the
last minute to begin your enrollment.
For your convenience, we have included detailed written benefit summaries for each of your benefit choices
with this package. This information is also available in the Reta Benefits Center where we encourage you to go
for information regarding your benefits plan. This comprehensive information resource center has a live
representative available to help you with any questions or needs. The Reta Trust services over 35,000
members across the United States, including over 50 Roman Catholic dioceses, archdioceses, and religious
communities.
Page 4 of 4 HEALTH BENEFITS SELECTION WORKSHEET 2016 – 2017
Use this sheet to complete your benefits selections. Then, go to myenroll.com and enter the information.
Flex
Credits
Monthly Flex Credits
($836.00)
($100.00)
Monthly Flex Benefits Credit if you elect medical
Monthly Flex Benefits Credit if you waive medical
enter flex credit here
Medical Plans – required unless you have other current Medical Coverage
Employee
only
Employee
Employee
Employee
and Spouse
and Child(ren)
and Family
Kaiser EPO
768.00
1013.00
914.00
1142.00
UHC PPO 500
768.00
1038.00
936.00
1185.00
UHC PPO 250
828.00
1049.00
961.00
1222.00
Benefit Selection
Before tax – enter cost here
Dental / Vision – required
Reta Delta Dental
91.00
Willamette Dental
65.00
Kaiser Permanente Dental
82.00
(included)
(included)
Vision - RETA VSP
123.00
107.00
140.00
89.00
78.00
101.00
121.00
105.00
137.00
(included)
(included)
Before tax – enter cost here
Additional Life /AD&D - Optional
To enroll family members, you must select coverage for yourself. See rate sheet for premiums and the schedule of age based premium increases.
Employee coverage amount
$____________________
(Cannot exceed lesser of $500,000 or 5 x annual wages. Do not include your basic life AD&D amount here)
Spouse coverage amount
After tax –
enter cost here
$____________________
(Cannot exceed 100% of employee coverage)
$2.40
($8,000.00)
$3.00
($10,000.00)
After tax –
enter cost here
$7.98
$5.64
STD 14-day
STD 30-day
$3.28
STD 44-day
After tax –
enter cost here
$1.80
($6,000.00)
Child(ren) coverage amount
(Cannot exceed 100% of employee coverage)
After tax –
enter cost here
Short Term Disability - Optional
44-day STD is automatic at initial enrollment if
you don’t opt out
$0.00
OPT OUT
Buy-Up Long Term Disability – Optional
LTD - 60% of wages
$6.62
LTD - 66 2/3% of wages
$9.75
After tax – enter
cost here
Healthcare Flexible Spending Account “FSA” – Optional
If you elect this coverage, a pro rata portion of your annual election will be deducted from each of 12 remaining pay periods in the plan year 2015.
Before tax –
enter cost here
Maximum election is $2,550.00 per year.
Write in the amount of your monthly election: $__________________
Total of Credits and Costs
Sum of Coverage Costs (add amounts in Cost column from above and enter here)
Flex Credit Amount (from above)
Total Cost to Employee (Sum Coverage Costs minus Flex Credit Amount)
COST
FREQUENTLY ASKED QUESTIONS FOR EMPLOYEES Here are questions that you may have regarding Health Benefit Enrollment and plan changes. Please contact BAS Customer Service at 1‐877‐303‐7382 between 5:30 AM and 5:00 PM PST with any other questions or concerns you may have. 1. Am I required to be enrolled in a medical insurance plan? Yes, with very few exceptions all legal US residents are required to have minimum essential coverage or face a tax penalty. If you are not currently covered under a medical plan, and you do not enroll in a Reta plan, you may choose to purchase coverage through the private marketplace. Note, however, the Reta medical plan will include a premium contribution from your employer. The Archdiocese requires all benefit eligible employees to enroll in a Dental/Vision plan. If you waive medical, you must elect a Dental/Vision plan. 2. How do I obtain my User ID and Password to access the Reta Benefits Center and RetaEnroll? You may obtain your User ID and Password by going to the Reta Trust home page (www.retatrust.org). Click on the help button in the upper right. Next, select Option 3: View User ID & Password, then on the next screen select Option 2, View User ID & Password. You will be prompted to enter:  Last Name  Date of Birth  5‐digit Zip Code  Last 4‐Digits of your Social Security Number RetaEnroll will immediately verify your information and ask you to enter an email address, if available. If you do not have an email address, select the option button indicating such, and then click on Continue. RetaEnroll will display your User ID and a temporary password. Please note that your User ID and Password will be displayed onscreen for only 45 seconds. Record this information immediately and click on the continue button. You will be asked to enter your user ID and temporary password. The temporary password will be good for 12 hours. Be sure to log on and create your own password within 12 hours; otherwise, you will need to request again. You will want to be sure to write it down and save your confidential User ID and password in a secure place. The only way to retrieve your forgotten user ID or password is by re‐entering the self‐service “Help” link at www.retatrust.org. 3. What happens if I miss the deadline or do not enroll?  If you do not complete the process within 30 days of hire, your 2016‐17 benefit elections will default to employee‐only coverage with UHC medical, Delta Dental and VSP vision.  There is no default enrollment for Healthcare FSA. You must re‐enroll every year or you will not have this benefit. 4. Can I change my benefit elections at any time throughout the year? The decisions you make during the enrollment period are unchangeable for the 2016‐2017 Plan Year. The only exception is if you have a “Life Event Change,” which includes events such as: marriage, divorce, birth or adoption of a child, reduction in work hours, loss of dependent status, or a change in your spouse’s employment status as defined by Section 125 of the Internal Revenue Code. 5. How will I know if my medical care provider is on the United Healthcare plan? Go to http://www.uhc.com/find‐a‐physician to review providers and their quality rating information. Select “Find a Physician.” On the next page, enter your location information above the search bar. You can search by provider name or by provider specialty. 6. Do I have a paper option for my enrollment? All enrollments will be done electronically through the RetaEnroll system. Included in this packet is a worksheet that you can use to prepare for your electronic enrollment. This year we have also supplied a fillable copy. You can make your selections, print your form, and log in and go through the enrollment process. If you want to keep a paper copy of your completed enrollment, you may print one, but you must enroll online. 7. How will I know my enrollment is complete and accurate? A benefit statement will be provided at the end of the enrollment process once benefits are confirmed. All benefit statements are electronically stored in the system. 8. What do I need to know regarding “Dependent Validation”? a. Why is it necessary? To ensure that only eligible dependents are enrolled on the plan. The plan is not responsible to cover claims for those individuals who do not meet eligibility guidelines. b. When will I receive the Request for Validation? For new dependents, the request for validation, including instructions, will be a part of the electronic enrollment process. Coverage for new dependents will be pending until documentation is submitted. c. What is the deadline? For new dependents, you will be asked at the time of enrollment to submit documentation within 60 days. The effective date of coverage will be retroactively assigned once documentation is received. 9. After the enrollment period, how can I add dependents to my plan? Employees will need to submit requested changes with a Life Event Change form. All changes will be pending until requested documentation has been received and approved. 10. Is there a glossary of acronyms? A glossary of acronyms for general healthcare terms is available at: http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf 11. Who do I call if I need provider assistance? See the attached Contact Information Sheet. 12. How will I be sure I have all of the information I need to enroll? Your location’s administrator or business manager can provide assistance. 13. Who do I contact if I need assistance, cannot access the online enrollment system, or my enrollment is rejected? You can call RetaEnroll Customer Service at 1‐877‐303‐7382 between 5:30 AM and 5:00 PM PST or email Service@RetaEnroll.org For Lay Employees
♦ Benefit Items included in this packet of material are listed here in order of content.
♦These items are included as a convenience. We would like you to log into
www.retatrust.org for comprehensive detailed benefit information and enrollment.
1. Reta Trust United Health Care Comparison of 250 and 500 PPO
2. Reta Trust United Health Care 250 PPO Benefit Plan Summary
3. Reta Trust United Health Care 500 PPO Benefit Plan Summary
4. Envision Prescription Rx Plan overview
5. Reta Trust Kaiser EPO Plan Comparison
6. Reta Trust Kaiser EPO Benefit Summary
7. Delta Dental PPO Plan Summary
8. Kaiser Permanente Dental Plan Summary
9. Willamette Dental Group Plan Summary
10. Reta Trust VSP Vision Care Summary
11. MHN EAP Benefit Plan Summary
12. UNUM Life AD & D Plan Highlights
13. UNUM LTD Plan Highlights
14. UNUM STD Plan Highlights
15. Monthly Life Rate Sheet
16. Healthcare Flexible Spending Account Guide
17. Dependent Validation Approved Documents
18. Important Contact Numbers
Archdiocese of Portland in Oregon
Reta Trust UHC 250 & 500 Plan Comparison
Reta United Healthcare 250
Reta United Healthcare 500
PPO
PPO
$250 Ded / $20 OV
$500 Ded / $25 OV
$500 OOP
$2,500 OOP
Out of
Out of
In Network
In Network
Network
Network
Annual Out-of-Pocket Maximum (Includes Deductible, Copays & Coinsurance)
$500
$1,000
$2,500
$5,000
For any one Member in the same Family Unit
For an entire Family Unit of two or more
$1,000
$2,000
$5,000
$10,000
Members
$250 Individual / $500 Family $500 Individual / $1,000 Family
Calendar Year Deductible
Outpatient Services
$20 copay,
$25 copay,
deductible
30%
deductible
40%
Office Visit Co-payments
waived
waived
$35 copay,
$40 copay,
deductible
30%
deductible
40%
Specialist Office Visit Co-payments
waived
waived
No charge,
No charge,
deductible
30%
deductible
40%
Well Child Care (Birth to age 7)
waived
waived
No charge,
No charge,
deductible
30%
deductible
40%
Adult Routine Exams
waived
waived
$35 copay,
$40 copay,
deductible
30%
deductible
40%
Chiropractic Care
waived
waived
Up to 24 visits in calendar
Up to 24 visits in calendar
year
year
Outpatient Services
10%
30%
20%
40%
Outpatient surgery
10%
30%
20%
40%
X-rays and lab tests
10%
30%
20%
40%
MRI, CT and PET
Inpatient Services
Room and board, surgery, anesthesia, X-rays,
10%
30%
20%
40%
lab tests, and drugs
Prior Authorization Required Prior Authorization Required
Non-preauthorized admissions
Emergency Health Coverage
$100
$200
$100 copay,
$200 copay,
copay,
copay,
Emergency Department visits
then 10%
then 20%
then 10%
then 20%
copay waived if admitted
Prescription Drug
RX provided through EnvisionRx**
Generic/Formulary/NonGeneric/Formulary/NonFormulary
Formulary
$10/$20/$30
$10/$20/$30
Retail (Up to 30-day supply)
$20/$40/$60
$20/$40/$60
Mail Order (Up to 90-day supply)
**Subject to RVO program
IMPORTANT NOTE: This comparison is designed to be a brief overview of the
health plan offerings of the Reta Trust. See the plan description for a full
description of covered provisions, limitations and exclusion, including customary
and reasonable (UCR) charges.
Updated April 11, 2016
Prepared by: Gallagher Benefit Services
California License #0D36879
Page 1
Reta Trust
United Health Care 250
Choice Plus Plan
Reta Trust Self-funded Plan
Archdiocese of Portland, Oregon
Schedule of Benefits
Choice Plus Plan
NOTE: To be a Covered Health Service, a service must: meet the requirements for coverage, as
described in this SPD; be shown as a Covered Health Service in this SPD; and be consistent with
the Ethical and Religious Directives for Catholic Health Care Services ("Directives").
Plan Features
Network
Non-Network
■ Individual
$250 per calendar year
■ Family (cumulative Annual Deductible)
$1,000 per calendar year
Annual Deductible1
Annual Out-of-Pocket Maximum1
■ Individual
■ Family (cumulative Out-of-Pocket
Maximum)
Penalty for Non-Preauthorized Hospital
Admission2
$500 per admission
■ Lifetime Maximum Benefit
There is no dollar limit to the amount the Plan
will pay for essential Benefits during the entire
period you are enrolled in this Plan.3
Unlimited
1
The Annual Deductible applies toward the Out-of-Pocket Maximum for all Covered Health Services.
2
Penalty does not apply toward the Out-of-Pocket Maximum.
3
Generally the following are considered to be essential benefits under the Patient Protection and
Affordable Care Act: Ambulatory patient services; emergency services, hospitalization; maternity and
newborn care, mental health and substance use disorder services (including behavioral health treatment);
prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and
wellness services and chronic disease management; and pediatric services, including oral and vision care.
Covered Health Services
Percentage of Eligible Expenses Payable by the
Plan:
Network
Non-Network
100% after you pay a
$35 Copay per visit3
70% after you meet the
Annual Deductible
Acupuncture Services
Up to 24 visits per calendar year
Ambulance Services - Emergency Only Ground Transportation Ground Transportation
Annual Deductible
Annual Deductible
Air Transportation
Air Transportation
Annual Deductible
Annual Deductible
Cancer Resource Services (CRS)
■ Hospital - Inpatient Stay
Not Covered
Annual Deductible
Depending upon where the Covered Health Service
Clinical Trials
is provided, benefits for Clinical Trials will be the
same as those stated under each Covered Health
Service category in this section.
Dental Services - Accident Only
Prior notification required before follow- 90% after you meet the
Annual Deductible
Annual Deductible
up treatment begins.
See Section 6, Coverage Details, for limits
Durable Medical Equipment (DME)
Emergency Health Services
Eye Examinations
Home Health Care
Annual Deductible
90% after you pay a
$100 Copay per visit3;
Copay waived if
admitted
Annual Deductible
Annual Deductible.
Prior Notification
required when cost is
more than $1,000.
90% after you pay a $100
Copay per visit3;
Copay waived if
admitted. Notification is
required if results in an
Inpatient Stay.
Annual Deductible
Annual Deductible.
Prior Notification
required.
Hospice Care
Up to 360 days per lifetime
Hospital - Inpatient Stay
Injections received in a Physician's
Office
Kidney Resource Services (KRS)
(These Benefits are for Covered Health
Services provided through KRS only)
Maternity Services
A Deductible will not apply for a
newborn child whose length of stay in
the Hospital is the same as the mother's
length of stay.
Mental Health Services
■ Physician's Office Services
See Section 6, Coverage Details for limits
Morbid Obesity Surgery
Plan:
Network
Annual Deductible
Annual Deductible
Non-Network
Annual Deductible.
Prior Notification
required.
Annual Deductible.
Prior Notification
required.
70% per injection
after you meet the Annual
Deductible
Benefits will be the
same as those stated
under each Covered
Not Covered
Health Service
category in this
section.
Benefits will be the same as those stated under each
Covered Health Service category in this section.
No copay applies to
Physician Office visits
for prenatal care after
the first visit.
Annual Deductible
$35 Copay per
individual visit3; $10
Copay per group visit3
Annual Deductible.
Prior notification required
through the Mental
Health/Substance Use
Disorder Administrator.
Annual Deductible.
through the Mental
Neurobiological Disorders - Mental
Health Services for Autism Spectrum
Disorders
Outpatient Surgery, Diagnostic and
Therapeutic Services
■ Outpatient Surgery
Plan:
Network
Non-Network
Annual Deductible
Annual Deductible.
through the Mental
$35 Copay per
Annual Deductible.
through the Mental
Annual Deductible
Annual Deductible
■ Outpatient Diagnostic Services


Preventive Lab and radiology/Xray
Preventive mammography testing

Sickness and Injury related
diagnostic services
■ Outpatient Diagnostic/Therapeutic
Services - CT Scans, PET Scans,
MRI and Nuclear Medicine
■ Outpatient Therapeutic Treatments
Physician's Office Services - Sickness
and Injury
■ Primary Physician
■ Specialist Physician
Physician Fees for Surgical and
Medical Services
90% after you meet
the Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
100%
100%
Plan:
Network
Non-Network
■ Physician Office Services
100%
100%
■ Breast Pumps
100%
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Preventive Care Services
Prosthetic Devices
Reconstructive Procedures
Rehabilitation Services - Outpatient
Therapy
Annual Deductible
Covered Health Service category in this section
Annual Deductible
Annual Deductible
Annual Deductible.
Prior Notification
required.
Annual Deductible
Annual Deductible
Annual Deductible.
through the Mental
100% after you pay
$35 Copay per
Annual Deductible.
through the Mental
Skilled Nursing Facility/Inpatient
Rehabilitation Facility Services
Up to 60 days per calendar year
Spinal Treatment
Substance Use Disorder Services
Transplantation Services
Notification is required for all transplant
services.
Transplantation Travel and Lodging
(If services rendered by a Designated
Facility)
Plan:
Network
Non-Network
is provided, benefits will be the same as those
stated under each Covered Health Service category
in this section.
For patient and companion(s) of patient undergoing
transplant procedures
Urgent Care Center Services
3
Copay per visit3
Copays apply toward the Annual Deductible or Out-of-Pocket Maximum. The Annual Deductible applies toward
the Out-of-Pocket Maximum for all Covered Health Services.
Reta Trust
United Health Care 500
Choice Plus Plan
Reta Trust Self-funded Plan
Archdiocese of Portland, Oregon
Schedule of Benefits
Choice Plus Plan
NOTE: To be a Covered Health Service, a service must: meet the requirements for coverage, as
described in this SPD; be shown as a Covered Health Service in this SPD; and be consistent with
the Ethical and Religious Directives for Catholic Health Care Services ("Directives").
Plan Features
Network
Non-Network
■ Individual
■ Family (cumulative Out-of-Pocket
Maximum)
Annual Deductible1
■ Individual
■ Family (cumulative Annual Deductible)
Annual Out-of-Pocket Maximum1
Penalty for Non-Preauthorized Hospital
Admission2
$500 per admission
■ Lifetime Maximum Benefit
There is no dollar limit to the amount the Plan
will pay for essential Benefits during the entire
period you are enrolled in this Plan.3
Unlimited
1
The Annual Deductible applies toward the Out-of-Pocket Maximum for all Covered Health Services.
2
Penalty does not apply toward the Out-of-Pocket Maximum.
3
Generally the following are considered to be essential benefits under the Patient Protection and
Affordable Care Act: Ambulatory patient services; emergency services, hospitalization; maternity and
newborn care, mental health and substance use disorder services (including behavioral health treatment);
prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and
wellness services and chronic disease management; and pediatric services, including oral and vision care.
Plan:
Network
Non-Network
Annual Deductible
Acupuncture Services
Ambulance Services - Emergency Only Ground Transportation Ground Transportation
Annual Deductible
Annual Deductible
Air Transportation
Air Transportation
Annual Deductible
Annual Deductible
Cancer Resource Services (CRS)
Not Covered
Annual Deductible
Clinical Trials
is provided, benefits for Clinical Trials will be the
same as those stated under each Covered Health
Service category in this section.
Dental Services - Accident Only
Prior notification required before follow- 80% after you meet the
Annual Deductible
Annual Deductible
up treatment begins.
Durable Medical Equipment (DME)
Emergency Health Services
Eye Examinations
Home Health Care
Annual Deductible
80% after you pay a
$200 Copay per visit3;
Copay waived if
admitted
Annual Deductible
Annual Deductible.
Prior Notification
required when cost is
more than $1,000.
Copay per visit3;
Copay waived if
admitted. Notification is
required if results in an
Inpatient Stay.
Annual Deductible
Annual Deductible.
Prior Notification
required.
Hospice Care
Up to 360 days per lifetime
Hospital - Inpatient Stay
Injections received in a Physician's
Office
Kidney Resource Services (KRS)
(These Benefits are for Covered Health
Services provided through KRS only)
Maternity Services
A Deductible will not apply for a
newborn child whose length of stay in
the Hospital is the same as the mother's
length of stay.
Mental Health Services
Morbid Obesity Surgery
Plan:
Network
Annual Deductible
Annual Deductible
Non-Network
Annual Deductible.
Prior Notification
required.
Annual Deductible.
Prior Notification
required.
60% per injection
after you meet the Annual
Deductible
Benefits will be the
same as those stated
under each Covered
Not Covered
Health Service
category in this
section.
No copay applies to
Physician Office visits
for prenatal care after
the first visit.
Annual Deductible
$40 Copay per
Annual Deductible.
through the Mental
Annual Deductible.
through the Mental
Neurobiological Disorders - Mental
Health Services for Autism Spectrum
Disorders
Outpatient Surgery, Diagnostic and
Therapeutic Services
■ Outpatient Surgery
Plan:
Network
Non-Network
Annual Deductible
Annual Deductible.
through the Mental
$40 Copay per
Annual Deductible.
through the Mental
Annual Deductible
Annual Deductible


Preventive Lab and radiology/Xray
Preventive mammography testing

Sickness and Injury related
diagnostic services
■ Outpatient Diagnostic/Therapeutic
Services - CT Scans, PET Scans,
MRI and Nuclear Medicine
■ Outpatient Therapeutic Treatments
Physician's Office Services - Sickness
and Injury
■ Primary Physician
■ Specialist Physician
Physician Fees for Surgical and
Medical Services
80% after you meet
the Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
100%
100%
Plan:
Network
Non-Network
■ Physician Office Services
100%
100%
■ Breast Pumps
100%
Annual Deductible
Annual Deductible
Annual Deductible
Annual Deductible
Preventive Care Services
Prosthetic Devices
Reconstructive Procedures
Rehabilitation Services - Outpatient
Therapy
Annual Deductible
Covered Health Service category in this section
Annual Deductible
Annual Deductible
Annual Deductible.
Prior Notification
required.
Annual Deductible
Annual Deductible
Annual Deductible.
through the Mental
100% after you pay
$40 Copay per
Annual Deductible.
through the Mental
Skilled Nursing Facility/Inpatient
Rehabilitation Facility Services
Up to 60 days per calendar year
Spinal Treatment
Substance Use Disorder Services
Transplantation Services
Notification is required for all transplant
services.
Transplantation Travel and Lodging
(If services rendered by a Designated
Facility)
Plan:
Network
Non-Network
is provided, benefits will be the same as those
stated under each Covered Health Service category
in this section.
For patient and companion(s) of patient undergoing
transplant procedures
Urgent Care Center Services
3
Copay per visit3
Copays apply toward the Annual Deductible or Out-of-Pocket Maximum. The Annual Deductible applies toward
the Out-of-Pocket Maximum for all Covered Health Services.
The Reta Trust – EnvisionRx Prescription Drug Plan
Pharmacy Schedule of Benefits
Summary of Benefits
Retail Pharmacy Copayment
(per Prescription Unit or up to 30 days)
Mail-Service Pharmacy Copayment
(up to 3 Prescription Units or up to 90 days)
Specialty Pharmacy Copayment (up to 30 days)
Reta Value Options (RVO) Market Priced Drugs
Generic
Brand
Formulary
Brand Non
Formulary
$10
$20
$30
$20
$40
$60
N/A
$30
N/A
See below description
What is my Schedule of Benefits?
This Schedule of Benefits provides specific details about your Prescription Drug Benefit, as well as its exclusions and
limitations.
How do I use my Prescription Drug Benefit?
Your Prescription Drug Benefit helps to cover the cost for some of the medications prescribed by a licensed
Physician. Using your benefit is simple.
 Present your doctor’s prescription and EnvisionRx ID card at any EnvisionRx Participating Pharmacy.
 Pay the Copayment for a Prescription Unit or its retail cost, whichever is less.
 Receive your medication.
What do I pay when I fill a prescription?
You will pay a Copayment when filling a prescription at an EnvisionRx Participating Pharmacy. You will pay a
Copayment every time a prescription is filled until you reach your medical plan annual out-of-pocket maximum. Your
benefits are as follows:
 When you fill or refill a prescription for a generic medication, your Copayment is $10 for a 30-day supply
(excluding maintenance medications).
 When you fill or refill a prescription for a Formulary brand-name medication, your Copayment is $20 for a 30day supply (excluding maintenance medications).
 When you fill or refill a prescription for a Non-Formulary brand-name medication, your Copayment is $30 for a
30-day supply (excluding maintenance medications).
Preferred Mail Service for Maintenance Medications - For maintenance medications, you must utilize
the Orchard Pharmaceutical (a division of EnvisionRx) mail service pharmacy and pay the mail service copayment
($20 generic, $40 Formulary Brand, $60 Non-Formulary Brand) for up to a 90 day supply. You will be able to receive
two fills at a retail pharmacy initially for maintenance medications, however, after two retail fills mail order is required through
Orchard Pharmaceuticals. You will need to obtain a NEW 90 Day supply prescription from your
physician. You also must REGISTER your member information with Orchard Mail Order Pharmacy. You may use
any of the following 3 easy registration options:
1. Online: (Recommended method) Visit www.orchardrx.com and select Not registered? Click here to
register. Your account will activate within 24 hours. By registering online, you can also track the progress of their
orders.
2. Phone: Call Orchard Pharmaceutical Services Customer Service at 1-866-909-5170 to speak with a representative.
3. Mail: Complete the Registration and Prescription Order Form enclosed in this packet.
1
Once registered, you may mail the original 90 day supply prescription(s) with the enclosed brochure or your physician can
fax your prescription(s) to Orchard at 1-866-909-5171. Please be sure that your prescriber includes your date of birth and
contact information on the fax. Only faxes sent from a physician’s office will be valid.
Reta Value Options (RVO)
Many brand-name medications have generics, brands, or over-the-counter (OTC) equivalents available that cost less and
are FDA-approved drugs with similar effectives. RVO drugs are:
 The most cost-effective FDA-approved drugs (generics, brands or OTC equivalents) that provide a therapeutically
equivalent result, based on available medical evidence.
 Designated as the formulary drug for each therapeutic category (a therapeutic category is a group of drugs that
treat a given diagnosis, such as statins used to treat high cholesterol).
If you are taking a drug in an RVO therapeutic category that is not the formulary RVO medication, you will be contacted
by EnvisionRx after your 1set prescription is filled with more information about the RVO program and your options.
How Reta Value Options Works
Under Reta Value Options pricing, you can choose to continue to use a drug that has a lower-priced, formulary drug
equivalent, but Reta will pay only the amount it would have paid for the therapeutically similar drug that costs less (the
RVO drug). You will pay the difference between the full market price of your prescription and the full market price of
the lowest cost RVO therapeutic alternative plus the copay for the lowest cost therapeutic alternative.
The Plan’s contribution for all therapeutic alternatives is based on what the Plan currently contributes to the lowest
cost alternative. The Plan does not provide a greater subsidy or benefit for more expensive, therapeutically similar,
medications. if you use a Non-Preferred Drug, you will pay more for it when you fill the prescription. You may avoid
the cost increase by taking action and talking with your doctor about Preferred Drugs as alternatives to NonPreferred Drugs.
Starting July 1, 2015, you can go to the “My Medicine Cabinet” website at www.EnvisionRx.com to find out how
much your current prescription drugs cost and research Preferred Drugs. Using this information, you’ll be able to
work more effectively with your doctor to make informed decisions about medications. All the drug options have
been approved by the Food and Drug Administration (FDA) for safety.
When I fill a prescription, how much medication do I receive?
 For a single retail Copayment, Members receive either one Prescription Unit or up to a 30-day supply of a drug.
 When you use the OrchardRx Mail Service Pharmacy program, you will receive three Prescription Units or up to
a 90- day supply of maintenance medications.
What if the Preferred Drug doesn’t work for me?
Your physician can file for a Physician Exception Request Form, by calling EnvisionRx at 1-844-852-7437, to have you
continue using a Non-Preferred Drug. Typically, exceptions are requested for reasons like the following:
 You’ve tried the Preferred Drug and it doesn’t work as well as the Non-Preferred Drug.
 The Preferred Drug won’t work with other medications you take.
 Your Physician feels your condition would be better treated with a Non-Preferred Drug.
 If the request is approved, you pay the applicable generic or brand copayment for the drug.
How can I request a Physician exception form?
You can call EnvisionRx at 1-844-852-7437, and ask them to send you a Physician Exception Request Form by mail.
Forms are also available for printing on Envisions website at www.EnvisionRx.com. Please note: your physician
must complete and submit the form to using the fax number on the form. EnvisionRx will perform a detailed clinical
review and then notify you and your physician of the decision. If you disagree with the decision, you have the right to file
an appeal with EnvisionRx.
2
What else do I need to know?
 You should become familiar with EnvisionRx’ prescription drug Formulary. Any medication not on the Formulary

you will pay the higher non-formulary copayment. For more information on the Formulary, please visit
www.EnvisionRx.com.
It is possible to buy a brand-name drug in place of a generic equivalent, even though the generic drug is the only
one listed on our Formulary. Your cost, however, will be higher (Non-Formulary copayment). For more
information, please continue to “Medications Covered by Your Benefit” and read the description for Generic
Drugs.
ADDITIONAL INFORMATION
Medications Covered by Your Benefit
The following medications are included in the EnvisionRx managed Formulary and are available to your Physician.
 Federal Legend Drugs: Any medicinal substance which bears the legend: “Caution: Federal law prohibits
dispensing without a prescription.”
 State Restricted Drugs: Any medicinal substance that may be dispensed by prescription only according to state
law.
 Generic Drugs: Comparable generic drugs may be substituted for brand-name drugs.
 For the purposes of determining coverage, the following items are considered prescription drug benefits:
glucagon, insulin, insulin syringes, blood glucose test strips, lancets, inhaler extender devices, urine test strips
and anaphylaxis prevention kits (including, but not limited to, EpiPen¨, Ana-Kits¨ and Ana-Guard¨).
 Injectable drugs (except as listed under “Exclusions and Limitations”).
Exclusions and Limitations
While the Prescription Drug Benefit covers most medications, there are some that are not covered:
 Drugs or medicines purchased and received prior to the Member’s effective date or subsequent to the Member’s
termination.
 Therapeutic devices or appliances, including hypodermic needles, syringes (except insulin syringes), support
garments and other nonmedicinal substances.
 All nonprescription (over-the-counter) contraceptive jellies, ointments, foams or devices.
 Contraceptives prescribed for birth control
 Medications to be taken or administered to the eligible Member while a patient in a hospital, rest home, nursing
home, sanitarium, etc.
 Drugs or medicines delivered or administered to the Member by the prescriber or the prescriber’s staff.
 Dietary supplements, including vitamins and fluoride supplements (except prenatal), health or beauty aids, herbal
supplements and/or Alternative Medicine.
 Compounded Medication: Any medicinal substance that has at least one ingredient that is Federal Legend or state
Restricted in a therapeutic amount. All compounded medications are subject to EnvisionRx’ prior
authorization process
 Medication for which the cost is recoverable under any workers’ compensation or occupational disease law or any
state or government agency, or medication furnished by any other drug or medical service for which no charge is
made to the patient.
 Medication prescribed for Experimental or Investigational therapies, unless required by an external independent
review panel pursuant to California Health and Safety Code Section 1370.4. For non-Food-and-DrugAdministration-approved indications, see the following exclusion.
 Off-Label Drug Use: Off-Label Drug Use means that the Provider has prescribed a drug approved by the Food and
Drug Administration (FDA) for a use that is different than that for which the FDA approved the drug. EnvisionRx
excludes coverage for Off-Label Drug Use, including off-label self-injectable drugs, except as described in the
Subscriber Agreement and any applicable Attachments. If a drug is prescribed for Off-Label Drug Use, the drug
and its administration will be covered only if it satisfies the following criteria:
o The drug is approved by the FDA.
o The drug is prescribed by a licensed health care professional for the treatment of a life-threatening
condition or for a chronic and seriously debilitating condition.
o The drug is Medically Necessary to treat the condition.
o The drug has been recognized for treatment of the life-threatening or chronic and seriously debilitating
condition by one of the following: The American Medical Association Drug Evaluations; The American
Hospital Formulary Service Drug Information; the United States Pharmacopeia Dispensing Information;
or in two articles from major peer-reviewed medical journals that present data supporting the proposed
3
Off-Label Drug Use or Uses as generally safe and effective.
The drug is administered as part of a core medical benefit as determined by EnvisionRx. Nothing in this
section shall prohibit EnvisionRx from use of a Formulary, Copayment, technology assessment panel or
similar mechanism as a means for appropriately controlling the utilization of a drug that is prescribed for
a use that is different from the use for which that drug has been approved for marketing by the FDA.
Denial of a drug as investigational or experimental will allow the Member to use the Independent Medical
Review System as defined in the medical Combined Evidence of Coverage and Disclosure Form.
Medications available without a prescription (over-the-counter) or for which there is a nonprescription equivalent
available, even if ordered by a Physician.
Elective or voluntary enhancement procedures, services, supplies and medications, including, but not limited to,
weight loss, hair growth, athletic performance, cosmetic purposes, anti-aging and mental performance. Examples
of these drugs include, but are not limited to, Penlac, Retin-A, Renova, Vaniqa, Propecia, Lustra, Xenical or
Meridia.
Medications dispensed by a non-Participating Pharmacy (except for prescriptions required as a result of an
Emergency or Urgently Needed Service for an acute condition).
Drugs prescribed by a dentist or drugs used for dental treatment.
Drugs used for diagnostic purposes.
Saline and irrigation solutions.
MUSE suppositories.
Replacement of lost, stolen or destroyed medications. EnvisionRx reserves the right to expand the prior
authorization requirement for any drug product to assure adherence to FDA-approved indications and national
practice standards.
o








The Appeals Process
EnvisionRx contracts with a leading independent review organization (IRO) for the administration and determination of
appeals. Your appeal will be reviewed and you will be notified in writing of the determination within 30 calendar days of
EnvisionRx receipt of the appeal. If your appeal is denied, your written response will include the specific reason for the
decision, describe the criteria or guidelines or benefit provision on which the denial decision was based, and notification
that upon request the Member may obtain a copy of the actual benefit provision, guideline protocol or other similar
criterion on which the denial is based. For determinations delaying, denying or modifying health care services based on a
finding that the services are not Covered Services, the response will specify the provisions in the pharmacy plan documents
that exclude that coverage. If you are not satisfied with the outcome of the first appeal, you may request a second appeal
within four months of the initial appeal.
Expedited Review Appeals Process
Appeals involving an imminent and serious threat to your health including, but not limited to, severe pain or the potential
loss of life, limb or major bodily function will be immediately referred to the IRO’s clinical review personnel. Expedited
appeals will be reviewed and you will be notified of the determination within 72 hours from EnvisionRx receipt of the
appeal. If your case does not meet the criteria for an expedited review, it will be reviewed under the standard appeal
process.
Specialty Pharmacy (Injectable Medications)
EnvisionRx Specialty Pharmacy will conveniently deliver your Injectable medications to your home or physician’s office, or
other location of choice. And there is no charge for shipping! Your prescription drug benefit allows one grace fill at any
retail pharmacy, for up to a 30-day supply each, to ensure you continue receiving your specialty medication(s) as
scheduled. After that, you are required to utilize Orchard Specialty Pharmacy for your specialty medications. Because
specialty medications can be more difficult to manage, Orchard Specialty Pharmacy offers the following patient support
services at no charge:

Personalized support to help you achieve the best results from your prescribed therapy

Convenient delivery to your home or prescriber’s office

Easy access to a Care Team who can answer medication questions, provide educational materials about your
condition, help you manage any potential medication side effects, and provide confidential support—all with one
toll-free phone call.

If you have any questions, or to begin taking advantage of these complimentary patient support services, please
call Orchard Specialty Pharmacy at 1-877-437-9012.
Who should I call with questions?
 Call EnvisionRx at 1-844-852-7437 for direct access to their customer service line.
4
Preferred Drug List
Introduction
How to Use the Preferred Drug List
The EnvisionRx Pharmacy and Therapeutics Committee is
responsible for the development and maintenance of the
Preferred Drug List. The Committee is comprised of
independent practicing physicians and pharmacists from a
wide variety of medical specialties. The Preferred Drug List
is reviewed and updated from time to time as new drugs or
new prescribing information becomes available. Factors
which affect decisions regarding the Preferred Drug List
include safe use, clinical efficacy, and therapeutic need.
Only after those factors are assessed is cost considered.
Compliance with the Preferred Drug List is important for
improving quality of care and restraining health care costs.
The EnvisionRx Preferred Drug List is a reference tool for
identifying preferred medications within certain therapeutic
categories. Generic medications should be considered the
first line of prescribing. If there is no generic medication
available to treat the condition, there may be more than
one brand medication available. Preferred brand
medications are listed to help identify products that are
clinically appropriate and cost effective. Generics within
therapeutic categories are listed for reference purposes.
You may be able to obtain a drug not included on the
Preferred Drug List for reasons of medical necessity or if
formulary alternatives are inappropriate. Quantity Limits
and Prior Authorizations and may be in place for certain
medications and will vary by plan. Check with member
services to see if your plan has these limitations in place.

Generics are listed in lowercase letters.

Brands are listed in UPPERCASE letters.

Non-Preferred products are listed with an [NP] symbol.

Specialty products are listed with an [SP] symbol.
The EnvisionRx Preferred Drug List is not all inclusive and
does not guarantee coverage of any medication.
Therapeutic Listing
ADHD/ANTINARCOLEPSY/ANTIOBESITY/ANOREXIANTS
*Amphetamines**
AmphetamineDextroamphetamine
Dextroamphetamine Sulfate
VYVANSE
*Anorexiants NonAmphetamine**
Phentermine HCl
*Attention-Deficit/Hyperactivity
Disorder (ADHD) Agents**
INTUNIV
*Stimulants - Misc.**
Dexmethylphenidate HCl
Modafinil
NUVIGIL
ANALGESICS - ANTIINFLAMMATORY
HUMIRA [SP]
SIMPONI [SP]
*Interleukin-1 Receptor
Antagonist (IL-1Ra)**
KINERET [SP] [NP]
*Interleukin-6 Receptor
Inhibitors**
ACTEMRA [SP] [NP]
*Nonsteroidal Antiinflammatory Agents
(NSAIDs)**
Ibuprofen
Meloxicam
Naproxen
CELEBREX
DUEXIS [NP]
VIMOVO [NP]
*Phosphodiesterase 4 (PDE4)
Inhibitors**
OTEZLA [SP] [NP]
*Antirheumatic - Enzyme
Inhibitors**
*Pyrimidine Synthesis
Inhibitors**
XELJANZ [SP] [NP]
Leflunomide
*Anti-TNF-alpha - Monoclonal
Antibodies**
*Selective Costimulation
Modulators**
ORENCIA [SP] [NP]
*Soluble Tumor Necrosis
Factor Receptor Agents**
ENBREL [SP]
ANALGESICS - NonNarcotic
*Analgesic Combinations**
Butalbital-AcetaminophenCaffeine
Butalbital-Aspirin-Caffeine
*Analgesics Other**
Acetaminophen
*Salicylates**
Aspirin
ANALGESICS - OPIOID
*Opioid Agonists**
Morphine Sulfate
Oxycodone HCl
Tramadol HCl
HYSINGLA ER
NUCYNTA
NUCYNTA ER
OPANA ER
OXYCONTIN
*Opioid Combinations**
[SP] = Specialty [NP] = Non-Preferred
Acetaminophen w/ Codeine
Hydrocodone-Acetaminophen
Oxycodone w/ Acetaminophen
*Opioid Partial Agonists**
Buprenorphine HCl
Buprenorphine HCl-Naloxone
HCl Dihydrate
BUTRANS
SUBOXONE
ANDROGENS-ANABOLIC
*Androgens**
Testosterone Cypionate
ANDRODERM [NP]
ANDROGEL
TESTIM
ANORECTAL AGENTS
*Rectal Combinations**
Hydrocortisone Acetate w/
Pramoxine
PROCTOFOAM
*Rectal Steroids**
Hydrocortisone (Rectal)
Hydrocortisone Acetate (Rectal)
ANTIANGINAL AGENTS
*Antianginals-Other**
XARELTO
RANEXA
*Nitrates**
*Heparins And Heparinoid-Like
Agents**
*Biguanides**
Metformin HCl
*Diabetic Other**
Isosorbide Mononitrate
Nitroglycerin
ANTIANXIETY AGENTS
*Benzodiazepines**
Enoxaparin Sodium
*Thrombin Inhibitors**
GLUCAGEN
GLUCAGON
PRADAXA
ANTICONVULSANTS
*Dipeptidyl Peptidase-4 (DPP4) Inhibitors**
Alprazolam
Diazepam
Lorazepam
ANTIARRHYTHMICS
*Antiarrhythmics Type I-C**
*Anticonvulsants Benzodiazepines**
JANUVIA
NESINA [NP]
ONGLYZA
Flecainide Acetate
Propafenone HCl
*Antiarrhythmics Type III**
Amiodarone HCl
MULTAQ
TIKOSYN
ANTIASTHMATIC AND
BRONCHODILATOR AGENTS
*Bronchodilators Anticholinergics**
Ipratropium Bromide
ANORO
INCRUSE
SPIRIVA
*Leukotriene Modulators**
Montelukast Sodium
*Selective Phosphodiesterase
4 (PDE4) Inhibitors**
DALIRESP
*Steroid Inhalants**
Budesonide (Inhalation)
ASMANEX
FLOVENT
PULMICORT FLEXHALER
QVAR
*Sympathomimetics**
Albuterol Sulfate
Ipratropium-Albuterol
Levalbuterol HCl
ADVAIR DISKUS/HFA
BREO ELLIPTA
COMBIVENT RESPIMAT
FORADIL
PROAIR
SEREVENT DISKUS
SYMBICORT
VENTOLIN
ANTICOAGULANTS
*Coumarin Anticoagulants**
Warfarin Sodium
*Direct Factor Xa Inhibitors**
ELIQUIS
Clonazepam
*Anticonvulsants - Misc.**
Gabapentin
Lamotrigine
Topiramate
LAMICTAL ODT
LYRICA
*Valproic Acid**
Divalproex Sodium
ANTIDEPRESSANTS
*Alpha-2 Receptor Antagonists
(Tetracyclics)**
Mirtazapine
*Antidepressants - Misc.**
Bupropion HCl
*Selective Serotonin Reuptake
Inhibitors (SSRIs)**
Citalopram Hydrobromide
Escitalopram Oxalate
Sertraline HCl
*Serotonin Modulators**
Trazodone HCl
BRINTELLIX
VIIBRYD
*Serotonin-Norepinephrine
Reuptake Inhibitors (SNRIs)**
Duloxetine HCl
Venlafaxine HCl
FETZIMA
PRISTIQ
*Tricyclic Agents**
Amitriptyline HCl
Doxepin HCl
Nortriptyline HCl
ANTIDIABETICS
*Antidiabetic Combinations**
Glyburide-Metformin
Pioglitazone HCl-Metformin HCl
INVOKAMET
JANUMET
JANUMET XR
KAZANO [NP]
KOMBIGLYZE
OSENI [NP]
PRANDIMET
*Incretin Mimetic Agents (GLP1 Receptor Agonists)**
TANZEUM
VICTOZA
*Insulin Sensitizing Agents**
Pioglitazone HCl
*Insulin**
APIDRA
LANTUS
LEVEMIR
NOVOLIN
NOVOLIN MIX
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX
*Meglitinide Analogues**
Repaglinide
*Sodium-Glucose CoTransporter 2 (SGLT2)
Inhibitors**
FARXIGA
INVOKANA
*Sulfonylureas**
Glimepiride
Glipizide
Glyburide
ANTIDIARRHEALS
*Antiperistaltic Agents**
Diphenoxylate w/ Atropine
Loperamide HCl
ANTIDOTES
*Opioid Antagonists**
Naltrexone HCl
ANTIEMETICS
*5-HT3 Receptor Antagonists**
Ondansetron
Ondansetron HCl
ANZEMET [SP]
*Antiemetics Anticholinergic**
Meclizine HCl
ANTIFUNGALS
*Antifungals**
Terbinafine HCl
*Imidazole-Related
Antifungals**
Fluconazole
Ketoconazole
ANTIHISTAMINES
*Antihistamines Ethanolamines**
Diphenhydramine HCl
*Antihistamines - NonSedating**
Cetirizine HCl
Levocetirizine Dihydrochloride
Loratadine
*Antihistamines Phenothiazines**
Promethazine HCl
*Antihistamines - Piperidines**
Cyproheptadine HCl
ANTIHYPERLIPIDEMICS
*Antihyperlipidemics - Misc.**
Omega-3-acid Ethyl Esters
VASCEPA
*Bile Acid Sequestrants**
Cholestyramine
Colestipol HCl
WELCHOL
*Fibric Acid Derivatives**
Choline Fenofibrate
Fenofibrate
Gemfibrozil
LIPOFEN
*HMG CoA Reductase
Inhibitors**
Atorvastatin Calcium
Pravastatin Sodium
Simvastatin
CRESTOR
LIVALO
*Intestinal Cholesterol
Absorption Inhibitors**
ZETIA
ANTIHYPERTENSIVES
*ACE Inhibitors**
Enalapril Maleate
Lisinopril
Ramipril
*Angiotensin II Receptor
Antagonists**
Irbesartan
Losartan Potassium
Telmisartan
BENICAR
*Antiadrenergic
Antihypertensives**
Clonidine HCl
Doxazosin Mesylate
Terazosin HCl
*Quinolinone Derivatives**
*Antihypertensive
Combinations**
ABILIFY
AMTURNIDE
AZOR
BENICAR HCT
DIOVAN
EXFORGE HCT
TARKA
TEKAMLO
TEKTURNA HCT
TRIBENZOR
*Direct Renin Inhibitors**
Lisinopril & Hydrochlorothiazide
Losartan Potassium &
Hydrochlorothiazide
Valsartan-Hydrochlorothiazide
TEKTURNA
*Vasodilators**
Hydralazine HCl
ANTINEOPLASTICS AND
ADJUNCTIVE THERAPIES
*Antineoplastic - Hormonal
and Related Agents*
ZYTIGA [SP]
ANTIPARKINSON AGENTS
*Antiparkinson
Anticholinergics**
Benztropine Mesylate
*Antiparkinson
Dopaminergics**
Carbidopa-Levodopa
Pramipexole Dihydrochloride
Ropinirole Hydrochloride
*Antiparkinson Monoamine
Oxidase Inhibitors**
AZILECT
ANTIPSYCHOTICS/ANTIMANIC
AGENTS
*Antimanic Agents**
Lithium Carbonate
*Antipsychotics - Misc.**
Ziprasidone HCl
*Benzisoxazoles**
Risperidone
*Butyrophenones**
Haloperidol
Haloperidol Lactate
*Dibenzapines**
Olanzapine
Quetiapine Fumarate
SEROQUEL XR
*Phenothiazines**
Prochlorperazine
Prochlorperazine Maleate
ANTIVIRALS
*CMV Agents**
Ganciclovir
*Hepatitis Agents**
HARVONI [SP]
PEG-INTRON [SP]
PEGASYS [SP]
Ribavirin [SP]
SOVALDI [SP]
*Herpes Agents**
Acyclovir
Famciclovir
Valacyclovir HCl
ZOVIRAX
*ASSORTED CLASSES*
*Immunosuppressive Agents**
Azathioprine
Mycophenolate Mofetil [SP]
Tacrolimus
BETA BLOCKERS
*Alpha-Beta Blockers**
Carvedilol
Labetalol HCl
COREG CR
LEVITRA
VIAGRA
Clindamycin Phosphate-Benzoyl
Peroxide
*Pulmonary Hypertension Endothelin Receptor
Antagonists**
Tretinoin
ACANYA
ATRALIN
AZELEX
RETIN-A MICR GEL 0.08%
*Antibiotics - Topical**
OPSUMIT [SP]
LETAIRIS [SP]
TRACLEER [SP]
CONTRACEPTIVES
*Combination Contraceptives Oral**
Norethin Acet & Estrad-Fe
Norgestimate-Ethinyl Estradiol
(Triphasic)
BEYAZ
NATAZIA
ORTHO TRI CYCLEN LO
SAFYRAL
*Progestin Contraceptives Injectable**
STELARA [SP]
*Burn Products**
Norelgestromin-Ethinyl Estradiol
*Combination Contraceptives Vaginal**
Atenolol
BYSTOLIC
*Progestin Contraceptives Oral**
*Beta Blockers CardioSelective**
Norethindrone (Contraceptive)
CORTICOSTEROIDS
*Glucocorticosteroids**
Digoxin
CARDIOVASCULAR AGENTS MISC.
*Cardiovascular Agents Misc. Combinations**
*Anti-inflammatory Agents Topical**
NUVARING
*Combination Contraceptives Transdermal**
Medroxyprogesterone Acetate
(Contraceptive)
Amlodipine Besylate
Diltiazem HCl Coated Beads
Nifedipine
CARDIOTONICS
*Cardiac Glycosides**
Clotrimazole w/ Betamethasone
Ketoconazole (Topical)
Nystatin (Topical)
MENTAX
FLECTOR
*Antineoplastic or
Premalignant Lesion Agents Topical**
Fluorouracil (Topical)
FLUOROPLEX
PICATO [NP]
*Antipsoriatics**
*Beta Blockers CardioSelective**
Metoprolol Succinate
Metoprolol Tartrate
*Beta Blockers NonSelective**
Nadolol
Propranolol HCl
Sotalol HCl
CALCIUM CHANNEL
BLOCKERS
*Calcium Channel Blockers**
Mupirocin
Mupirocin Calcium (Topical)
*Antifungals - Topical**
Dexamethasone
Methylprednisolone
Prednisone
UCERIS [NP]
*Mineralocorticoids**
Fludrocortisone Acetate
COUGH/COLD/ALLERGY
*Antitussives**
Benzonatate
Hydrocodone w/ Homatropine
*Cough/Cold/Allergy
Combinations**
Hydrocodone PolistirexChlorpheniramine Polistirex
Promethazine w/Codeine
Promethazine-DM
*Expectorants**
Amlodipine Besylate-Atorvastatin
Calcium
Guaifenesin
DERMATOLOGICALS
*Acne Products**
*Impotence Agents**
Clindamycin Phosphate (Topical)
Silver Sulfadiazine
*Emollient/Keratolytic
Agents**
Urea
*Emollients**
Lactic Acid (Ammonium Lactate)
*Immunomodulating Agents Topical**
Imiquimod
ZYCLARA [NP]
*Immunosuppressive Agents Topical**
ELIDEL
PROTOPIC
*Local Anesthetics - Topical**
Lidocaine-Prilocaine
*Misc. Topical**
Aluminum Chloride
DIAGNOSTIC PRODUCTS
*Diagnostic Tests**
BREEZE
CONTOUR
FREESTYLE
PRECISION
DIGESTIVE AIDS
*Digestive Enzymes**
CREON
SUCRAID
ZENPEP
DIURETICS
*Carbonic Anhydrase
Inhibitors**
Acetazolamide
*Diuretic Combinations**
Spironolactone &
Hydrochlorothiazide
Triamterene &
Hydrochlorothiazide
*Loop Diuretics**
Bumetanide
Furosemide
Torsemide
*Potassium Sparing
Diuretics**
Spironolactone
*Thiazides and Thiazide-Like
Diuretics**
Chlorthalidone
Hydrochlorothiazide
Metolazone
ENDOCRINE AND METABOLIC
AGENTS - MISC.
*Bone Density Regulators**
Alendronate Sodium
Ibandronate Sodium
ACTONEL 5MG, 30MG, 35MG
ATELVIA
*Fertility Regulators**
FOLLISTIM AQ [SP]
*Growth Hormones**
GENOTROPIN [SP]
NORDITROPIN [SP]
*Hormone Receptor
Modulators**
Raloxifene HCl
*Posterior Pituitary
Hormones**
Desmopressin Acetate [SP]
*Prolactin Inhibitors**
Cabergoline
ESTROGENS
*Estrogen Combinations**
Esterified Estrogens &
Methyltestosterone
Estradiol & Norethindrone
Acetate
CLIMARA PRO
COMBIPATCH
PREMPHASE
PREMPRO
*Estrogens**
Estradiol
MENEST
MENOSTAR
PREMARIN
VIVELLE-DOT
FLUOROQUINOLONES
*Fluoroquinolones**
Ciprofloxacin HCl
Levofloxacin
Moxifloxacin HCl
GASTROINTESTINAL AGENTS
- MISC.
*Gallstone Solubilizing
Agents**
Ursodiol
*Gastrointestinal Chloride
Channel Activators**
AMITIZA
*Gastrointestinal Stimulants**
Metoclopramide HCl
*Inflammatory Bowel Agents**
Sulfasalazine
APRISO
CIMZIA [SP] [NP]
LIALDA
*Irritable Bowel Syndrome
(IBS) Agents**
LINZESS
LOTRONEX
*Intestinal Acidifiers**
Lactulose (Encephalopathy)
*Phosphate Binder Agents**
FOSRENOL
RENAGEL
RENVELA
GENITOURINARY AGENTS MISCELLANEOUS
*Alkalinizers**
Potassium Citrate (Alkalinizer)
*Prostatic Hypertrophy
Agents**
Alfuzosin HCl
Finasteride
Tamsulosin HCl
AVODART
JALYN
RAPAFLO
*Urinary Analgesics**
Phenazopyridine HCl
GOUT AGENTS
*Gout Agents**
Allopurinol
COLCRYS
ULORIC
HEMATOLOGICAL AGENTS MISC.
*Platelet Aggregation
Inhibitors**
Cilostazol
Clopidogrel Bisulfate
AGGRENOX
BRILINTA
EFFIENT
HEMATOPOIETIC AGENTS
*Folic Acid/Folates**
Folic Acid
NOVOTWIST
ULTICARE LANCETS
ULTICARE PEN NEEDLES
ULTICARE SYRINGES
MIGRAINE PRODUCTS
*Migraine Combinations**
*Hematopoietic Growth
Factors**
Acetaminophen-IsomethepteneDichloralphenazone
EPOGEN [SP]
NEULASTA [SP]
NEUPOGEN [SP]
PROCRIT
HEMOSTATICS
*Hemostatics - Systemic**
TREXIMET
*Serotonin Agonists**
Rizatriptan Benzoate
Sumatriptan Succinate
Zolmitriptan
RELPAX
Tranexamic Acid
HYPNOTICS
*Barbiturate Hypnotics**
*Anesthetics Topical Oral**
Phenobarbital
*Non-Barbiturate Hypnotics**
Lidocaine HCl (Mouth-Throat)
*Anti-infectives - Throat**
Eszopiclone
Temazepam
Zolpidem Tartrate
LAXATIVES
Clotrimazole
Nystatin (Mouth-Throat)
*Antiseptics - Mouth/Throat**
PEG 3350-KCl-Sod Bicarb-Sod
Chloride-Sod Sulfate
PEG 3350-Potassium ChlorideSod Bicarbonate-Sod Chloride
Sennosides-Docusate Sodium
*Laxative Combinations**
MOVIPREP
*Laxatives - Miscellaneous**
Lactulose
Polyethylene Glycol 3350
KRISTALOSE
*Stimulant Laxatives**
Bisacodyl
Sennosides
*Surfactant Laxatives**
Docusate Sodium
MACROLIDES
*Azithromycin**
Azithromycin
*Clarithromycin**
Clarithromycin
*Erythromycins**
MOUTH/THROAT/DENTAL
AGENTS
Chlorhexidine Gluconate (MouthThroat)
*Dental Products**
Sodium Fluoride (Dental)
*Steroids - Mouth/Throat**
Triamcinolone Acetonide
(Mouth)
MULTIVITAMINS
*Ped MV w/ Fluoride**
Pediatric Multivitamins w/Fl
*Prenatal Vitamins**
Prenatal Vit w/ Ferrous
Fumarate-Folic Acid
PRENATE DHA
PRENATE ELITE
PRENATE ESSENTIAL
MUSCULOSKELETAL
THERAPY AGENTS
*Central Muscle Relaxants**
Carisoprodol
Cyclobenzaprine HCl
Tizanidine HCl
NASAL AGENTS - SYSTEMIC
AND TOPICAL
Erythromycin Base
MEDICAL DEVICES
*Diabetic Supplies**
*Nasal Agent Cominations**
BREEZE
CONTOUR
FREESTYLE
PRECISION
*Parenteral Therapy Supplies**
Azelastine HCl
*Nasal Anticholinergics**
NOVOFINE
DYMISTA [NP]
*Nasal Antiallergy**
Ipratropium Bromide (Nasal)
*Nasal Steroids**
Fluticasone Propionate (Nasal)
Triamcinolone Acetonide (Nasal)
NASONEX
QNASL
VERAMYST
OPHTHALMIC AGENTS
*Beta-blockers - Ophthalmic**
Dorzolamide HCl-Timolol
Maleate
Timolol Maleate (Ophth)
BETIMOL
BETOPTIC-S
COMBIGAN
*Cycloplegic Mydriatics**
Atropine Sulfate (Ophthalmic)
*Ophthalmic Adrenergic
Agents**
Brimonidine Tartrate
ALPHAGAN P
*Ophthalmic Anti-infectives**
Erythromycin (Ophth)
Polymyxin B-Trimethoprim
Tobramycin (Ophth)
VIGAMOX
*Ophthalmic
Immunomodulators**
RESTASIS
*Ophthalmics - Misc.**
Azelastine HCl (Ophth)
Dorzolamide HCl
Ketorolac Tromethamine (Ophth)
ACUVAIL
ALOMIDE
AZOPT
LASTACAFT
NEVANAC
PATADAY
*Prostaglandins Ophthalmic**
Latanoprost
Travoprost
LUMIGAN
TRAVATAN Z
OTIC AGENTS
*Otic Anti-infectives**
Ofloxacin (Otic)
*Otic Combinations**
Antipyrine-Benzocaine
Neomycin-Polymyxin-HC (Otic)
CIPRO HC
CIPRODEX
PENICILLINS
*Aminopenicillins**
Amoxicillin
Ampicillin
*Natural Penicillins**
Penicillin V Potassium
*Penicillin Combinations**
Amoxicillin & Pot Clavulanate
*Penicillinase-Resistant
Penicillins**
Dicloxacillin Sodium
PROGESTINS
*Progestins**
Norethindrone Acetate
Progesterone Micronized
MEGACE ES SUSP
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS MISC.
*Antidementia Agents**
Donepezil Hydrochloride
EXELON
NAMENDA
NAMENDA XR
*Fibromyalgia Agents**
SAVELLA
*Multiple Sclerosis Agents**
AVONEX [SP]
BETASERON [SP] [NP]
COPAXONE [SP]
GILENYA [SP]
TECFIDERA [SP]
*Smoking Deterrents**
Nicotine
CHANTIX
TETRACYCLINES
*Tetracyclines**
Doxycycline (Monohydrate)
Doxycycline Hyclate
Minocycline HCl
SOLODYN [NP]
THYROID AGENTS
*Antithyroid Agents**
Methimazole
*Thyroid Hormones**
Levothyroxine Sodium
Levoxyl
Liothyronine Sodium
SYNTHROID
ULCER DRUGS
*Antispasmodics**
Dicyclomine HCl
Glycopyrrolate
Hyoscyamine Sulfate
CANTIL
*H-2 Antagonists**
Cimetidine
Famotidine
Ranitidine HCl
*Misc. Anti-Ulcer**
Sucralfate
CARAFATE SUS
*Proton Pump Inhibitors**
Lansoprazole
Omeprazole
Pantoprazole Sodium
DEXILANT
NEXIUM
*Ulcer Drugs Prostaglandins**
Misoprostol
*Ulcer Therapy
Combinations**
Omeprazole-Sodium
Bicarbonate
URINARY ANTI-INFECTIVES
*Urinary Anti-infectives**
Nitrofurantoin Macrocrystal
Nitrofurantoin Monohyd Macro
URINARY ANTISPASMODICS
*Urinary Antispasmodic Antimuscarinics
(Anticholinergic)**
Oxybutynin Chloride
Tolterodine Tartrate
VESICARE
*Urinary Antispasmodics Beta-3 Adrenergic Agonists**
MYRBETRIQ
VAGINAL PRODUCTS
*Vaginal Anti-infectives**
Metronidazole Vaginal
Terconazole Vaginal
AVC
*Vaginal Estrogens**
ESTRING
PREMARIN
PREMARIN VAGINAL CREAM
VAGIFEM
VASOPRESSORS
*Anaphylaxis Therapy
Agents**
AUVI-Q
EPIPEN
EPIPEN-JR
*Vasopressors**
Midodrine HCl
Note: Preferred Multiple Sclerosis agents must be tried prior to obtaining fill for non-preferred agent
Alphabetical Listing
Atropine Sulfate (Ophthalmic)
Cetirizine HCl
Digoxin
ABILIFY
AUVI-Q
CHANTIX
Diltiazem HCl Coated Beads
ACANYA
AVC
DIOVAN
Acetaminophen
AVODART
Chlorhexidine Gluconate
(Mouth-Throat)
Acetaminophen w/ Codeine
AcetaminophenIsomethepteneDichloralphenazone
Acetazolamide
AVONEX [SP]
Chlorthalidone
Diphenoxylate w/ Atropine
Azathioprine
Cholestyramine
Divalproex Sodium
Azelastine HCl
Choline Fenofibrate
Docusate Sodium
Azelastine HCl (Ophth)
Cilostazol
Donepezil Hydrochloride
AZELEX
Cimetidine
AZILECT
CIMZIA [SP] [NP]
Azithromycin
CIPRO HC
AZOPT
CIPRODEX
Dorzolamide HCl
Dorzolamide HCl-Timolol
Maleate
Doxazosin Mesylate
AZOR
Ciprofloxacin HCl
A
ACTEMRA [SP] [NP]
ACTONEL 5MG, 30MG,
35MG
ACUVAIL
Acyclovir
ADVAIR DISKUS/HFA
AGGRENOX
Albuterol Sulfate
Alendronate Sodium
Alfuzosin HCl
Allopurinol
ALOMIDE
ALPHAGAN P
Alprazolam
Aluminum Chloride
Amiodarone HCl
AMITIZA
Amitriptyline HCl
Amlodipine Besylate
Amlodipine BesylateAtorvastatin Calcium
Amoxicillin
Amoxicillin & Pot Clavulanate
AmphetamineDextroamphetamine
Ampicillin
AMTURNIDE
ANDRODERM [NP]
ANDROGEL
Antipyrine-Benzocaine
ANORO
B
BENICAR
Aspirin
ATELVIA
Atenolol
Atorvastatin Calcium
ATRALIN
Doxycycline (Monohydrate)
Doxycycline Hyclate
DUEXIS [NP]
BETASERON [SP] [NP]
BETIMOL
Clonazepam
EFFIENT
BETOPTIC-S
Clonidine HCl
ELIDEL
BEYAZ
Clopidogrel Bisulfate
ELIQUIS
Bisacodyl
Enalapril Maleate
BREO ELLIPTA
Clotrimazole
Clotrimazole w/
Betamethasone
COLCRYS
BRILINTA
Colestipol HCl
Brimonidine Tartrate
EPIPEN-JR
COMBIGAN
BRINTELLIX
EPOGEN [SP]
COMBIPATCH
Budesonide (Inhalation)
Erythromycin (Ophth)
COMBIVENT RESPIMAT
Bumetanide
Erythromycin Base
CONTOUR
Buprenorphine HCl
Escitalopram Oxalate
COPAXONE [SP]
Buprenorphine HCl-Naloxone
HCl Dihydrate
COREG CR
Esterified Estrogens &
Methyltestosterone
CREON
Estradiol
CRESTOR
Cyclobenzaprine HCl
Estradiol & Norethindrone
Acetate
Cyproheptadine HCl
ESTRING
Benzonatate
Benztropine Mesylate
BREEZE
Bupropion HCl
Butalbital-AcetaminophenCaffeine
Butalbital-Aspirin-Caffeine
D
BUTRANS
DALIRESP
BYSTOLIC
C
APIDRA
ASMANEX
Clarithromycin
Doxepin HCl
CLIMARA PRO
Clindamycin Phosphate
(Topical)
Clindamycin PhosphateBenzoyl Peroxide
BENICAR HCT
ANZEMET [SP]
APRISO
Citalopram Hydrobromide
Diphenhydramine HCl
Cabergoline
CANTIL
CARAFATE SUS
Carbidopa-Levodopa
Carisoprodol
Carvedilol
CELEBREX
Desmopressin Acetate [SP]
Duloxetine HCl
DYMISTA [NP]
E
ENBREL [SP]
Enoxaparin Sodium
EPIPEN
Eszopiclone
EXELON
EXFORGE HCT
F
Dexamethasone
DEXILANT
Famciclovir
Dexmethylphenidate HCl
Famotidine
Dextroamphetamine Sulfate
FARXIGA
Diazepam
Fenofibrate
Dicloxacillin Sodium
FETZIMA
Dicyclomine HCl
Finasteride
Flecainide Acetate
INTUNIV
Lithium Carbonate
FLECTOR
INVOKAMET
LIVALO
FLOVENT
INVOKANA
Loperamide HCl
Fluconazole
Ipratropium Bromide
Loratadine
Fludrocortisone Acetate
Ipratropium Bromide (Nasal)
Lorazepam
FLUOROPLEX
Ipratropium-Albuterol
Losartan Potassium
Fluorouracil (Topical)
Fluticasone Propionate
(Nasal)
Folic Acid
Irbesartan
Losartan Potassium &
Hydrochlorothiazide
FOLLISTIM AQ [SP]
JALYN
FORADIL
JANUMET
FOSRENOL
JANUMET XR
FREESTYLE
JANUVIA
Isosorbide Mononitrate
J
NEULASTA [SP]
NEUPOGEN [SP]
NEVANAC
NEXIUM
Nicotine
Nifedipine
LOTRONEX
Nitrofurantoin Macrocrystal
LUMIGAN
Nitrofurantoin Monohyd Macro
LYRICA
M
Meclizine HCl
K
Furosemide
Neomycin-Polymyxin-HC
(Otic)
NESINA [NP]
Nitroglycerin
NORDITROPIN [SP]
Norelgestromin-Ethinyl
Estradiol
Norethin Acet & Estrad-Fe
KAZANO [NP]
(Contraceptive)
Gabapentin
Ketoconazole
MEGACE ES SUSP
Norethindrone Acetate
Ganciclovir
Ketoconazole (Topical)
Ketorolac Tromethamine
(Ophth)
KINERET [SP] [NP]
Meloxicam
MENEST
MENOSTAR
(Triphasic)
KOMBIGLYZE
MENTAX
Nortriptyline HCl
KRISTALOSE
Metformin HCl
NOVOFINE
Methimazole
NOVOLIN
Methylprednisolone
NOVOLIN MIX
Metoclopramide HCl
NOVOLIN N
Metolazone
NOVOLIN R
G
Gemfibrozil
GENOTROPIN [SP]
GILENYA [SP]
Glimepiride
Glipizide
L
GLUCAGEN
Norethindrone (Contraceptive)
Glyburide-Metformin
Labetalol HCl
Lactic Acid (Ammonium
Lactate)
Lactulose
Metoprolol Succinate
NOVOLOG
Glycopyrrolate
Lactulose (Encephalopathy)
Metoprolol Tartrate
NOVOLOG MIX
Guaifenesin
LAMICTAL ODT
Metronidazole Vaginal
NOVOTWIST
Lamotrigine
Midodrine HCl
NUCYNTA
Lansoprazole
Minocycline HCl
NUCYNTA ER
LANTUS
Mirtazapine
NUVARING
LASTACAFT
Misoprostol
NUVIGIL
Latanoprost
Modafinil
Nystatin (Mouth-Throat)
Leflunomide
Montelukast Sodium
Nystatin (Topical)
LETAIRIS [SP]
Morphine Sulfate
Levalbuterol HCl
MOVIPREP
Ofloxacin (Otic)
LEVEMIR
Moxifloxacin HCl
Olanzapine
Hydrocodone w/ Homatropine
LEVITRA
MULTAQ
Omega-3-acid Ethyl Esters
Hydrocodone-Acetaminophen
Levocetirizine Dihydrochloride
Mupirocin
Omeprazole
Hydrocortisone (Rectal)
Hydrocortisone Acetate
(Rectal)
Hydrocortisone Acetate w/
Pramoxine
Levofloxacin
Mupirocin Calcium (Topical)
Levothyroxine Sodium
Mycophenolate Mofetil [SP]
Omeprazole-Sodium
Bicarbonate
Levoxyl
MYRBETRIQ
Ondansetron
Hyoscyamine Sulfate
Lidocaine HCl (Mouth-Throat)
HYSINGLA ER
Lidocaine-Prilocaine
GLUCAGON
Glyburide
H
Haloperidol
Haloperidol Lactate
HARVONI [SP]
HUMIRA [SP]
Hydralazine HCl
Hydrochlorothiazide
Hydrocodone PolistirexChlorpheniramine Polistirex
I
Ibandronate Sodium
Ibuprofen
Imiquimod
INCRUSE
LIALDA
LINZESS
Liothyronine Sodium
LIPOFEN
Lisinopril
Lisinopril &
Hydrochlorothiazide
N
Nadolol
Naltrexone HCl
NAMENDA
NAMENDA XR
Naproxen
NASONEX
NATAZIA
O
Ondansetron HCl
ONGLYZA
OPANA ER
OPSUMIT [SP]
ORENCIA [SP] [NP]
ORTHO TRI CYCLEN LO
OSENI [NP]
OTEZLA [SP] [NP]
Oxybutynin Chloride
Propranolol HCl
Oxycodone HCl
PROTOPIC
Tacrolimus
VENTOLIN
Oxycodone w/ Acetaminophen
PULMICORT FLEXHALER
Tamsulosin HCl
VERAMYST
TANZEUM
VESICARE
OXYCONTIN
Q
T
Venlafaxine HCl
QNASL
TARKA
VIAGRA
Pantoprazole Sodium
Quetiapine Fumarate
TECFIDERA [SP]
VICTOZA
PATADAY
QVAR
TEKAMLO
VIGAMOX
TEKTURNA
VIMOVO [NP]
P
Pediatric Multivitamins w/Fl
R
PEG 3350-KCl-Sod BicarbSod Chloride-Sod Sulfate
PEG 3350-Potassium
Chloride-Sod Bicarbonate-Sod
Chloride
PEGASYS [SP]
Raloxifene HCl
TEKTURNA HCT
VIIBRYD
Ramipril
Telmisartan
VIVELLE-DOT
RANEXA
Temazepam
VYVANSE
Ranitidine HCl
Terazosin HCl
RAPAFLO
Terbinafine HCl
Warfarin Sodium
PEG-INTRON [SP]
WELCHOL
W
RELPAX
Terconazole Vaginal
Penicillin V Potassium
RENAGEL
TESTIM
Phenazopyridine HCl
RENVELA
Testosterone Cypionate
XARELTO
Phenobarbital
Repaglinide
TIKOSYN
XELJANZ [SP] [NP]
Phentermine HCl
RESTASIS
Timolol Maleate (Ophth)
PICATO [NP]
RETIN-A MICR GEL 0.08%
Tizanidine HCl
Pioglitazone HCl
Pioglitazone HCl-Metformin
HCl
Polyethylene Glycol 3350
Ribavirin [SP]
Tobramycin (Ophth)
Risperidone
Tolterodine Tartrate
Rizatriptan Benzoate
Topiramate
Polymyxin B-Trimethoprim
Ropinirole Hydrochloride
Torsemide
S
Potassium Citrate (Alkalinizer)
PRADAXA
SAFYRAL
Pramipexole Dihydrochloride
SAVELLA
PRANDIMET
Sennosides
Pravastatin Sodium
Sennosides-Docusate Sodium
PRECISION
SEREVENT DISKUS
Prednisone
SEROQUEL XR
PREMARIN
PREMARIN VAGINAL
CREAM
PREMPHASE
Sertraline HCl
PREMPRO
Prenatal Vit w/ Ferrous
Fumarate-Folic Acid
Silver Sulfadiazine
SIMPONI [SP]
Simvastatin
Sodium Fluoride (Dental)
SOLODYN [NP]
PRENATE DHA
Sotalol HCl
PRENATE ELITE
SOVALDI [SP]
X
TRACLEER [SP]
Tramadol HCl
Tranexamic Acid
TRAVATAN Z
Travoprost
Trazodone HCl
Tretinoin
TREXIMET
(Mouth)
(Nasal)
Triamterene &
Hydrochlorothiazide
TRIBENZOR
U
PRENATE ESSENTIAL
SPIRIVA
PRISTIQ
Spironolactone
ULORIC
PROAIR
Spironolactone &
Hydrochlorothiazide
ULTICARE LANCETS
STELARA [SP]
ULTICARE SYRINGES
SUBOXONE
Urea
SUCRAID
Ursodiol
Prochlorperazine Maleate
PROCRIT
PROCTOFOAM
Progesterone Micronized
Promethazine HCl
Promethazine w/Codeine
Promethazine-DM
Propafenone HCl
ULTICARE PEN NEEDLES
V
Sucralfate
ZETIA
Ziprasidone HCl
Zolmitriptan
UCERIS [NP]
Prochlorperazine
Z
ZENPEP
Sulfasalazine
VAGIFEM
Sumatriptan Succinate
Valacyclovir HCl
SYMBICORT
Valsartan-Hydrochlorothiazide
SYNTHROID
VASCEPA
Zolpidem Tartrate
ZOVIRAX
ZYCLARA [NP]
ZYTIGA [SP]
Preferred Drug List
Reta Trust Kaiser EPO Plan Comparison
Plan Design
Reta Kaiser Permanente
EPO
$0 Ded / $15 OV
$1,500 OOP
In Network
Out of Network
Annual Out-of-Pocket Maximum (Includes Deductible, Copays & Coinsurance)
For any one Member in the same
Family Unit
For an entire Family Unit of two or
more Members
In Network Deductible
$1,500
No coverage
$3,000
No coverage
None
No coverage
No coverage
Out of Network Deductible
Professional Services
Office Visit Co-payments
$15 copay
No coverage
Well Child Care (Birth to age 7)
No charge
No coverage
Adult Routine Exams and Preventive
Services (mammograms, Pap smears,
& prostate cancer screenings)
No charge
No coverage
No coverage
Chiropractic Care
Outpatient Services
Outpatient surgery
$15 copay
No coverage
No charge
No coverage
MRI, CT and PET
No charge
No coverage
$250 per admission
No coverage
Inpatient Services
Room and board, surgery, anesthesia,
X-rays, lab tests, and drugs
Non-preauthorized admissions
Emergency Health Coverage
N/A
$100 copay
Emergency Department visits
Prescription Drug
RX provided through Kaiser
Generic/Formulary
Retail
$10/$20
Mail Order
$20/$40
IMPORTANT NOTE: This comparison is designed to be a brief overview of the
health plan offerings of the Reta Trust. See the plan description for a full
description of covered provisions, limitations and exclusion, including customary
and reasonable (UCR) charges.
Prepared by: Gallagher Benefit Services
California License #0D36879
Page 1
The Exclusive Provider Organization (EPO) Plan from Kaiser Permanente
Reta Trust – Archdiocese of Portland Employee Benefit Summary
The services described below are covered only if all of the terms and conditions in the Summary Plan Description are satisfied.
PLAN FEATURES
Annual out-of-pocket maximum for certain services
Per person/Per family
Professional services
Routine preventive physical exams
Primary care (includes urgent care)
Well-child preventive care visits
Family planning visits (Counseling and instruction in natural family planning)
Scheduled prenatal care visits and first postpartum visit
Routine vision exams (refractive)
Routine hearing tests
Physical, occupational, and speech therapy visits (unlimited visits per Plan year)
Outpatient services
Outpatient surgery and certain other outpatient procedures
Allergy injections (during an office visit – office visit cost share will also apply)
Allergy injections (without an office visit)
Allergy testing visits
Non-routine vaccines (immunizations) (during an office visit – office visit cost share will also
apply)
Non-routine vaccines (immunizations) (without an office visit)
Hospitalization services, per admission
Room and board, surgery, anesthesia, X-rays, lab tests, and drugs
Emergency health coverage
Emergency Department visits (copay waived if admitted)
Ambulance services
Ambulance services (per trip)
Infertility services
Infertility office visits and infertility treatments
Infertility diagnostic lab tests, X-rays, and surgery
Prescription drug coverage (covered in accordance with Northwest Formulary guidelines)1
Participating pharmacies generic
Participating pharmacies brand
Mail-order generic
Mail-order brand
$1500/$3000
YOU PAY
$0
$15
$0
$0
$0
$0
$0
$15
$15
$0
$5
$15
$0
$0
$0
$250
$100
$50
Not covered
Not covered
$10/ Up to 30 day supply
$20/ Up to 30 day supply
$10/Up to 30 day supply; $20 31 – 90
day supply
$20/Up to 30 day supply; $40 31 – 90
day supply
Infertility, Weight Loss, Contraceptive and Emergency Contraceptive Drugs and devices not covered. Smoking Cessation
covered at no charge.
1
Mental health services
Inpatient psychiatric hospitalization, residential treatment, per admission
Outpatient individual visits
Outpatient group visits
Chemical dependency services
Inpatient hospitalization, per admission
Residential treatment
Outpatient individual visits
Outpatient group visits
Home health services
Home health care (up to 100 visits per Calendar year)
Other
Dialysis visits
Health Education
Nutrition visits
Bariatric Surgery
Transgender Surgery
Skilled nursing facility care (up to 100 days per Calendar year)
Hospice care2
Durable Medical Equipment, Prosthetics and Orthotics (covered in accordance with Northwest
Formulary guidelines)
Medically Necessary Eyewear - Glasses3
$250
$15
$7
$250
$100
$15
$7
$0
$15
$15
$15
Same cost share as other services
Same cost share as other services
$0
$0
20%
No charge
This chart is a summary. It does not explain maximums, exclusions, or limitations, nor does it list all benefits and cost sharing. For a
complete description of your Plan, please refer to the Summary Plan Description.
Your health benefits are self-insured by your employer, union, or Plan sponsor. Kaiser Permanente provides only administrative services
for the Plan and is not an insurer of the Plan or financially liable for health care benefits under the Plan.
2
3
Respite care limits: 5 days per month
For diagnoses of aniridia and aphakia up to age 12 after cataract surgery
Reta Trust - Archdiocese of Portland
EPO Oregon Benefit Summary
KP Use only: Plan IDs
Effective Date: 07/01/2016 - 6/30/2017
This is a Benefit Summary for your Kaiser Permanente EPO Plan
OVERALL PLAN FEATURES
Plan Accumulation Type
Annual Out of Pocket Maximum
Per Person
Per Family
Calendar Year
$1,500
$3,000
Each family member has an individual Out-of-Pocket Maximum amount
within the family Out-of-Pocket Maximum. The individual cannot contribute to
the family Out-of-Pocket Maximum more than the amount of a single Out-ofPocket Maximum ]
Copays: One Copay per provider is charged per day.
Visits: One visit counted per day
ROUTINE PREVENTIVE EXAMS AND SERVICES
Preventive Lab and Xray screenings
not specifically listed under the Preventive Screenings section are treated the same as non-preventive Lab and
Xray Services. See Preventive Services Listing, Screenings and Immunizations for a comprehensive list of
Covered Services. Frequency and Age Limits managed by Network Provider except where noted
Benefit Type
You Pay and/or Maximums
Wellness Exams – Adults (Including Well Woman) Includes
vision and hearing screenings. See Vision Exams for Refractions and
Hearing Exams for audiologic testing.
Wellness Exams – Children Includes vision and hearing
screenings. See Vision Exams for Refractions and Hearing Exams for
audiologic testing.
$0
Applies to
OOP
N/A
$0
N/A
Preventive Screenings
$0
N/A
Immunizations (Preventive) Coverage applies to Adults and
$0
N/A
Children.
OUTPATIENT SERVICES (Office or Outpatient Facility) Primary Care Cost Share
will be charged for Family Practice, General Internal Medicine, General Pediatrics, Obstetrics and Gynecology
specialties and Dieticians. Specialty Care Cost Share will be charged for visits with all other medical specialties
except Mental Health providers are considered to be Primary Care providers for the purposes of determining
Participant cost share.
Benefit Type
Applies to
OOP
Office Visits
Office Visit
$15
Yes
Allergy
Office Visit
$15
Yes
Injection as part of an office visit (Includes serum)
$0
N/A
Injection only (administration and materials) in the absence of an office
$5
Yes
visit)
Testing
Biofeedback Services Includes Medical and Mental Health Services
Mental Health provider
Medical Services provider.
Cardiac Rehab
Reta Trust EPO Plan
$15 EPO NW (19) 2016 Renewal v1
$15
Yes
$15
$15
$15
Yes
Yes
Yes
Oregon BST
1/13
OUTPATIENT SERVICES (Office or Outpatient Facility) cont'd
Benefit Type
Applies to
OOP
$0
$0
$15
N/A
N/A
Yes
$0
Not covered
Not covered
N/A
N/A
N/A
$15
$0
Yes
N/A
$0
N/A
$15
$0
$0
Yes
N/A
N/A
Injections, Administered Medications and Immunizations
(Non-Routine) Office Visit or in the Nurse Treatment Room
Office Visit
Provided during an Office Visit
$15
$0
Yes
N/A
Injection only (administration and materials) in the absence of an office
$0
N/A
Office Visit
$15
$0
Yes
N/A
Injection only (Cost of administration and materials or Office Visit Cost
Share, whichever is less)
$0
N/A
Nutrition Visits
$15
Yes
Radiation Therapy
Respiratory/Pulmonary Therapy
TMJ/TMD Therapy
Office Visit
Vision Refraction Exam
Office Visit (Optometry)
Office Visit (Ophthalmology)
NOTE: Medical care for eye illness or injury are covered
under the medical benefit by provider specialty
$0
$15
N/A
Yes
$15
Yes
$0
$0
N/A
N/A
Chemotherapy Services
Office Visit
Injectibles/Infusibles
Dialysis Services
Family Planning
Counseling and instruction in natural family planning
All other family planning services
Implantable or injectable contraceptives
Health Education Applicable Office Visit Cost Share based on
provider type. Services include: diabetic counseling, diabetic and other
outpatient self-management training and education, medical nutritional
therapy for diabetes, post coronary counseling and nutritional counseling.
Office Visit
Hearing Exam Includes audiometry exam
House Calls
Office Visit
Infusion Services Requires skilled or medical administration.
Office Visit
Infusion only (Cost of administration and materials or Office Visit Cost
Share, whichever is less)
visit)
Travel Clinic - Travel Related Services including consults and
immunizations (Japanese Encephalitis, Typhoid, Yellow Fever)
Reta Trust EPO Plan
Oregon BST
2/13
HOSPITAL / SURGERY SERVICES
Benefit Type
Applies to
OOP
$250
Yes
$50
$50
No charge
Yes
Yes
Inpatient Hospital Includes room and board for private and semiprivate rooms; ICU/CCU, Acute Rehab, Inpatient Professional Services,
Medically Necessary Private Duty Nursing, Ancillary Services, and Supplies.
Per admission
Ambulance
Emergency Ground and Air Ambulance
Scheduled Ground Ambulance
Non-Network or Network Hospital to Network Hospital
(repatriation)
Emergency Services Accident and Illness
Copay waived if admitted
Urgent and After Hours Care Urgent Care and After Hours
$100
$15
Yes
$15
Yes
Not covered
Not covered
Not covered
N/A
N/A
N/A
$15
$15
$250
Yes
Yes
Yes
$15
$15
$250
Yes
Yes
Yes
$15
$15
$250
Yes
Yes
Yes
None
None
N/A
N/A
N/A
settings
Outpatient Surgery Performed in Outpatient Hospital or Ambulatory
Surgery Center.
Abortion
Office Visit
Outpatient Surgery
Inpatient Hospital per admission
Bariatric Surgery
Office Visit
Outpatient Surgery
Temporomandibular Surgery (TMD/TMJ)
Office Visit
Outpatient Surgery
Organ Transplants Includes organ acquisition, diagnostic testing for
donor and recipient
Office Visit
Outpatient Surgery
Travel and Lodging for Organ Transplants For recipient, caregiver, and donor
Transportation Limits
Lodging Limits
Daily Expense Limits
Reimbursement up to $50 per day per
person
Daily expenses include incidental expenses such as meals
and does not include personal expenses.
Benefit Maximum
Benefit Lifetime Maximum
None
None
N/A
N/A
Applies to
OOP
$0
N/A
$250
Yes
MATERNITY
Benefit Type
Routine Pre-Natal and Post-Partum Care
Pre-natal and first post-partum visit
Hospital Inpatient
Per admission
Reta Trust EPO Plan
Oregon BST
3/13
DIAGNOSTIC TESTS & PROCEDURES
Includes Preventive Lab and Xray screenings not
specifically listed under Preventive Screenings: These Services are treated the same as Lab and Xray
Benefit Type
Applies to
OOP
Diagnostic Lab & Xray
$0
N/A
High Tech/Advanced Radiology - CT, MRI, Nuclear
Medicine and PET
Special Procedures
$0
N/A
$0
N/A
INFERTILITY SERVICES
Benefit Type
Hospital Charges
Office Visit
Diagnostic Lab & Xray
Not covered
Not covered
Not covered
Applies to
OOP
N/A
N/A
N/A
Outpatient hospital or Ambulatory Surgery Center (ASC)
Not covered
N/A
MENTAL HEALTH & CHEMICAL DEPENDENCY SERVICES
Benefit Type
Mental Health - Inpatient and Residential Treatment
Per admission
Partial Hospitalization
Mental Health - Intensive Outpatient Includes all Services
Applies to
OOP
$250
$0 per day
$0 per day
Yes
N/A
N/A
$15
$7 per day
Yes
Yes
$250
Yes
$100
$0 per day
$0 per day
N/A
N/A
$15
$7 per day
Yes
Yes
provided during the day
Mental Health – Outpatient/Office
Individual Visit Cost Share
Group Visit Cost Share
Chemical Dependency - Inpatient
Per admission
Chemical Dependency - Residential Treatment
Per admission
Chemical Dependency - Partial Hospitalization
Chemical Dependency - Intensive Outpatient Includes all
Services provided during the day.
Chemical Dependency – Outpatient/Office
Individual Visit Cost Share
Group Visit Cost Share
PHYSICAL, OCCUPATIONAL & SPEECH THERAPIES
Outpatient Cost Share for
therapies is applied as one Copay per provider per day. Visits are counted on a 'per visit' basis.
Benefit Type
Physical Therapy
Visit maximum
Occupational Therapy
Visit maximum
Speech Therapy
Visit maximum
Reta Trust EPO Plan
$15
Unlimited
$15
Unlimited
$15
Unlimited
Applies to
OOP
Yes
N/A
Yes
N/A
Yes
N/A
Oregon BST
4/13
SKILLED CARE
Benefit Type
Applies to
OOP
N/A
N/A
N/A
N/A
N/A
Home Dialysis
Home Health Care therapy visits and supplies.
Visit maximum
Home Infusion Infusion materials, drugs and supplies
Hospice
Respite Care limits
$0
$0
100 visits per calendar year
$0
$0
5 days per month
Skilled Nursing Facility
Per admission
Day maximum
$0
100 days per calendar year
N/A
N/A
You Pay
Applies to
OOP
ALTERNATIVE CARE
Benefit Type
Acupuncture Medically Referred
Visit limits
Chiropractic Services Medically Referred
Visit limits
Naturopathy Medically Referred
Visit limits
Massage Therapy Medically Referred
$15
12 visits per calendar year
$15
Unlimited per calendar year
$15
$15
Visit limits
N/A
You Pay
N/A
N/A
N/A
OTHER SERVICES
Benefit Type
Repair of sound and natural teeth
directly related to an accidental injury.
Autism A diagnosis of ASD is required for benefits to apply
Not covered
Applies to
OOP
N/A
Applied Behavior Analysis (ABA)
Age Limit
Physical Therapy
Visit maximum
Occupational Therapy
Visit maximum
Speech Therapy
Visit maximum
Durable Medical Equipment
Based on NW Region Formulary
Prosthetics and Orthotics Colostomy/ostomy and urological
$15
Yes
$15
20%
Yes
N/A
Yes
N/A
Yes
N/A
No
20%
No
Not covered
N/A
$0
Not covered
N/A
N/A
Not covered
Not covered
N/A
N/A
$0
N/A
Accidental Injury to Teeth
Unlimited
$15
Unlimited
$15
Unlimited
supplies.
Based on NW Region Formulary
Hearing Aids Mandated for Participants under 18 years of age and
qualified dependents Includes tests to determine appropriate model, fitting,
counseling, adjustment, cleaning and inspection after warranty is exhausted
and any necessary ear mold, part, attachments or accessory for the
instrument or device except batteries & cords
Special Oral Foods Amino Acid Modified Products
Out of Area Student Benefit: Coverage for pharmacy, routine and
follow-up care Outside the Kaiser Network (within the U.S.)
Adult Vision Hardware - Contact Lenses
Adult Vision Hardware - Frames and Eyeglass Lenses
Medically Necessary Eyewear
Glasses or Lenses as Medically Necessary
Reta Trust EPO Plan
Oregon BST
5/13
OUTPATIENT PRESCRIPTION DRUGS
Must be obtained from Network Pharmacies and on
the KP formulary (list of approved drugs), unless otherwise specified
Benefit Type
2 Tier
Generic
Brand
Mail Order Drugs
2 Tier Mail Order
Generic
Brand
Blood Factors
Diabetic Coverage
- Oral Medications and Insulin
- Diabetic testing supplies (test strips)
- Diabetic administration devices (syringes, Glucagon
emergency kits)
Infertility Drug Coverage
Growth Hormone
Post-surgical immunosupressive drugs after covered
transplant
Sexual Dysfunction
Limit: 8 doses, 30 days
Smoking Cessation
Weight Loss
ACA Mandated Drugs*
Contraceptive Devices (diaphragms, cervical caps, etc.) and
Contraceptive Drugs
Emergency Contraception
Anti-Breast Cancer Drug
OTC*
Aspirin
Oral Fluoride
Folic Acid
Iron Supplements
Vitamin D
Female Contraceptives (spermicides, female condoms and sponges,
Applies to
Plan OOP
$10 up to 30 days supply
$20 up to 30 days supply
Yes
Yes
$10 up to 30 days supply and
$20 from 31 up to 90 days
supply
$20 up to 30 days supply and
$40 from 31 up to 90 days
supply
$0
Yes
=Generic/Brand
Yes
20%
=Generic/Brand
No
Not covered
=Generic/Brand
=Generic/Brand
N/A
Yes
Yes
= Generic/Brand
Yes
$0
Not covered
N/A
N/A
Not covered
N/A
Not covered
$0
N/A
N/A
$0
$0
$0
$0
$0
Not covered
N/A
N/A
N/A
N/A
N/A
N/A
Yes
N/A
emergency contraceptives)
* With prescription, no cost share. Without prescription,
Participant pays retail cost
For items or injections dispensed by Pharmacy and requiring
skilled administration in the Physician's Office (Implantable
contraceptives, administered meds, etc.) Office Visit Cost
Share for administration may apply.
Reta Trust EPO Plan
Oregon BST
6/13
Kaiser Permanente Northwest Health Care Reform Preventive Services
Medical plans with plan years beginning on or after January 1, 2015 must cover the following preventive Services without a
Copayment, Coinsurance, or Deductible, when these Services are delivered by a Network provider.
Preventive Services for adults
Age-appropriate preventive medical examination
Discussion with Primary Care Provider regarding alcohol misuse
Discussion with Primary Care Provider regarding obesity and weight management
Abdominal aortic aneurysm— screening by ultrasonography in men who have ever smoked
Blood pressure screening for all adults.
Cholesterol screening for adults at higher risk of cardiovascular disease
Colon cancer screening for adults
Prostate cancer screening in men
Depression screening for adults
Type 2 diabetes screening for adults with high blood pressure
Hepatitis C virus screening for persons at high risk of infection and one-time screening for adults
Discussion with Primary Care Provider regarding aspirin for adults at higher risk of cardiovascular disease
Discussion with Primary Care Provider regarding diet counseling for adults at higher risk for chronic disease
Immunizations for adults (doses, recommended ages, and recommended populations vary):
Hepatitis A
Hepatitis B
Herpes zoster
Human papillomavirus
Influenza
Measles, mumps, rubella
Meningococcal
Pneumococcal
Tetanus, diphtheria, pertussis
Varicella
Screening for all adults at higher risk for sexually transmitted infections and counseling for prevention of sexually transmitted
infections, including:
HIV
Gonorrhea
Syphilis
Chlamydia
Discussion with Primary Care Provider regarding tobacco cessation
Physical therapy to prevent falls in community-dwelling adults who are at increased risk of falling
Over-the-counter drugs when prescribed by a physician for preventive purposes, including:
Aspirin to reduce the risk of heart attack
Vitamin D supplements for adults to prevent falls
Lung cancer screening including CT scan of the thorax when ordered for smokers
Screening for hepatitis B virus infection in adults and adolescents at high risk for infection(effective 6/1/2015)
Preventive Services for women, including pregnant women
Discussion with Primary Care Provider regarding chemoprevention in women at higher risk for breast cancer
Discussion with Primary Care Provider regarding inherited susceptibility to breast and/or ovarian cancer
Mammography screening for breast cancer for women
Cervical cancer screening in women
Osteoporosis screening for women
Discussion with Primary Care Provider regarding tobacco cessation
Chlamydia infection screening for sexually active women (and men) at higher risk
Gonorrhea screening for all women at higher risk
Syphilis screening for all pregnant women and other women at higher risk
Anemia screening for pregnant women
Urinary tract or other infection screening for pregnant women
Hepatitis B screening for pregnant women at their first prenatal visit
Discussion with Primary Care Provider about folic acid supplements for women who may become pregnant
Reta Trust EPO Plan
NW Customer Preventive 2016 Renewal v1
Oregon BST
7/13
Rh incompatibility screening for pregnant women and follow-up testing for women at higher risk
Routine prenatal care visits
Discussion with Primary Care Provider regarding preconception care
Discussion with Primary Care Provider about interventions to promote and support breastfeeding and comprehensive lactation
support and counseling
Provision of breastfeeding equipment
Gestational diabetes screening for pregnant women between 24 and 28 weeks of gestation and for pregnant women identified to
be at high risk for diabetes
Discussion with Primary Care Provider about interpersonal and domestic violence
Over-the-counter folic acid for women to reduce the risk of birth defects when prescribed by a physician for preventive services
For women who have family members with breast, ovarian, tubal, or peritoneal cancer, screening for family history that may be
associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2)
BRCA genetic testing when clinically indicated after genetic counseling.
Breast Cancer Chemoprevention - Consultation and medications prescribed for risk reduction of primary breast cancer in high-risk
women
Preventive Services for children
Medical history for all children throughout development
Height, weight, and body mass index measurements for children
Behavioral assessments for children of all ages by Primary Care Provider
Developmental screening for children and surveillance throughout childhood by Primary Care Provider
Discussion with Primary Care Provider regarding alcohol and drug use assessments for adolescents
Autism screening for children by Primary Care Provider
Cervical dysplasia screening for sexually active females
Congenital hypothyroidism screening for newborns
Phenylketonuria (PKU) screening in newborns
Dyslipidemia screening for children at higher risk of lipid disorders
Oral health risk assessment for young children by Primary Care Provider
Lead screening for children at risk of exposure
Discussion with Primary Care Provider regarding obesity screening and counseling
Gonorrhea prevention medication for the eyes of all newborns
Hearing screening for all newborns
Vision screening for all children
Hematocrit or hemoglobin screening for children
Hemoglobinopathies or sickle cell screening for newborns
Tuberculin testing for children at higher risk of tuberculosis
HIV screening for adolescents at higher risk
Sexually transmitted infection (STI) prevention counseling for adolescents at higher risk
Discussion with Primary Care Provider regarding fluoride supplements for children who have no fluoride in their water source
Application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption
Discussion with Primary Care Provider regarding iron supplements for children who are at risk for anemia
Over-the-counter drugs when prescribed by a physician for preventive purposes:
Iron supplements for children to reduce the risk of anemia
Oral fluoride for children to reduce the risk of tooth decay
Immunizations for children (doses, recommended ages, and recommended populations vary):
Diphtheria, tetanus, pertussis
Haemophilus influenzae type B
Hepatitis A
Hepatitis B
Human papillomavirus
Inactivated poliovirus
Influenza
Measles, mumps, rubella
Meningococcal
Pneumococcal
Reta Trust EPO Plan
Oregon BST
8/13
Rotavirus
Varicella
State-Mandated Preventive Services for Adults and Children/Oregon
Below are lists of state- or region-mandated services. For contracts issued in one of these states or regions, our Health Care
Reform Preventive Services Package also includes the services listed for that state or region.
Oregon
Prostate cancer screenings (e.g., prostate-specific antigen testing and digital rectal examination)
First postpartum visit
Additional information about preventive services
Preventive and other Services provided during the same visit
There are some additional things to keep in mind about coverage for mandated preventive Services that are provided along with
other Services during the same visit:
The following Cost Share rules apply when a mandated preventive Service is provided during an office visit:
If the preventive Service is billed separately (or is tracked as individual encounter data separately) from the office visit, then cost
sharing may apply to the office visit.
If the preventive Service is not billed separately (or is not tracked as individual encounter data separately) from the office visit,
o If the primary purpose of the office visit is the delivery of the preventive service, then no cost sharing may apply to the office
o If the primary purpose of the office visit is not the delivery of the preventive service, then cost sharing may apply to the office
Note: The Preventive List is subject to changes based on new Federal recommendations (and clinical interpretations) issued
after the date of this document
Reta Trust EPO Plan
Oregon BST
9/13
Reta Trust
General Exclusions
Acupuncture. Services for acupuncture are limited to when a Network Provider makes a referral for Services in accord with
Medical Group criteria and are subject to benefit limitations (if any) as shown in the “Benefit Summary”.
Certain exams and Services. Physical examinations and other Services are excluded when: (a) required for obtaining or
maintaining employment or participation in employee programs, (b) required for insurance or governmental licensing, (c) court
ordered or required for parole or probation, or (d) received while incarcerated.
Chiropractic Services are limited to when a Network Provider makes a referral for Services in accord with Medical Group criteria
and are subject to benefit limitations (if any) as shown in the “Benefit Summary”.
Cosmetic Services. Cosmetic Services, which means those Services that are intended primarily to change or maintain your
appearance and will not result in significant improvement in physical function. This exclusion does not apply to Services that are
covered under “Reconstructive Surgery Services”.
Custodial Services. Nonskilled, personal Services such as help with activities of daily living (like bathing, dressing, getting in and
out of a bed or chair, moving around and using the bathroom. It may also include care that most people do themselves, like using
eye drops. In most cases, Medicare does not pay for Custodial Services.
Dental Services. Dental care including dental Xrays; Dental Services following accidental injury to teeth; dental appliances; dental
implants; orthodontia; and Dental Services necessary for or resulting from medical treatment such as surgery on the jawbone and
radiation treatment is limited to: (a) emergency Dental Services; or (b) extraction of teeth to prepare the jaw for radiation
treatments of neoplastic disease.
General anesthesia and associated hospital or ambulatory surgical facility Services in conjunction with Non-Covered Dental
Services are excluded, except when Medically Necessary for Participants who have a medical condition that your Network
P
id d t Blood
i Donations.
ld l Collection,
t dprocessing,
i k if th and
d storage
t l
f by donors
di
dwhom
t l you
ffi designate,
Th
d
t
Designated
ofd blood donated
and
procurement and storage of cord blood is covered only when Medically Necessary for the imminent use at the time of collection
fDetained
d i or Confined
t d
i i Participants.
t
Services provided or arranged by criminal justice officials or institutions for detained or
confined Participants are limited to Services which meet the requirements of Emergency Care.
Employer Responsibility. We do not reimburse the employer for any Services that the law requires an employer to provide.
When we cover any of these Services we may recover the Charges for the Services from the employer.
Experimental or Investigational Services. Services are excluded if any of the following is true about the Service:
'-They cannot be legally marketed in the United States without the approval of the U.S. Food and Drug Administration (FDA), and
the FDA has not granted this approval.
-They are the subject of a current new drug or new device application on file with the FDA.
-They are provided as part of a Phase I, Phase II, or Phase IV clinical trial, as the experimental or research arm of a Phase III
clinical trial, or in any other manner that is intended to evaluate the safety, toxicity, or efficacy of the Services.
-They are provided pursuant to a written protocol or other document that lists an evaluation of the Services’ safety, toxicity, or
efficacy as among its objectives.
-They are subject to the approval or review of an Institutional Review Board (IRB) or other body that approves or reviews research
concerning the safety, toxicity, or efficacy of Services.
-They are provided pursuant to informed consent documents that describe the Services as experimental or investigational, or in
other terms that indicate that the Services are being evaluated for their safety, toxicity, or efficacy.
-The prevailing opinion among experts as expressed in the published authoritative medical or scientific literature is that:
•Use of the Services should be substantially confined to research settings, or
•Further research is necessary to determine the safety, toxicity, or efficacy of the Services.
In making determinations whether a Service is experimental or investigational, the following sources of information will be relied
upon exclusively:
-Your medical records.
-The written protocols and other documents pursuant to which the Service has been or will be provided.
-Any consent documents you or your representative has executed or will be asked to execute, to receive the Service.
-The files and records of the IRB or similar body that approves or reviews research at the institution where the Service has been
or will be provided, and other information concerning the authority or actions of the IRB or similar body.
-The published authoritative medical or scientific literature about the Service, as applied to your illness or injury.
-Regulations, records, applications, and any other documents or actions issued by, filed with, or taken by, the FDA or other
agencies within the United States Department of Health and Human Services, or any state agency performing similar functions.
We consult Medical Group and then use the criteria described above to decide if a particular Service is experimental or
investigational.
Reta Trust EPO Plan
OR Customer Exclusions 2016 Renewal v1
Oregon BST
10/13
Reta Trust
General Exclusions
Eye Surgery. Radial keratotomy, photorefractive keratectomy, and refractive surgery, including evaluations for the procedures.
Family Services. Services provided by a member of your immediate family.
Genetic Testing. Genetic testing and related Services are limited to genetic counseling and medically appropriate genetic testing
for the purpose of diagnostic testing to determine disease and/or predisposition of disease and to develop treatment plans.
Covered Services are limited to preconception and prenatal testing for detection of congenital and heritable disorders, and testing
for the prediction of high-risk occurrence or reoccurrence of disease when Medically Necessary as determined by a Network
Provider, in accordance with applicable law. However, testing for family members who are not Participants is always excluded.
Government Agency Responsibility. We do not reimburse the government agency for any Services that the law requires be
provided only by or received only from a government agency. When we cover any of these Services we may recover the Charges
for the Services from the government agency. However, this exclusion does not apply to Medicaid.
Hearing Aids. Hearing Aids, tests to determine their efficacy, and hearing tests to determine an appropriate Hearing Aid are
excluded. This exclusion does not apply to Services that are covered under “Hearing Services” in the “Benefits” section.
Hypnotherapy. All Services related to hypnotherapy.
Intermediate Services. Services in an intermediate care facility are excluded.
Infertility Services
Donor semen, donor eggs, and Services related to their procurement and storage.
Drugs, both oral and injectable, used in the treatment of infertility
Services related to conception by artificial means, such as in vitro fertilization (IVF), ovum transplants,
gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT), except artificial
insemination
Services to reverse voluntary, surgically induced infertility
Low-Vision Aids
Massage Therapy Services. Massage therapy and related Services are limited to when a Network Provider makes a referral for
Services in accord with Medical Group criteria and are subject to benefit limitations (if any) as shown in the “Benefit Summary”.
Naturopathy Services. Naturopathy and related Services are limited to when a Network Provider makes a referral for Services in
accord with Medical Group criteria and are subject to benefit limitations (if any) as shown in the “Benefit Summary”.
Non-Medically Necessary Services. Services that are not Medically Necessary.
Nonreusable Medical Supplies. Nonreusable medical supplies, such as splints, slings, and wound dressing, including bandages
and ace wrap bandages, are limited to those supplied and applied by a licensed health care provider, while providing a covered
Service. Nonreusable medical supplies that a Participant purchases or obtains from another source are excluded.
Outpatient Prescription Drugs, Supplies, and Supplements Exclusions
Any packaging, such as blister or bubble repacking, other than the dispensing pharmacy’s standard
packaging.
Drugs prescribed for an indication if the U.S. Food and Drug Administration (FDA) determined that use
of that drug for that indication is contraindicated.
Drugs prescribed for an indication if the FDA has not approved the drug for that indication, except that
this exclusion does not apply if the Oregon Health Resources Commission or our Regional Formulary
and Therapeutics Committee determines that the drug is recognized as effective for that use (i) in one of the standard reference
compendia, or (ii) in the majority of relevant peer-reviewed medical literature, or
(iii) by the Secretary of the U.S. Department of Health and Human Services.
Drugs, supplies, and supplements that are available without a prescription, even if the nonprescription
item is in a different form or different strength (or both), except that this exclusion does not apply to
drugs, supplies, or supplements that our drug formulary lists for your condition.
Drugs that the FDA has not approved.
Drugs used in weight management.
Drugs used to enhance athletic performance.
Extemporaneously compounded drugs, unless the formulation is approved by our Regional Formulary
and Therapeutics Committee.
Mail-order drugs for anyone who is not a resident of Oregon or Washington.
Replacement of drugs, supplies, and supplements due to loss, damage, or carelessness.
Contraceptive drugs and devices including injectable and emergency contraceptives
Drugs used in the treatment of infertility
Professional Services for Fitting and Follow-Up Care for Contact Lenses
Reta Trust EPO Plan
Oregon BST
11/13
Reta Trust
General Exclusions
Services performed by Unlicensed People. Services that are performed safely aond effectively by people who do not require
licenses or certificates by the state to proide health care Services and where the Participant's condition does not require that the
Servcies be provided by a licensed health care provider.
Services related to a Non-Covered Service. When a Service is not covered, all Services related to the Non-Covered Service
are also excluded. However, this exclusion does not apply to Services we would otherwise cover if they are to treat complications
which arise from the Non-Covered Service and to Medically Necessary Services for a Participant enrolled in and participating in a
qualifying clinical trial if we would typically cover those Services absent a clinical trial.
Sexual Reassignment surgery.
Services That are Not Health Care Services, Supplies or Items. For example, we do not cover:
'-Teaching manners and etiquette
-Teaching and support services to develop planning skills such as daily activity planning and project or task planning.
-Items and services that increase academic knowledge or skills.
-Teaching and support services to increase intelligence.
-Academic coaching or tutoring for skills such as grammar, math, and time management.
-Teaching you how to read, whether or not you have dyslexia
-Educational testing.
-Teaching art, dance, horse riding, music, play or swimming.
-Teaching skills for employment or vocational purposes.
-Vocational training or teaching vocational skills.
-Professional growth courses.
-Training for a specific job or employment counseling.
-Aquatic therapy and other water therapy.
Supportive care and other Services. Supportive care primarily to maintain the level of correction already achieved; care
primarily for the convenience of the Participant; and care on a non-acute, symptomatic basis are excluded.
Surrogacy. Services for anyone in connection with a Surrogacy Arrangement, except for otherwise-covered Services provided to
a Participant who is a surrogate. A "Surrogacy Arrangement" is one in which a woman (the surrogate) agrees to become pregnant
and to surrender the baby (or babies) to another person or persons who intend to raise the child (or children), whether or not the
woman receives payment for being a surrogate. See "Surrogacy Arrangements" for information about your obligations to us in
connection with a Surrogacy Arrangement, including your obligations to reimburse us for any Services we cover and to provide
information about anyone who may be financially responsible for Services the baby (or babies) receive.
Travel and lodging. Transportation or living expenses for any person, including the patient, are limited to: (a) Medically
Necessary ambulance Service covered under “Ambulance Services”, and (b) certain expenses that we Pre-Authorize in accord
with our travel and lodging guidelines under “Transplant Services”. Your transplant coordinator can provide information about
Vision Hardware Optical Services. Corrective lenses, eyeglasses, and contact lenses
Vision therapy and Orthoptics or Eye Exercises. Services related to vision therapy and orthoptics and eye exercises are
Source: 2015 Oregon EOC
Added from Reta Trust CA Plans:
Abortions - Elective, Medically Necessary and Rape/Incest procedures
Sterilization and Reversal of Sterilization
Source:Customer Exclusions
Blood-The cost of whole red blood or red blood cells when they are donated or replaced or billed, except expenses for
administration and processing of Blood and Blood Products (except Blood Factors) covered as part of inpatient and outpatient
Crime-Treatment of injuries sustained while committing a crime
Care in a halfway house
Personal Comfort Items – Personal comfort items such as those that are furnished primarily for your personal comfort or
convenience, including those Services and supplies not directly related to medical care, such as guest’s meals and
accommodations, hospital admission kit, barber services, telephone charges, radio and television rentals, homemaker services,
travel expenses, over the counter convenience items and take-home supplies.
Hypnotherapy (Hypnosis)
Private Duty Nursing as a registered bed patient unless a Plan physician determines medical necessity.
Private Duty Nursing in home or long term facility
Religious, personal growth counseling or marriage counseling including Services and treatment related to religious, personal
growth counseling or marriage counseling, unless the primary patient has a DSM IV diagnosis
Reta Trust EPO Plan
Oregon BST
12/13
Reta Trust
General Exclusions
Services provided outside the United States-Services, other than Emergency Services, received outside the United States
whether or not the Services are available in the United States
Equipment: that basically serves comfort or convenience functions or is primarily for the convenience of a person caring for you or
your Dependent, i.e., exercycle or other physical fitness equipment, elevators, hoyer lifts, shower/bath bench, air conditioners, air
purifiers and filters, batteries and charges, dehumidifiers, humidifiers, air cleaners and dust collection devices.
Reta Trust EPO Plan
Oregon BST
13/13
Plan Benefit Highlights for: 7KH5HWD7UXVW±3ODQ$
Effective Date: 6
Eligibility
3ULPDU\HQUROOHHVSRXVHDQGHOLJLEOHGHSHQGHQWFKLOGUHQWRDJH
Deductibles
,Q1HWZRUNSHUSHUVRQSHUIDPLO\HDFKFDOHQGDU\HDU
2XWRI1HWZRUNSHUSHUVRQSHUIDPLO\HDFKFDOHQGDU\HDU
<HV
'HGXFWLEOHVZDLYHGIRU'3"
Maximums
Waiting Period(s)
SHUSHUVRQSHUFDOHQGDU\HDU
%DVLF%HQHILWV
0DMRU%HQHILWV
1RQH
1RQH
2UWKRGRQWLFV
1RQH
Benefits and
Covered Services*
Delta Dental PPO dentists**
Out-of-PPO Network**
In-PPO Network
Premier and Non-Delta Dentists
Diagnostic & Preventive
Services (D & P) /LIHWLPH
/LIHWLPH
([DPVFOHDQLQJV[UD\VVHDODQWV
Basic Services )LOOLQJVVLPSOHWRRWKH[WUDFWLRQV
Endodontics URRWFDQDOV
&RYHUHG8QGHU%DVLF6HUYLFHV
Periodontics JXPWUHDWPHQW
Oral Surgery
Major Services &URZQVLQOD\VRQOD\VDQGFDVW
UHVWRUDWLRQVEULGJHVDQGGHQWXUHV
LPSODQWV
Orthodontic Benefits
$GXOWVDQGGHSHQGHQWFKLOGUHQ
Orthodontic Maximums
/LPLWDWLRQVRUZDLWLQJSHULRGVPD\DSSO\IRUVRPHEHQHILWVVRPHVHUYLFHVPD\EHH[FOXGHGIURP\RXUSODQ
5HLPEXUVHPHQWLVEDVHGRQ'HOWD'HQWDOPD[LPXPFRQWUDFWDOORZDQFHVDQGQRWQHFHVVDULO\HDFKGHQWLVW¶V
VXEPLWWHGIHHV
5HLPEXUVHPHQWLVEDVHGRQ332FRQWUDFWHGIHHVIRU332GHQWLVWV3UHPLHUFRQWUDFWHGIHHVIRU3UHPLHU
GHQWLVWVDQGSURJUDPDOORZDQFHIRUQRQ'HOWD'HQWDOGHQWLVWV
'HOWD'HQWDORI&DOLIRUQLD
)LUVW6W
6DQ)UDQFLVFR&$
Customer Service
Claims Address
32%R[
6DFUDPHQWR&$
deltadentalins.com
7KLVEHQHILWLQIRUPDWLRQLVQRWLQWHQGHGRUGHVLJQHGWRUHSODFHRUVHUYHDVWKHSODQ¶V(YLGHQFHRI&RYHUDJHRU
6XPPDU\3ODQ'HVFULSWLRQ,I\RXKDYHVSHFLILFTXHVWLRQVUHJDUGLQJWKHEHQHILWVOLPLWDWLRQVRUH[FOXVLRQVIRU\RXU
SODQSOHDVHFRQVXOW\RXUFRPSDQ\¶VEHQHILWVUHSUHVHQWDWLYH
+/7B332B&2/B''&5HY&$
3/$1$B/+
All plans offered and underwritten by Kaiser Foundation Health Plan
of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR 97232
Summary of Dental Benefits
Oregon P
July 1, 2016 - June 30, 2017
Archdiocese of Portland In Oregon
Group Number: 3766
Benefit Maximum per Calendar Year
None
You Pay
Dental Office Visit Charge – Applies to all visits
$5
Deductible (Per Calendar Year; applies to all services unless otherwise indicated)
For one Member
$0
For an entire Family
$0
Preventive and Diagnostic Services (Not subject to or counted toward
the Deductible or the Benefit Maximum)
Oral exam
No additional charge
X-rays
Teeth cleaning
Fluoride
Basic Restoration Services
Routine fillings
No additional charge
Plastic and steel crowns
Simple extractions
Oral Surgery Services
20% Coinsurance
Surgical tooth extractions
Periodontics
Treatment of gum disease
20% Coinsurance
Scaling and root planing
Endodontics
20% Coinsurance
Root canal therapy
Major Restoration Services
Gold or porcelain crowns
20% Coinsurance
Bridges
Removable Prosthetic Services
Full and partial dentures
20% Coinsurance
Relines
20% Coinsurance
Rebases
20% Coinsurance
Nitrous oxide (Not subject to or counted toward the Deductible or Benefit Maximum)
Adults and children age 13 years and older
$15
Children age 12 years and younger
$0
Orthodontics
Not a covered benefit
SSOB ORLGTRADDENTAL 0116_0415
343MMC-14/7-14
Page 1
Exclusions and Limitations
The Services listed below are either completely excluded from coverage or partially limited. This applies to all
Services that would otherwise be covered and is in addition to the exclusions and limitations that apply only to a
particular Service as listed in the description of that Service in the Evidence of Coverage (EOC). For a complete
list and description of Exclusions and Limitations please refer to EOC.
Continuation of Services performed or started prior to your coverage becoming effective and/or after your
membership terminates. Cosmetic Services, supplies, or prescription drugs intended primarily to improve
appearance, repair, and/or replace cosmetic dental restorations. Dental implants, unless your Group has
purchased coverage for dental implants as an additional benefit. Dental Services not listed in the “Benefits”
section. Experimental or investigational treatments, procedures, and other Services that are not
commonly considered standard dental practice or that require governmental approval. Fees a provider may
charge for an Emergency Dental Care or Urgent Dental Care visit. Full mouth reconstruction and occlusal
rehabilitation, including appliances, restorations, and procedures needed to alter vertical dimension, occlusion,
or correct attrition or abrasion. Genetic testing. Medical or Hospital Services, unless otherwise specified in
the EOC. Missed appointment fees a provider may charge for a missed appointment. Orthodontic Services,
unless your Group has purchased orthodontic coverage as an additional benefit. Prosthetic devices following
your decision to have a tooth (or teeth) extracted for nonclinical reasons or when a tooth is restorable.
Replacement of prefabricated, noncast crowns, including noncast stainless steel crowns that were not
placed by a Participating Provider. Services furnished by a family member. Services provided or arranged
by criminal justice institutions for Members confined therein, unless care would be covered as Emergency
Dental Care. Speech aid prosthetic devices and follow up modifications. Surgery to correct malocclusion
or temporomandibular joint disorders; treatment for problems of the jaw joint, including
temporomandibular joint syndrome and craniomandibular disorders; and treatment of conditions of the
joint linking the jaw bone and skull and of the complex of muscles, nerves, and other tissues related to that joint.
Treatment to restore tooth structure lost due to attrition, erosion, or abrasion. Repair or replacement
needed due to normal wear and tear of fixed and removable prosthetic devices that are less than five years old
is not covered. Sedation and general anesthesia (including, but not limited to, intramuscular IV sedation, nonIV sedation, and inhalation sedation) are not covered, except nitrous oxide.
Questions? Call Member Services (M-F, 8 am-6 pm) or visit kp.org
Portland area.503-813-2000. All other areas.1-800-813-2000. TTY.711. Language Interpretation Services, all
areas.1-800-324-8010
This is not a contract. This benefit summary does not fully describe your benefit coverage with Kaiser
Foundation Health Plan of the Northwest. For more details on benefit coverage, claims review, and adjudication
procedures, please see your EOC or call Membership Services. In the case of conflict between this summary
and the EOC, the EOC will prevail.
SSOB ORLGTRADDENTAL 0116_0415
Page 2
Group Number: OR10
Effective Date: July 1, 2016
BENEFITS
COPAYS
Annual Maximum
No Annual Maximum
Deductible
No Deductible
General & Orthodontic Office Visit
You pay a $4 Copay per Visit
DIAGNOSTIC AND PREVENTIVE SERVICES
Routine and Emergency Exams
Covered with the Office Visit Copay
X-rays
Teeth Cleaning
Fluoride Treatment
Sealants (per Tooth)
Head and Neck Cancer Screening
Oral Hygiene Instruction
Periodontal Charting
Periodontal Evaluation
RESTORATIVE DENTISTRY
Fillings (Amalgam)
Porcelain-Metal Crown
You pay a $110 Copay
PROSTHODONTICS
Complete Upper or Lower Denture
Bridge (per Tooth)
ENDODONTICS AND PERIODONTICS
You pay a $45 Copay
Root Canal Therapy – Anterior
You pay a $75 Copay
Root Canal Therapy – Bicuspid
You pay a $95 Copay
Root Canal Therapy – Molar
Osseous Surgery (per Quadrant)
You pay a $40 Copay
Root Planing (per Quadrant)
ORAL SURGERY
Routine Extraction (Single Tooth)
Surgical Extraction
You pay a $70 Copay
ORTHODONTIA TREATMENT
Pre-Orthodontia Treatment
You pay a $150 Copay*
Comprehensive Orthodontia Treatment
You pay a $1,700 Copay
MISCELLANEOUS
Local Anesthesia
Dental Lab Fees
Nitrous Oxide
You pay a $20 Copay
Specialty Office Visit
You pay a $30 Copay per Visit
Out of Area Emergency Care Reimbursement
You pay charges in excess of $100
*Copay credited towards the Comprehensive Orthodontia Treatment copay if patient accepts treatment plan.
Underwritten by Willamette Dental Insurance, Inc.
This plan provides extensive coverage of services and supplies to prevent, diagnose, and treat diseases or
conditions of the teeth and supporting tissues. Presented are just some of the most common procedures covered
in your plan. Please see the Certificate of Coverage for a complete plan description, limitations, and exclusions.
Form No. 028-OR(5/15)
Contract No. 001-OR(2/14)
Exclusions
Bridges, crowns, dentures or any prosthetic devices
requiring multiple treatment dates or fittings if the
prosthetic item is installed or delivered more than 60 days
after termination of coverage.
The completion or delivery of treatments, services, or
supplies initiated prior to the effective date of coverage.
Dental implants, including attachment devices,
maintenance, and dental implant-related services.
Endodontic services, prosthetic services, and implants that
were provided prior to the effective date of coverage.
Endodontic therapy completed more than 60 days after
termination of coverage.
Exams or consultations needed solely in connection with a
service not listed as covered.
Experimental or investigational services or supplies and
related exams or consultations.
Full mouth reconstruction, including the extensive
restoration of the mouth with crowns, bridges, or implants;
and occlusal rehabilitation, including crowns, bridges, or
implants used for the purpose of splinting, altering vertical
dimension, restoring occlusions or correcting attrition,
abrasion, or erosion.
General anesthesia, moderate sedation and deep
sedation.
Hospitalization care outside of a dental office for dental
procedures, physician services, or facility fees.
Nightguards.
Orthognathic surgery.
Personalized restorations.
Plastic, reconstructive, or cosmetic surgery and other
services or supplies, which are primarily intended to
improve, alter, or enhance appearance.
Prescription and over-the-counter drugs and premedications.
Provider charges for a missed appointment or appointment
cancelled without 24 hours prior notice.
Replacement of lost, missing, or stolen dental appliances;
Replacement of dental appliances that are damaged due
to abuse, misuse, or neglect.
Replacement of sound restorations.
Services and related exams or consultations that are not
within the prescribed treatment plan and/or are not
recommended and approved by a Willamette Dental
Group dentist.
Services and related exams or consultations to the extent
they are not necessary for the diagnosis, care, or
treatment of the condition involved.
Services by any person other than a licensed dentist,
denturist, hygienist, or dental assistant.
Services for the diagnosis or treatment of
temporomandibular joint disorders.
Form No. 028-OR(5/15)
Contract No. 001-OR(2/14)
Services for the treatment of an injury or disease that is
covered under workers’ compensation or that are an
employer’s responsibility.
Services for treatment of injuries sustained while practicing
for or competing in a professional athletic contest.
Services for treatment of intentionally self-inflicted injuries.
Services for which coverage is available under any federal,
state, or other governmental program, unless required by
law.
Services not listed as covered in the contract.
Services where there is no evidence of pathology,
dysfunction, or disease other than covered preventive
services.
Limitations
If alternative services can be used to treat a condition, the
service recommended by the Willamette Dental Group
dentist is covered.
Services listed in the contract, which are provided to
correct congenital or developmental malformations which
impair functions of the teeth and supporting structures will
be covered if primarily for the purpose of controlling or
eliminating infection, controlling or eliminating pain, or
restoring function.
Crowns, casts, or other indirect fabricated restorations are
covered only if dentally necessary and if recommended by
the Willamette Dental Group dentist.
When initial root canal therapy was performed by a
Willamette Dental Group dentist, the retreatment of such
root canal therapy will be covered as part of the initial
treatment for the first 24 months. When the initial root
canal therapy was performed by a non-participating
provider, the retreatment of such root canal therapy by a
Willamette Dental Group dentist will be subject to the
applicable copayments.
The services provided by a dentist in a hospital setting are
covered if medically necessary; pre-authorized by a
Willamette Dental Group dentist; the services provided are
the same services that would be provided in a dental
office; and applicable copayments are paid.
The replacement of an existing denture, crown, inlay,
onlay, or other prosthetic appliance is covered if the
appliance is more than 5 years old and replacement is
dentally necessary.
Your Vision
Benefits Summary
Get the best in eye care and eyewear with RETA TRUST- Plan
4 and VSP® Vision Care.
Using your VSP benefit is easy.
Register at vsp.com Once your plan is effective, review your
benefit information.
Find an eye care provider who’s right for you. The decision
is yours to make—choose a VSP doctor, a participating retail
chain, or any out-of-network provider. To find a VSP provider,
visit vsp.com or call 800.877.7195.
Benefit
Description
Copay
Your Coverage with a VSP Provider
Focuses on your eyes and overall
wellness
Every 12 months
WellVision
Exam
Prescription Glasses
$10
$25
Frame
$150 allowance for a wide selection
of frames
$170 allowance for featured frame
brands
20% savings on the amount over your
allowance
$80 Costco® frame allowance
Every 24 months
Included in
Prescription
Glasses
Lenses
Best Eye care
Single vision, lined bifocal, and lined
trifocal lenses
Polycarbonate lenses for dependent
children
Every 24 months
Included in
Prescription
Glasses
You’ll get the highest level of care, including a WellVision
Exam®– the most comprehensive exam designed to detect eye
and health conditions. Plus, when you see a VSP provider, you'll
get the most out of your benefit, have lower out-of-pocket costs,
and your satisfaction is guaranteed.
Lens
Enhancements
Standard progressive lenses
Premium progressive lenses
Custom progressive lenses
Average savings of 20-25% on other
lens enhancements
Every 24 months
Contacts
(instead of
glasses)
$150 allowance for contacts; copay
does not apply
Contact lens exam (fitting and
evaluation)
Every 24 months
Diabetic
Eyecare Plus
Program
Services related to diabetic eye
disease, glaucoma and age-related
macular degeneration (AMD). Retinal
screening for eligible members with
diabetes. Limitations and coordination
with medical coverage may apply. Ask
your VSP doctor for details.
As needed
At your appointment, tell them you have VSP. There’s no ID
card necessary. If you’d like a card as a reference, you can
print one on vsp.com.
That’s it! We’ll handle the rest—there are no claim forms to
complete when you see a VSP provider.
Choice in Eyewear
From classic styles to the latest designer frames, you’ll find
hundreds of options. Choose from featured frame brands like
Anne Klein, bebe®, Calvin Klein, Flexon®, Lacoste, Nike, Nine
1
West, and more . Visit vsp.com to find a VSP provider who
carries these brands.
Plan Information
VSP Coverage Effective Date: 06/01/2016
VSP Provider Network: VSP Choice
RETA TRUST- Plan 4 and VSP provide you with an affordable
eyecare plan.
$55
$95 - $105
$150 - $175
Up to $60
$20
Glasses and Sunglasses
Extra $20 to spend on featured frame brands. Go to
vsp.com/specialoffers for details.
20% savings on additional glasses and sunglasses,
including lens enhancements, from any VSP provider
within 12 months of your last WellVision Exam.
Extra Savings
Retinal Screening
No more than a $39 copay on routine retinal screening
as an enhancement to a WellVision Exam
Laser Vision Correction
Average 15% off the regular price or 5% off the
promotional price; discounts only available from
contracted facilities
Your Coverage with Out-of-Network Providers
Visit vsp.com or call 800.877.7195
for more details on your vision
coverage and exclusive savings
and promotions for VSP members.
1
Brands/Promotion subject to change.
©
2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam
are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon
Eyewear, Inc. All other company names and brands are trademarks or registered trademarks
of their respective owners.
Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.
Exam .................................................. up to $45
Lined Trifocal Lenses .............. up to $65
Frame ................................................ up to $70
Progressive Lenses .................. up to $50
Single Vision Lenses ............... up to $30
Contacts ........................................ up to $105
Lined Bifocal Lenses ............... up to $50
Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com
for details. Coverage information is subject to change. In the event of a conflict between this information
and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable
laws, benefits may vary by location.
Enjoy Low Prices on Hearing Aids
Like vision loss, hearing loss can have a huge impact on your
quality of life. However, the cost of a pair of quality hearing aids
usually costs more than $5,000, and few people have hearing
aid insurance coverage.
TruHearing® is making hearing aids affordable by providing exclusive savings
to all VSP® Vision Care members. You can save up to $2,400 on a pair of
hearing aids with TruHearing pricing. What’s more, your dependents and even
extended family members are eligible, too.
In addition to great pricing, TruHearing provides you with:
• Three provider visits for fitting, adjustments, and cleanings
• 45-day money back guarantee
• Three-year manufacturer’s warranty for repairs and one-time loss
and damage
• 48 free batteries per hearing aid
Plus, with TruHearing you’ll get:
• Access to a national network of more than 4,500 licensed hearing aid
professionals
• Straightforward, nationally fixed pricing on a selection of more than 90
digital hearing aids in 400 styles
• Deep discounts on replacement batteries shipped directly to your door
Best of all, if you already have a hearing aid benefit from your health plan or
employer, you can combine it with this program to maximize the benefit and
reduce your out-of-pocket expense.
Here’s how it works:
1. Call TruHearing.
Call 877.396.7194. You and
your family members must
mention VSP.
2.Schedule exam.
TruHearing will answer
your questions and schedule
a hearing exam with a
local provider.
3.Attend appointment.
The provider will make a
recommendation, order the
hearing aids through TruHearing
and fit them for you.
Learn more about this VSP Exclusive Member Extra at
vsp.truhearing.com. Or, call 877.396.7194 with questions.
Not made available by VSP in the state of Washington
The relationship between VSP and TruHearing is that of independent contractors. VSP makes no endorsement, representations or warranties
regarding any products or services offered by TruHearing, a third-party vendor. The vendor is solely responsible for the products or services
offered by them. If you have any questions regarding the services offered here, you should contact the vendor directly.
©2015 Vision Service Plan. All rights reserved.
VSP is a registered trademark of Vision Service Plan. All other brands or marks are the property of their respective owners.
JOB#19826CM 1/15
Account Number 5125
Benefit Summary
Clinical Counseling

5 face-to-face sessions or telephonic or web-video consultations per individual, per issue,
per year
Telephonic Work-life Services

Child and Elder Care Referrals (confirmed provider openings)

Legal Consultations

Financial Consultations

Identity Theft Prevention and Recovery Assistance

Daily Living Services

Wellness Coaching Program:
o
Weight management
o
Smoking cessation
o
Fitness and exercise
o
Stress management
o
Overall lifestyle improvement
o
Lifestyle support for chronic conditions
Member Website - members.mhn.com
Company Code: aportland

Assessments: depression, alcoholism, insomnia and stress, and more

Self-help programs, articles and resources

Wellness Portal - Health Assessment

Online Smoking Cessation, Weight Loss and Nutrition Programs

Downloadable legal forms and online Estate Planning

Self-paced e-Learning training workshops
Client Services:

Job Performance Referrals

Critical Incident Response (20 hours free onsite time per event)

Management Consultations
Account Number 5125
Benefit Summary
Training Services

Training Workshops: 10 hours (4 of which may be used for Organizational Development)
per year with option to buy additional hours on a Fee For Service basis
Health Fairs & Orientations

As requested in person and telephonic Employee Orientations about Employee EAP
benefits per year

As requested in person and telephonic Supervisor Orientations about Supervisor EAP
benefits per year

As requested Health Fair attendance per year
The Archdiocese of Portland in Oregon a Corporation Sole
Life/AD&D
Employer Paid Plan Highlights
LIFE/AD&D INSURANCE
Eligibility
Unum Policy # 105259
Group 1
Lay employee or permanent deacon employed by Archdiocese, an
affiliated parish or school, or participating employer, in active
employment, in the United States with the Employer, scheduled
to work:
a. at least 20 hours a week, 52 weeks a year, or
b. at least 26 hours a week, 39 weeks a year, or
c. an average of at least 20 hours a week over 12 months
Note: Employees scheduled to work 6 months or less during 12
consecutive months are not eligible employees
Group 2
A seminarian, diocesan priest, or member of a religious order
under the care of and for whom the Employer has financial
responsibility and who is not classified as a retiree in active
employment in the United States with the Employer
Group 3
Licensed or waivered elementary or secondary classroom teachers
who are scheduled to work at least 20 hours a week with an
employment agreement for longer than six months in active
employment in the United States with the Employer
Benefit Amount
$10,000
Accelerated Death Benefit
75% to $500,000
Survivor Support
Included
Portability
If you retire, reduce your hours or leave your Employer, you can
take this coverage with you according to the terms of the contract.
Life Planning Financial
And Legal Resources
Included
Life Benefit Reduction
65% at age 65 and 45% at age 70
Premium
Employer Paid
This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Details may differ
from state to state. Please refer to your certificate booklet for your complete plan description. If the terms of this plan
highlight summary or your certificate differ from your policy, the policy will govern.
Term Life Insurance and AD&D
Coverage Highlights
The Archdiocese of Portland in Oregon
Policy # 393809
Please read carefully the following description of your Unum Term Life and AD&D insurance plan.
Your Plan
Eligibility
All employees working working in the following groups in the U.S. with the
employer, and their eligible spouses and children (up to age 23).
*Note: Disabled children over the maximum child age may be eligible for benefits,
please see your plan administer for more details.
Group 1
Lay employee or permanent deacon employed by the Archdiocese, an affiliated
parish or school, or participating employer, in active employment in the United
States with the Employer, scheduled to work:
Note: Employees scheduled to work 6 months or less during 12 consecutive months
are not eligible employees
Group 2
Diocesan priests under the care of and for whom the Employer has financial
responsibility and who are not classified as retirees in active employment in the
United States with the Employer
Coverage Amounts
Group 3
Licensed or waivered elementary or secondary teachers who are scheduled to work
at least 20 hours a week with an employment agreement for longer than 6 months in
active employment in the United States with the Employer
Note: Employees scheduled to work 6 months or less during 12 consecutive months
are not eligible employees
Your Term Life coverage options are:
Employee: Up to 5 times salary in increments of $10,000.
Not to exceed $500,000.
Spouse:
Up to 100% of employee amount in increments of $5,000. Not to
exceed $500,000. Benefits will be paid to the employee.
Child:
Option A: $6,000
Option B: $8,000
Option C: $10,000
The maximum death benefit for a child between the ages of live birth
and 6 months is $1,000. Benefits will be paid to the employee.
In order to purchase Life coverage for your spouse and/or child, you
must purchase Life coverage for yourself.
ADR1879-2001
Coverage Highlights (Continued)
Your AD&D coverage options are:
Employee: Up to 5 times salary in increments of $10,000.
Not to exceed $500,000.
You may purchase AD&D coverage for yourself regardless of whether
you purchase Life coverage.
Spouse:
Up to 100% of employee amount in increments of $5,000.
Not to exceed $500,000. Benefits will be paid to the employee.
Child:
$8,000
The maximum death benefit for a child between the ages of live birth
and 6 months is $1,000. Benefits will be paid to the employee.
In order to purchase AD&D coverage for your spouse and/or child,
you must purchase AD&D coverage for yourself.
AD&D Benefit Schedule: The full benefit amount is paid for loss of:
• Life
• Both hands or both feet or sight of both eyes
• One hand and one foot
• One hand and the sight of one eye
• One foot and the sight of one eye
• Speech and hearing
Other losses may be covered as well. Please see your Plan Administrator.
Coverage amount(s) will reduce according to the following schedule:
Age:
65
70
Insurance Amount Reduces to:
65% of original amount
45% of original amount
Coverage may not be increased after a reduction.
Guarantee Issue
If you enroll within 31 days of your eligibility date, you may apply for any
amount of Life insurance coverage up to $150,000 for yourself and any amount
of coverage up to $25,000 for your spouse. Any Life insurance coverage over
the Guarantee Issue amount(s) will be subject to evidence of insurability. If you
and your eligible dependents do not enroll within 31 days of your eligibility date,
you can apply for coverage only during an annual enrollment period and will be
required to furnish evidence of insurability for the entire amount of coverage.
If you and your eligible dependents enroll within 31 days of your eligibility date,
and later, wish to increase your coverage, you may increase your coverage, with
evidence of insurability, at anytime during the year. However, you may wait
until the next annual enrollment and only coverage over the Guarantee Issue
amount(s) will be subject to evidence of insurability. AD&D coverage does not
require evidence of insurability.
Please see your Plan Administrator for your eligibility date.
Term Life Coverage Rates
Age Band
- 24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
AD&D Coverage Rates
Insurance Age
Rates shown are your Monthly deduction:
Employee
per $10,000
$.660
$.660
$.80
$.970
$1.580
$2.800
$4.770
$7.800
$10.180
$17.790
$39.390
$39.390
Spouse
per $5,000
$.440
$.440
$.500
$.610
$.960
$1.670
$2.770
$4.350
$6.810
$11.940
$23.250
$45.380
Child per
$2,000
$.500
NOTE: The
premium
paid for child
coverage is
based on the
cost of
coverage for
one child,
regardless of
how many
children you
have.
NOTE: Your rate will increase as you age and move to the next age band.
AD&D Cost Per:
Monthly Rate
Employee:
$10,000
$.300
Spouse:
$ 5,000
$.160
Child:
$ 2,000
$.100
Your rate is based on your insurance age. To calculate your insurance age, subtract
your year of birth from the year your coverage becomes effective.
To calculate your cost, complete the following by selecting your coverage amount and rate (based on your insurance age).
Term Life Calculation
Worksheet
AD&D Calculation
Worksheet
Coverage Amount
Increment
Employee
$________
÷ $10,000 x
Spouse
$________
÷ $ 5,000 x
Children
$________
÷ $ 2,000 x
Total Monthly Cost
Rate
$______
$______
$______
Coverage Amount
Increment
Employee
$________
÷ $10,000 x
Spouse
$________
÷ $ 5,000 x
Children
$________
÷ $ 2,000 x
Total Monthly Cost
Rate
$______
$______
$______
=
=
=
=
=
=
=
=
Monthly
Cost
$_________
$_________
$_________
$_________
Monthly
Cost
$_________
$_________
$_________
$_________
Additional Benefits
Life Planning Financial &
Legal Resources
This personalized financial counseling service provides expert, objective financial
counseling to survivors and terminally ill employees at no cost to you. This service
is also extended to you upon the death or terminal illness of your covered spouse.
The financial consultants are master level consultants. They will help develop
strategies needed to protect resources, preserve current lifestyles, and build future
security. At no time will the consultants offer or sell any product or service.
Portability/Conversion
If you retire, reduce your hours or leave your employer, you can take this coverage
with you according to the terms outlined in the contract. However, if you have a
medical condition which has a material effect on life expectancy, you will be
ineligible to port your coverage. You may also have the option to convert your
Term life coverage to an individual life insurance policy.
Accelerated Benefit
If you become terminally ill and are not expected to live beyond a certain time
period as stated in your certificate booklet, you may request up to 75% of your life
insurance amount up to $500,000, without fees or present value adjustments. A
doctor must certify your condition in order to qualify for this benefit. Upon your
death, the remaining benefit will be paid to your designated beneficiary(ies). This
feature also applies to your covered dependents.
Waiver of Premium
If you become disabled (as defined by your plan) and are no longer able to work,
your premium payments will be waived during the period of disability.
Retained Asset Account
Benefits of $10,000 or more are paid through the Unum Retained Asset Account.
This interest bearing account will be established in the beneficiary's name. He or
she can then write a check for the full amount or for $250 or more, as needed.
Additional AD&D Benefits
Education Benefit: If you or your insured spouse die within 365 days of an
accident, an additional benefit is paid to your dependent child(ren). Your child(ren)
must be a full-time student beyond grade 12. (Not available in Illinois or New
York.)
Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car
accident and are wearing a properly fastened seat belt and/or are in a seat with an
air bag, an amount will be paid in addition to the AD&D benefit.
Limitations/Exclusions/
Termination of Coverage
Suicide Exclusion
Life benefits will not be paid for deaths caused by suicide in the first twenty-four
months after your effective date of coverage.
No increased or additional benefits will be payable for deaths caused by suicide
occurring within 24 months after the day such increased or additional insurance is
effective.
AD&D Benefit Exclusions
AD&D benefits will not be paid for losses caused by, contributed to by, or resulting
from:
•
Disease of the body or diagnostic, medical or surgical treatment or mental
disorder as set forth in the latest edition of the Diagnostic and Statistical
Manual of Mental Disorders;
•
Suicide, self-destruction while sane, intentionally self-inflicted injury while
sane, or self-inflicted injury while insane;
•
War, declared or undeclared, or any act of war;
•
Active participation in a riot;
•
Attempt to commit or commission of a crime;
•
The voluntary use of any prescription or non-prescription drug, poison, fume,
or other chemical substance unless used according to the prescription or
direction of your or your dependent’s doctor. This exclusion does not apply to
you or your dependent if the chemical substance is ethanol;
•
Intoxication. (“Intoxicated” means that the individual’s blood alcohol level
equals or exceeds the legal limit for operating a motor vehicle in the state or
jurisdiction where the accident occurred.)
Your coverage and your dependents’ coverage under the Summary of Benefits ends
on the earliest of:
•
The date the policy or plan is cancelled;
•
The date you no longer are in an eligible group;
•
The date your eligible group is no longer covered;
•
The last day of the period for which you made any required contributions;
•
The last day you are in active employment unless continued due to a covered
layoff or leave of absence or due to an injury or sickness, as described in the
certificate of coverage;
•
For dependent’s coverage, the date of your death.
In addition, coverage for any one dependent will end on the earliest of:
•
The date your coverage under a plan ends;
•
The date your dependent ceases to be an eligible dependent;
•
For a spouse, the date of divorce or annulment.
Unum will provide coverage for a payable claim which occurs while you and your
dependents are covered under the policy or plan.
Next Steps
How to Apply
To apply for coverage, complete your enrollment form within 31 days of your
eligibility date.
All employees: If you apply for coverage after your effective date, or if you
choose coverage over the guarantee issue amount, you will need to complete a
medical questionnaire which you can get from your Plan Administrator. You may
also be required to take certain medical tests at Unum’s expense.
Effective Date of Coverage
Please see your Plan Administrator for your effective date.
Delayed Effective Date of
Coverage
Employee: Insurance coverage will be delayed if you are not in active employment
because of an injury, sickness, temporary layoff, or leave of absence on the date
that insurance would otherwise become effective.
Dependent: Insurance coverage will be delayed if that dependent is totally disabled
on the date that insurance would otherwise be effective. Exception: infants are
insured from live birth.
“Totally disabled” means that, as a result of an injury, a sickness or a disorder, your
dependent is confined in a hospital or similar institution; is unable to perform two
or more activities of daily living (ADLs) because of a physical or mental incapacity
resulting from an injury or a sickness; is cognitively impaired; is receiving or is
entitled to receive any disability income from any source due to any sickness or
injury; is receiving chemotherapy radiation therapy or dialysis treatment; or has a
life threatening condition.
Changes to Coverage
Each year you and your spouse will be given the opportunity to change your Life
coverage and AD&D coverage. You and your spouse may purchase additional Life
coverage up to the Guarantee Issue amounts without evidence of insurability if you
are already enrolled in the plan. Life coverage over the Guarantee Issue amounts
will be medically underwritten and will require evidence of insurability and
approval by Unum’s Medical Underwriters. The suicide exclusion will apply to
any increase in coverage. AD&D coverage does not require evidence of insurability
for increase amounts.
Questions
If you should have any questions about your coverage or how to enroll, please
contact your Plan Administrator.
This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions
may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If
the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete
details of coverage, please refer to policy form number C.FP-1, et al.
Life Planning is provided by Ceridian Incorporated. The services are subject to availability and may be withdrawn by Unum without prior notice.
Underwritten by: Unum Life Insurance Company of America, 2211 Congress Street, Portland, Maine 04122, www.unum.com
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. ©2007 Unum Group. All rights reserved.
LTD
Employer Paid Plan Highlights
LONG TERM DISABILITY
Unum Policy # 105259
Eligibility
All Diocesean Clergy in the United States working:
Benefit Amount
50% of your monthly earnings, to max of $4,000 per month.
Definition of Disability:
During the first 24 months, Unum will define disability as follows:
• you are limited from performing the material and substantial
duties of your regular occupation due to sickness or injury; and
• you have a 20% or more loss of indexed monthly earnings due to
the same sickness or injury..
Elimination Period
90 days
Duration
The duration of your benefit payments is based on your age when
your disability occurs. Your LTD benefits are payable for the
period during which you continue to meet the definition of
disability. If your disability occurs before age 60, your benefits
could be payable until you reach age 65. If your disability occurs at
or after age 60, benefits could be paid according to a benefit
duration schedule.
Pre-existing Condition
3/12
Travel Assistance Program
Included
Premium
Employer Paid
This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Details may differ
from state to state. Please refer to your certificate booklet for your complete plan description. If the terms of this plan
highlight summary or your certificate differ from your policy, the policy will govern.
Long Term Disability Income Protection
Insurance Plan Highlights
Policy # 105259
Please read carefully the following description of your Unum Long Term Disability Income Protection insurance
plan.
Your Plan
Eligibility
Benefit Amount
Group 1
As a lay employee or permanent deacon employed by the Archdiocese, an
affiliated parish or school, or other participating employer in active
employment, you're eligible for benefits if you meet any of these criteria:
Employees scheduled to work 6 months or less during 12 consecutive
months are not eligible employees
Group 2
Licensed or waivered elementary or secondary classroom teachers who are
scheduled to work at least 20 hours a week with an employment agreement
for longer than six months in active employment.
Base LTD Benefit:
• 50% of your monthly earnings
• To a maximum of $4000
Buy up LTD Benefit:
Buy up LTD Benefit:
Definition of Disability
•
•
60% of your monthly earnings.
To a maximum of $6,000
•
•
66 2/3% of your monthly earnings.
To a maximum of $6,000
You would be considered disabled and eligible for benefits because of
sickness or injury if:
•
you are limited from performing the material and substantial duties of
your regular occupation; and
•
you have a 20% or more loss in indexed monthly earnings due to the
same sickness or injury.
You will continue to receive benefits if:
ADR1877-2001
•
after benefits have been paid for 24 months, you are working in any
occupation and continue to have a 20% or more loss in indexed monthly
earnings due to your sickness or injury; or
•
you are not working and, due to the same sickness or injury, are unable
to perform the duties of any gainful occupation for which you are
reasonably fitted by education, training or experience.
Elimination Period
The Elimination Period is the length of time of continuous disability which
must be satisfied before you are eligible to receive benefits.
LTD benefits would begin after 90 days of disability, as described in the
definition above.
Benefit Duration
Your duration of benefits is based on your age when the disability occurs.
Your LTD benefits are payable for the period during which you continue to
meet the definition of disability. If your disability occurs before age 60,
benefits will be payable until age 65. If your disability occurs at or after age
60, benefits would be paid according to a benefit duration schedule.
Gainful Occupation
Gainful occupation means an occupation that is or can be expected to
provide you with an income at least equal to your gross disability payment
within 12 months of your return to work.
Federal Income Taxation
You may wonder if your disability benefit amount will be taxed. It depends
on how your premium — the price of your coverage — is paid.
If your premium is paid with:
•
Both Pre-Tax and Post-Tax Dollars, a portion of your benefit
amount will be taxed
The disability benefit amounts you receive will be reported annually on a
W-2. It will show any taxable and non-taxable portions separately.
*Pre-Tax Dollars are dollars paid by your employer toward premium that are not reported
as earnings on your annual W-2. They are also dollars you pay toward premium through a
cafeteria plan.
**Post-Tax Dollars are dollars paid through payroll deductions after taxes and
withholdings have been subtracted from your earnings. They are also dollars paid by your
employer toward premium that are reported as earnings on your annual W-2 and taxed
accordingly.
Additional Benefits
Rehabilitation and Return to
Work Assistance
Unum has a vocational rehabilitation program available to assist you to
return to work. This program is offered as a service, and is voluntary on
your part and on Unum’s part. Unum may elect to offer you a return-towork program including, but not limited to, the following services:
•
coordination with your Employer to assist you to return to work;
•
evaluation of adaptive equipment to allow you to work;
• vocational evaluation to determine how your disability may impact
your employment options;
• job placement services;
• resume preparation;
• job seeking skills training; or
• retraining for a new occupation.
Waiver of Premium
You will not be required to pay LTD premiums as long as you are receiving
LTD benefits.
Worldwide
Emergency Travel
Assistance Services
Whether your travel is for business or pleasure, our worldwide
emergency travel assistance program is there to help you when an
unexpected emergency occurs. With one phone call anytime of the
day or night, you, your spouse and dependent children can get
immediate assistance anywhere in the world. Emergency travel
assistance is available to you when you travel to any foreign
country, including neighboring Canada or Mexico. It is also
available anywhere in the United States for those traveling more
than 100 miles from home. Your spouse and dependent children do
not have to be traveling with you to be eligible. However, spouses
traveling on business for their employer are not covered by this
program.
Survivor Benefit
Unum will pay your eligible survivor a lump sum benefit equal to 3 months
of your gross disability payment.
This benefit will be paid if, on the date of your death, your disability
had continued for 180 or more consecutive days, and you were
receiving or were entitled to receive payments under the plan. If you
have no eligible survivors, payment will be made to your estate, unless
there is none. In this case, no payment will be made. However, we will
first apply the survivor benefit to any overpayment which may exist on
your claim.
Pre-existing Condition
Exclusion
Instances When Benefits
Would Not Be Paid
You have a pre-existing condition if:
•
you received medical treatment, consultation, care or services
including diagnostic measures, or took prescribed drugs or
medicines in the 3 months just prior to your effective date of
coverage; and
•
the disability begins in the first 12 months after your effective
date of coverage.
Benefits would not be paid for disabilities caused by, contributed to by, or
resulting from:
• intentionally self-inflicted injuries;
• active participation in a riot;
• war, declared or undeclared, or any act of war;
• conviction of a crime under state or federal law; loss of professional
license, occupational license or certification;
• pre-existing conditions (see definition).
Unum will not pay a benefit for any period of disability during which you
are incarcerated.
Mental and Nervous
LTD benefits would be paid for 24 months per lifetime for disabilities
caused by mental illness that meet the definition of disability. Mental and
nervous benefits would continue beyond 24 months only if you are
institutionalized or hospitalized as a result of the disability.
Your coverage under the policy ends on the earliest of the following:
• The date the policy or plan is cancelled;
• The date you no longer are in an eligible group;
• The date your eligible group is no longer covered;
• The last day of the period for which you made any required
contributions;
• The last day you are in active employment except as provided
under the covered layoff or leave of absence provision.
Unum will provide coverage for a payable claim which occurs while you
are covered under the policy or plan.
Next Steps
How to Apply
To apply for coverage, complete your enrollment form within 31 days of
your eligibility date.
Effective Date of Coverage
Delayed Effective Date of
Coverage
Insurance will be delayed if you are not in active employment because of
an injury, sickness, temporary layoff, or leave of absence on the date that
insurance would otherwise become effective.
Changes to Coverage
Each year, or when you have a change in status, you will have the
opportunity to change your long term disability coverage by one level. Any
increase in coverage will be subject to the pre-existing condition exclusion.
Questions
If you should have any questions about your coverage or how to enroll,
please contact your Plan Administrator.
This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some
provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete
plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the
policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al.
All worldwide emergency travel assistance must be arranged by Assist America, which pays for all services it provides. Medical expenses such as
prescriptions or physician, lab or medical facility fees are paid by the employee or the employee’s health insurance.
Underwritten by:
Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com
©2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
Short Term Disability Income Protection
Insurance Plan Highlights
Policy # 105259
Please read carefully the following description of your Short Term Disability Income Protection insurance plan,
underwritten by Unum Life Insurance Company of America.
Your Plan
Eligibility
Group 1
As a lay employee or permanent deacon employed by the Archdiocese, an affiliated
parish or school, or other participating employer in active employment, you're
eligible for benefits if you meet any of these criteria:
Employees scheduled to work 6 months or less during 12 consecutive months are not
eligible employees
Group 2
Licensed or waivered elementary or secondary classroom teachers who are
scheduled to work at least 20 hours a week with an employment agreement for
longer than six months in active employment.
Weekly Benefit
Amount
Definition of
Disability
60% of your basic weekly earnings to a maximum of $500
Your disability benefit may be reduced by deductible sources of income and any
earnings you have while disabled. Deductible sources of income may include such
items as disability income or other amounts you receive or are entitled to receive
under: workers compensation or similar occupational benefit laws; state compulsory
benefit laws; automobile liability and no fault insurance; legal judgments and
settlements; certain retirement plans; salary continuation or sick leave plans; other
group or association disability programs or insurance; and amounts you or your
family receive or are entitled to receive from Social Security or similar governmental
programs.
You are disabled when Unum determines that:
•
•
ADR1878-2001
you are limited from performing the material and substantial duties of
your regular occupation due to your sickness or injury; and
you have a 20% or more loss in weekly earnings due to the same sickness or
injury.
Elimination Period
and Benefit Duration
The Elimination Period is the length of time of continuous disability which must
be satisfied before you are eligible to receive benefits.
Option A: No Coverage
Option B: If your disability is the result of an injury that occurs while you are
covered under the plan, your Elimination Period is 44 days. If your disability is
due to a sickness, your Elimination Period is 44 days. If you meet the
definition of disability you may receive a benefit for 7 weeks.
Option C: If your disability is the result of an injury that occurs while you are
Option D: If your disability is the result of an injury that occurs while you are
Federal Income
Taxation
You may wonder if your disability benefit amount will be taxed. It depends on how
your premium — the price of your coverage — is paid.
If your premium is paid with:
•
•
•
Pre-Tax Dollars,* your benefit amount will be taxed
Post-Tax Dollars,** your benefit amount will not be taxed
Both Pre-Tax and Post-Tax Dollars, a portion of your benefit amount will
be taxed
The disability benefit amounts you receive will be reported annually on a W-2. It
will show any taxable and non-taxable portions separately.
*Pre-Tax Dollars are dollars paid by your employer toward premium that are not reported as earnings
on your annual W-2. They are also dollars you pay toward premium through a cafeteria plan.
**Post-Tax Dollars are dollars paid through payroll deductions after taxes and withholdings have been
subtracted from your earnings. They are also dollars paid by your employer toward premium that are
reported as earnings on your annual W-2 and taxed accordingly.
Additional Benefits
Rehabilitation and
Return to Work
Assistance
ADR1878-2001
Unum has a vocational Rehabilitation and Return to Work Assistance program
available to assist you in returning to work. We will make the final determination of
your eligibility for participation in the program, and will provide you with a written
Rehabilitation and Return to Work Assistance plan developed specifically for you.
This program may include, but is not limited to the following benefits:
•
coordination with your Employer to assist your return to work;
•
adaptive equipment or job accommodations to allow you to work;
•
vocational evaluation to determine how your disability may impact your
employment options;
•
job placement services;
•
resume preparation;
•
job seeking skills training; or
•
education and retraining expenses for a new occupation.
If you are participating in a Rehabilitation and Return to Work Assistance program,
we will also pay an additional disability benefit of 10% of your gross disability
payment to a maximum of $250 per week. In addition, we will make weekly
payments to you for 3 weeks following the date your disability ends, if we determine
you are no longer disabled while:
•
you are participating in a Rehabilitation and Return to Work Assistance
program; and
•
you are not able to find employment.
Pre-existing
Condition Exclusion
Instances When
Benefits Would Not
Be Paid
This exclusion applies only to amounts greater than the basic coverage. You
have a pre-existing condition if:
•
you received medical treatment, consultation, care or services
including diagnostic measures, or took prescribed drugs or
medicines in the 3 months just prior to your effective date of
coverage; and
•
the disability begins in the 12 months after your effective date of
coverage.
Benefits would not be paid for loss resulting from:
•
war, declared or undeclared, or any act of war;
•
active participation in a riot;
•
intentionally self-inflicted injuries;
•
loss of a professional license, occupational license or certification;
•
commission of a crime for which you have been convicted under state or
federal law;
•
any period of disability during which you are incarcerated;
•
an occupational injury or sickness,(this will not apply to a partner or sole
proprietor who cannot be covered by law under Workers' Compensation or
any similar law);
•
pre-existing condition. This applies only to amounts greater than the
basic coverage.
Your coverage under the policy ends on the earliest of the following:
The date the policy or plan is cancelled;
The date you no longer are in an eligible group;
The date your eligible group is no longer covered;
The last day of the period for which you made any required contributions;
The last day you are in active employment except as provided under the covered
layoff or leave of absence provision. Please see your Plan Administrator for further
information on these provisions.
Unum will provide coverage for a payable claim which occurs while you are covered
ADR1878-2001
under the policy or plan.
Next Steps
How to Apply
To apply for coverage, complete your enrollment form within 31 days of your
eligibility date.
Effective Date of
Coverage
Delayed Effective
Date of Coverage
Insurance coverage will be delayed if you are not in active employment because
of an injury, sickness, temporary layoff, or leave of absence on the date that
insurance would otherwise become effective.
Changes to Coverage
Each year, or when you have a change in status, you will have the opportunity to
change your short term disability coverage. Any increase in coverage will be subject
to the pre-existing condition exclusion.
Questions
If you should have any questions about your coverage or how to enroll, please
contact your Plan Administrator.
This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions
may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the
terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details
of coverage, please refer to policy form number C.FP-1, et al.
Underwritten by:
Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com
©2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
ADR1878-2001
UNUM Monthly Rates
Additional Life/Accidental Death and Dismemberment Insurance
Employee Additional Life/AD&D
Age of Employee on
December 31 of Current Year
Under 30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70 or over
Monthly Rate for Each
$10,000 in Coverage
$.96
$1.10
$1.27
$1.88
$3.10
$5.07
$8.10
$10.48
$18.09
$39.69
Employee coverage cannot exceed the lesser of $500,000 or 5 times the employee’s annual wages.
Spouse Additional Life/AD&D
Age of Spouse on
December 31 of Current Year
Under 30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75 or over
Monthly Rate for Each
$5,000 in Coverage
$.60
$.66
$.77
$1.12
$1.83
$2.93
$4.51
$6.97
$12.10
$23.41
$45.54
Spouse coverage cannot exceed 100% of the employee’s coverage.
If you and your spouse are both eligible employees for the Flexible Benefits Program, you cannot
be covered both as a spouse and an employee. Also, only one of you can cover your dependent
children (see the enrollment form for children’s rates).
Your premium for additional life/AD&D is based on your age as of December 31 of the current
year. For example, if your coverage starts July 2016, and you will turn age 30 on November 10,
2016, effective with July coverage you will pay the monthly premium for a person age 30-34 until
2021. Effective with your January 2021 coverage, your monthly premium will increase to the age
35-39 rate, since your age on December 31, 2021 will be 35.
7/1/2016
Reta Trust Dependent Validation Approved Documents
Dependent Type
Spouse
Child to age 26
Stepchild
Disabled Dependent
Adoption/placed for adoption
Approved Documents Requirement
Marriage certificate plus one piece of documentation dated within
the past 60 days to establish a common residence or financial
interdependence – Examples of secondary documentation:

Jointly filed Form 1040

Separately filed Form 1040 with the same address

Financial documents in both parties name

Utility bill in both parties name
Birth certificate listing the employee's name
Hospital Birth Record (newborns only)
Birth certificate naming spouse as the child’s biological parent
and Marriage Certificate
and Jointly filed 1040*
Separately filed 1040 with same address*
Financial document in both names
Utility bill in both names
Birth certificate and a copy of the employee's recent Form 1040
claiming the individual as a dependent OR the dependent's Form
1040 filed from the employee's address OR SSDI documentation
Appropriate court document
Court document establishing employee or the employee's spouse is
Legal Guardianship/Foster Child
the legal guardian
*Not required of marriage less than 90 days
Health Benefits Contact Sheet
Medical / Pharmacy Plans
Reta United Health Care (UHC) Plan
Group ID #: 904702
(800) 741-8786
https://www.myuhc.com
(844) 852-7437
https://www.envisionrx.com
(800) 533-1833
https://www.kp.org
(855) 433-6825
https://www.willamettedental.com/arch
(800) 765-6003
https://www.deltadentalins.com
(800) 813-2000
http://www.kaiserpermanentedentalnw.org
(800) 877-7195
https://www.vsp.com
Envisions Rx
(UHC and Reta Value Option Program)
Group ID #: 0011172003 (UHC 250 Plan)
Group ID #: 0011172004 (UHC 500 Plan)
Reta Kaiser Medical & Pharmacy Plan
Group ID #: 19969
Dental / Vision Plans
Willamette Dental
Group ID #: OR10
Delta Dental of California
Group ID #: 17706
Kaiser Permanente Dental
Group ID #: 03766
VSP Vision
Group ID #: 30032427
UNUM Short-/Long-Term Disability, Additional Life / AD&D Plans
Basic Life / AD&D
Group ID #: 105259
Additional Life
Group ID #: 393809
Short-/Long-Term Disability (STD & LTD)
Group ID #: 105259
(800) 445-0402
http://www.unum.com
(800) 445-0402
http://www.unum.com
(877) 851-7637
http://www.unum.com
(877) 303-7382
service@retaenroll.org
(800) 277-1060
https://members.mhn.com
(800) 302-6343
https://www.retatrust.org (click ‘WebMD’ link)
(503) 233-8343 (ph)
(503) 235-0417 (fax)
mmcpartland@archdpdx.org
Employee Services
BAS Customer Service (MyEnroll Services)
Employee Assistance Program (EAP)
Group ID #: 5125
Access Code: aportland
Employee Wellness Program
(WebMD)
Archdiocese of Portland
Mary McPartland
Employee Benefits Analyst
If you would like to read more about a specific benefit, log in to the Reta Benefits Center at RetaTrust.org.
The Reta Benefits Center is available to you 24 hours a day, 7 days a week.
If you need assistance or you have forgotten your user ID and/or password, please contact MyEnroll Services at
(877)-303-7382 or service@retaenroll.org.

Employee Benefits Plan Information Packet

Transcription

Similar documents

2014 Benefits Summary FINAL - Lindley Habilitation Services

2011 – 2016 AGREEMENT Between PHILIPPINE AIRLINES, INC

1xYESonJ_ Endorse LVJUSD 032116F

GE Appliances Benefits Guide

Health care benefits for your on demand life.