NDCP medical and dental plans

Transcription

Dear Franchise Owner:
The attached Participant Enrollment Kit for your employees contains the plan designs
for all NDCP medical and dental plans. The Patient Protection and Affordable Care
Act now requires employers to provide the full Summary of Benefits and
Coverage (SBC) for all available medical plans to each enrolled employee no later
than December 31, 2014. The SBCs can be found at www.nationaldcp.com on the
Healthcare page.
Prior to distributing the enrollment kit to eligible employees, please remove and discard
plan designs for the plans you are not offering to your employees. You must also provide
your employee with the cost (payroll deduction amount) for each plan option available
to him/her, along with information on Health Savings Accounts, if you elect to make this
an option for your employees.
Each eligible employee who elects to enroll will complete the Employee Information
section, including signature, of the CBA Blue Enrollment / Change Form. As the
employer, you will verify the accuracy of the employee/dependent information and
complete the bottom of the form labeled “Employer (or Plan Sponsor) Statement” to
authorize the enrollment/change. Eligible Employees who decline coverage must
complete a waiver, indicating they do not wish to elect coverage. Please make sure you
maintain copies of all enrollment documents in a secure location as these are subject
to audit.
After your initial enrollment into our plan, you will have the option to process enrollments,
changes, or terminations on the CBA Blue website. Verification of the completion of your
online access and instructions will be sent to you within a few weeks of your effective
date on the plans. You also have the option to fax the completed Enrollment/Change
From directly to CBA Blue at 802-862-7661. If you have any questions, please do not
hesitate to contact the Healthcare Hotline at 1.888.365.4327, Option 4.
National DCP | 3805 Crestwood Parkway | Suite 400 | Duluth, GA 30096
p: 770.369.8600 | w: NationalDCP.com
Dunkin’ Donuts Franchisee & Distribution Center Health Plan
©
CBA Blue- 2015
Participant Enrollment Kit
Welcome Benefit Eligible Employee,
This is your opportunity to join the Dunkin’ Donuts Franchisee & Distribution Center Health and/or Dental
Plans. Your employer has offered you the most recognized and most accepted health plan in the nation.
We’ve assembled this participant enrollment kit to aid you in your benefit plan selection.
Enclosed you’ll find:
1.)
CBA Blue Member Brochure - learn more about CBA Blue
2.)
CBA Blue Blueprints – provide plan details to evaluate your plan options
3.)
Benecard Brochure – learn more about your prescription drug plan
4.)
CBA Blue – Enrollment/Change or Waiver Form - after you’ve made your decision to enroll or
waive coverage, complete the applicable form and return it to your Supervisor or Human
Resources Representative
4.)
COBRA – Initial Notice of Coverage Rights
Thank you for the opportunity to tell you about the resources available as a CBA Blue Member.
CBA Blue is an independent licensee of the Blue Cross Blue Shield Association, serving Vermont.
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PPO doctor or hospital to make sure you receive
the highest level of benefits.
If you’re a PPO member, always use a BlueCard®
¨ Call CBA Blue at 1.888.CBA.9206
for the names and addresses of doctors
and hospitals in the area where you or a
covered dependent need care.
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Visit the BlueCard Doctor and Hospital finder at cbabluevt.com to locate
doctors and hospitals, along with maps
and directions to find them.
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When you see a BlueCard® provider, you take advantage
of savings that the local Blue plan has negotiated with doctors and hospitals in the area. You won’t have to pay any
amount above these negotiated rates (except co-pays).
Designed to save you money

have you received my claim?
BlueCard® program?
is my provider participating in the
what’s the status of my claim?

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¨ Find what you need
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Customer
Service
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BluePrint® - 2015 Premium PPO Plan (No PPO Deductible)
Benefit
Lifetime Benefit Maximum
Per individual.
PPO1
Unlimited
Deductible
The amount an individual or family must pay each calendar year before payments begin for services.
Out-of-Pocket Expense Limit
The maximum amount of money that any individual or family will have to pay towards covered health expenses during any
one calendar year. Includes medical co-payments. Excludes prescription co-payments.
None
$500 Member
$1000 Family
$4000 Member
$8000 Family
$6000 Member
$12000 Family
Preventive Care Adult
Includes: office visits, pap smear, prostate exam, GYN exam (one per year), x-rays, lab tests, hearing tests,
immunizations, colorectal screenings, & flu shots.
100%
70%; after
deductible
100%
70%; after
deductible
100%
70%; after
deductible
Routine Mammogram
Age 35-39 1 Baseline; age 40 + 1 per calendar year
Routine Child Well Care
Primary and Specialist Physician Office Visits
Out-ofNetwork
PCP $20 co-pay
Spec. $30 co-pay
70%; after
deductible
$150 co-pay
$150 co-pay
60 visits combined per member per calendar year maximum.
$30 co-pay
70%; after
deductible
Allergy Testing
$30 co-pay
70%; after
deductible
100%
70%; after
deductible
Once per member – every 24 months.
$20 co-pay
$20 co-pay
Chiropractic
$30 co-pay
70%; after
deductible
$30 co-pay
70%; after
deductible
100%
70%; after
deductible
100%
70%; after
deductible
100%
70%; after
deductible
$75 co-pay
70%; after
deductible
$150 co-pay
70%; after
deductible
$250 co-pay
70%; after
deductible
100%
100%
One co-payment per physician per day.
Emergency Room
Co-payment waived if admitted.
Physical Therapy/Occupational Therapy & Speech Therapy
Durable Medical Equipment
Pre-certification required for items in excess of $1500.00.
Routine Vision Exams
Per member per calendar year maximum of 12 visits
Cardiac Rehabilitation
Requires Pre-certification.
Radiation Therapy and Chemotherapy
Home Health Care
Outpatient Diagnostic Lab & X-ray
High Tech Radiology
MRI, PET, CAT Scans.
Outpatient Facility Day Surgery
Inpatient Hospital Services
Requires Pre-certification. Maximum of two co-payments per member per plan year.
Ambulance Services
Emergency Services.
These pages summarize the benefits of your health care plan. Your Summary Plan Description defines the full terms and conditions in greater detail. Should any
questions arise concerning benefits, the Summary Plan Description shall govern.
CBA Blue, of Vermont, is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Trademarks of the
Blue Cross and Blue Shield Association.
Benefit
PPO1
Out-ofNetwork
100%
70%; after
deductible
Ambulance
Services
Non Emergency Services. Requires Pre-certification.
Infertility (Outpatient)
Maximum of six attempts per lifetime
$30 co-pay
Not Covered
$250 co-pay
70%; after
deductible
$20 co-pay
70%; after
deductible
Mental Health/Substance Abuse Inpatient Services
Requires Pre-certification. Maximum of two co-payments per member per plan year.
Mental Health/Substance Abuse Outpatient Services
Prescription Drug Benefit
Prescription Drug Benefit (Retail 34 Day Supply)2
Generic Drug
Preferred Name Drug
Non-Preferred Name Drug
$10 co-pay
$30 co-pay
$50 co-pay
None
$20 co-pay
$60 co-pay
$100 co-pay
None
Prescription Drug Benefit (Mail Order 90 Day Supply)
Generic Drug
Preferred Name Drug
1
The CBA Blue Premium PPO Plan utilizes the National BlueCard® PPO Network.
2
The CBA Blue Premium PPO Plan utilizes a Step Therapy Program. The program moves you along a well-planned path with
your doctor approving your medications. Generic or OTC drugs are usually the first step – these drugs have the lowest member
co-payment. Brand names drugs are usually the second step. Your health plan will require that you have tried a first-step drug,
before approving second level drugs.
The plan requires that all non-emergency hospital admissions and certain outpatient procedures (Infertility, Radiation and
Chemotherapy, Cardiac Rehabilitation Therapy, Ambulance Services for non-emergency services, Home Infusion Therapy, Home
Health Care, Private Duty Nursing and Durable Medical Equipment items in excess of $1500.00) be pre-certified and authorized
by the Contract Administrator. Please contact CBA Blue’s Utilization Department at 1-888-222-9206 Option 6 prior to receiving
services.
Questions: Please Call CBA Blue at 1‐888‐222‐9206. To locate a participating BlueCard® PPO Network provider, or to learn more about CBA Blue, please visit www.cbabluevt.com. CBA Blue, of Vermont, is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Trademarks of the
BluePrint® - 2015 Quality PPO Plan ($500/$1000 Deductible Plan)
Benefit
Per individual.
Deductible
The maximum amount of money that any individual or family will have to pay towards covered health expenses during any
one calendar year. Includes medical co-payments. Excludes prescriptions co-payments.
PPO1
Unlimited
$500 member
$1000 family
$1500 member
$3000 family
$4000 member
$8000 family
$6000 member
$12000 family
Includes: office visits, pap smear, prostate exam, GYN exam (one per year), x-rays, lab tests, hearing tests,
immunizations, colorectal screenings, & flu shots.
100%
70%; after
deductible
100%
70%; after
deductible
100%
70%; after
deductible
Routine Mammogram
Non-PPO
PCP $30 co-pay
Spec. $40 co-pay
70%; after
deductible
$200 co-pay
$200 co-pay
60 visits combined per calendar year maximum.
$40 co-pay
70%; after
deductible
Allergy Testing
$40 co-pay
70%; after
deductible
90%; after
deductible
70%; after
deductible
$30 co-pay
$30 co-pay
Chiropractic
$40 co-pay
70%; after
deductible
$40 co-pay
70%; after
deductible
90%; after
deductible
70%; after
deductible
90%; after
deductible
70%; after
deductible
90%; after
deductible
70%; after
deductible
90%; after
deductible
70%; after
deductible
Outpatient Diagnostic Laboratory and X-ray
90%; after
deductible
70%; after
deductible
$150 co-pay; after
deductible
70%; after
deductible
90%; after
deductible
90%; after innetwork
deductible
One co-payment per physician per day..
Emergency Room
Co-payment waived if admitted.
Pre-certification required for items in excess of $1500.
12 visits per calendar year per member maximum.
Cardiac Rehabilitation
Home Health Care
High Tech Radiology
MRI, PET, CAT Scans.
Ambulance Services
Emergency Services.
Benefit
Ambulance
Services
Non-Emergency Services.
Maximum of two co-payments per member per calendar year.
PPO1
Non-PPO
90%; after
deductible
70%; after
deductible
90%; after
deductible
70%; after
deductible
$30 co-pay
70%; after
deductible
$40 co-pay
Not Covered
$15 co-pay
$45 co-pay
$60 co-pay
None
$30 co-pay
$90 co-pay
$120 co-pay
None
Infertility Services (Outpatient)
Maximum of six treatments per member per lifetime.
Generic Drug
Preferred Name Drug
Generic Drug
Preferred Name Drug
* These pages summarize the benefits of your health care plan. Your Summary Plan Description defines the full terms and conditions in greater detail. Should any
1
The CBA Blue Quality PPO Plan utilizes the National BlueCard® PPO Network.
2 The
CBA Blue Quality PPO Plan utilizes a Step Therapy Program. The program moves you along a well-planned path with your
doctor approving your medications. Generic or OTC drugs are usually the first step – these drugs have the lowest member copayment. Brand names drugs are usually the second step. Your health plan will require that you have tried a first-step drug,
services.
BluePrint® - 2015 Value HSA PPO Health Plan ($2000/$4000 PPO Deductible)
Benefit
PPO1
Unlimited
Per individual.
Deductible (Combined Medical and Prescription)
The maximum amount of money that any individual or family will have to pay towards covered health expenses during
any one calendar year. Includes medical and prescription co-payments.
$2,000 member
$4,000 family
$4,000 member
$8,000 family
$4,000 member
$8,000 family
$6,000 member
$12,000 family
Includes: office visits, pap smear, prostate exam, GYN exams, x-rays, lab tests, hearing tests, immunizations, colorectal
screenings, & flu shots.
100%
60%; after
deductible
100%
60%; after
deductible
100%
60%; after
deductible
Routine Mammogram
One co-payment per physician per day.
Emergency Room
60 visits combined per member per calendar year maximum.
Allergy Testing
Pre-certification required for items in excess of $1500.00.
Out-ofNetwork
$25 co-pay; after
deductible
60%; after
deductible
$250 co-pay; after
deductible
$250 co-pay;
after in-network
deductible
$25 co-pay; after
deductible
60%; after
deductible
80%; after
deductible
60%; after
deductible
80%; after
deductible
60%; after
deductible
$25 co-pay
$25 co-pay
Chiropractic
Per member per calendar year maximum of 12 visits.
Cardiac Rehabilitation Therapy
$25 co-pay; after
deductible
60%; after
deductible
80%; after
deductible
60%; after
deductible
80%; after
deductible
60%; after
deductible
80%; after
deductible
60%; after
deductible
Outpatient Diagnostic Lab & X-ray
80%; after
deductible
60%; after
deductible
High Tech Radiology
80%; after
deductible
60%; after
deductible
80%; after
deductible
60%; after
deductible
80%; after
deductible
60%; after
deductible
80%; after
deductible
80%; after
in-network
deductible
Home Health Care
MRI, PET, CAT Scans
Ambulance Services
Emergency Services.
PPO1
Benefit
Ambulance
Services
80%; after
deductible
Non Emergency Services. Requires Pre-certification.
Infertility (Outpatient)
$25 co-pay; after
deductible
Maximum of six attempts per lifetime
Out-ofNetwork
60%; after
deductible
60%; after
deductible
80%; after
deductible
60%; after
deductible
$25 co-pay; after
deductible
60%; after
deductible
Generic Drug
Preferred Name Drug
Generic Drug
Preferred Name Drug
$15 co-pay; after deductible
None
None
1
The CBA Blue Value HSA Qualified PPO Plan utilizes the National BlueCard® PPO Network.
2 The
CBA Blue Value PPO Plan utilizes a Step Therapy Program. The program moves you along a well-planned path with your
doctor approving your medications. Generic or OTC drugs are usually the first step – these drugs have the lowest member copayment. Brand names drugs are usually the second step. Your health plan will require that you have tried a first-step drug,
services.
For two-person or family coverage, expenses incurred by each person accumulates and is credited toward the one family
deductible. The Plan will not pay benefits until the family deductible amount has been completely satisfied by any combination of
covered participants included under two-person or family coverage.
A Hassle-Free HealthEquity® HSA:
A Healthy Choice for Saving
Discover an easy, hassle-free health savings account (HSA) from HealthEquity and
discover the best way to save for health care, and a great way to save on taxes.
What Is an HSA?
Individual HSA Contribution Limit
An HSA is a tax-free savings account that works with a qualified health plan to help
you pay your insurance deductible and qualified out-of-pocket medical expenses.
$3,350 (2015)
$3,300 (2014)
You take the money you would have paid for higher health insurance premiums
and use it to pay qualified medical expenses or save it and let it grow from year
to year. What’s more:
 Your HSA—including all the money you and your employer
contribute—is yours.
- You won’t lose it if you don’t spend it, change jobs, retire,
or leave the health plan.
Family HSA Contribution Limit
 You never pay taxes on withdrawals for qualified medical expenses1.
 Your money earns interest and you don’t pay taxes on the interest earned1.
 Your contributions are tax-free and reduce your overall taxable income.
$6,650 (2015)
$6,550 (2014)
Why Choose a HealthEquity® HSA?
Your HealthEquity HSA includes:
 Easy-to-use online access to claims
and payments—access claims2,
pay bills, get reimbursements, and
more—all from a single, easy-to-use
online portal.
 Live service 24/7/365—get the
same service at 2 a.m. or 2 p.m.
from knowledgeable, US-based
HealthEquity Member
Services specialists.
 Remarkable education and
support—Rely on HealthEquity
Member Services and online
resources to get the most from your
HSA, find comparative pricing
on prescriptions and medical services,
research diseases, and more.
 Everything you get from a typical HSA
and more—including:
- FDIC-insured cash deposits that earn
competitive interest rates
- Free mutual fund investment
options with no transaction fees3
- Free HealthEquity Visa® health
account card†
Who’s Eligible for an HSA?
Anyone meeting the following
requirements is eligible for an HSA.
 Be enrolled in a qualified health plan.
 Have no other health coverage
except what’s permitted by the IRS
(see IRS Publication 969).
 Not be enrolled in Medicare.
 Not be claimed as a dependent on
someone else’s tax return.
Is an HSA Right for You?
Seventy percent of people have less than $1,000 of medical expense a year (including what both the insured and the health plan pay4).
Why not invest the money you’d pay for premiums in an interest-bearing, tax-advantaged HSA and lower-premium health plan?
Even if you have higher medical expenses, an HSA often costs less than a traditional plan when you combine what you save on
premiums and your out-of-pocket maximum. See the health plan comparison tool in the resource center at www.healthequity.com or
ask your employer for a cost comparison and see the savings for yourself.
Frequently Asked Questions
To learn even more, visit www.healthequity.com or contact HealthEquity Member Services by phone
or at memberservices@healthequity.com.
Q. How much can contributing
to an HSA save me on taxes?
A. If you’re in the 25% tax bracket and
contribute $1,500, you save $375 in
taxes*! In addition your $1,500 grows
tax-free in your HSA. And when you
incur costs, you have money you can
withdraw with no tax penalty for
qualified medical expenses.
Sample Tax Savings
Your contribution: $1,500
Annual medical expenses: $500
Saving with
interest at
year’s end*
Cumulative
tax savings*
5 years
10 years
20 years
$5,101
$10,462
$22,019
$2,295
$4,670
$9,671
*Examples based on a 1% interest rate on HSA compounded
over time, a 5% state tax rate, and a 25% federal tax bracket.
Individual results will vary based on the amount contributed to
the HSA, medical expenses, and tax bracket.
Calculate your own savings at
http://healthequity135.vtoolkit.com/
appToolkit/app/login/loginGlobal.cfm.
Q. What’s a qualified
medical expense?
A. Qualified medical expenses are
those that generally qualify for the
income tax deduction outlined in IRS
Publication 502. See www.irs.gov/pub/
irs-pdf/p502.pdf for a complete list
or visit the resource center on www.
healthequity.com.
Q. Who can put money in my HSA?
A. Anyone can contribute to your HSA.
Only you and your employer receive
tax deductions on monies contributed.
And your contribution is tax-free.
Q. How much money can I
CoNtRIBUtE to MY HSA?
A. In 2014, the maximum contribution
set by the IRS for an individual is
$3,300 and $6,550 for family
coverage (up from $3,250 and $6,450
in 2013). People 55 and older can
make an additional $1,000 “catch-up”
contribution. Limits are the same
regardless of the source.
Q. Can I take the money out of my
HSA any time I want?
A. Yes. You can take money out anytime
tax-free and without penalty as long
as it’s to pay for qualified medical
expenses. If you take money out for
other purposes, you’ll pay income
taxes plus a 20% penalty.
Q. Can I use the money in my
HSA to pay for my children’s
medical expenses?
A. Yes. Your HSA can be used to pay the
qualified medical expenses of any
family member who qualifies as a
dependent on your tax return. If the
dependent isn’t on your health plan,
his/her expenses won’t apply to
your deductible.
Q. Can I access my HSA online?
A. Yes. Simply visit your member portal
or www.myhealthequity.com.
www.healthequity.com
866.346.5800
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Requires that your health plan be integrated with HealthEquity.
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Investment options and balance thresholds required to invest vary and are subject to change.
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2006 claims data from insurer with more than 700,000 lives.
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HE HSA1P 20120601/1
BluePrint® - 2015 Premium Dental Plan
Benefit
Calendar Year Benefit Maximum
$2,000
Per individual.
Lifetime Orthodontic Benefit Maximum
1
$1,500
Maximum is per individual.
Deductible
The amount an individual or family must pay each calendar year before payments begin for services
Single
$50
Family
$100
Preventive Services
Oral Exams, Cleanings, X-rays (Bitewing- 1 every six months, Full Mouth- 1 every 60 months), Sealants (up to age 19),
Fluoride (up to age 19).
100%
Basic Restorative Services
Periodontal Services, Periodontal Cleanings, Endodontic Services, Root Canals, Pulp Capping, Sedative Fillings, Composite
Fillings, Amalgam Fillings, Crown Repairs, Denture Adjustments, Dental Reline, Bridge Repairs, Dental Anesthesia, Simple
Extractions, Palliative Treatment.
Major Restorative Services
80%; after
deductible
1
Inlay/Onlay Restoration, Implants, Stainless Steel Crown, Bridgework, Crowns, Dentures, Partial Dentures, Temporary
Crowns.
50%; after
deductible
These pages summarize the benefits of your dental care plan. Your Summary Plan Description defines the full terms and conditions in greater detail. Should any
Questions: Please Call CBA Blue at 1-888-222-9206. For more information about CBA Blue, visit
www.cbabluevt.com.
BluePrint® - 2015 Quality Dental Plan
Benefit
Calendar Year Benefit Maximum
$750
Per individual.
Not Covered
Lifetime Orthodontic Benefit Maximum
Deductible
Single
$50
Preventive Services
Family
$150
100%
Oral Exams, Cleanings, X-rays (Bitewing- 1 every six months, Full Mouth- 1 every 60 months), Sealants (up to age 19),
Fluoride (up to age 19).
Basic Restorative Services
Periodontal Services, Periodontal Cleanings, Endodontic Services, Root Canals, Pulp Capping, Sedative Fillings, Composite
Fillings, Amalgam Fillings, Crown Repairs, Denture Adjustments, Denture Reline, Bridge Repairs, Dental Anesthesia, Simple
Extractions, Palliative Treatment.
Major Restorative Services
80%;after
deductible
Not Covered
Inlay/Onlay Restoration, Stainless Steel Crown, Bridgework, Crowns, Dentures, Partial Dentures, Temporary Crowns.
These pages summarize the benefits of your dental care plan. Your Summary Plan Description defines the full terms and conditions in greater detail. Should any
Questions: Please Call CBA Blue at 1-888-222-9206. For more information about CBA Blue, visit
www.cbabluevt.com.
Plan Sponsor: National DCP, LLC
Plan Year: Jan. 1‐ Dec. 31
Benefits Covered: Medical, Prescription RX
Revision Date: 12/1/2014
BluePrint™ National DCP, LLC MEC Plan
National DCP, LLC Employee Benefit Plan
Summary of Benefits Effective January 1, 2015
BlueCard®1
BENEFIT CATEGORY
Coinsurance
PREVENTIVE HEALTH SERVICES ADULTS/CHILDREN2
Plan
Member
100%
0%
BlueCard® (You Pay)
•
•
Routine physical examinations
Alcohol misuse screening and counseling (primary
care visits only, beginning at age 11)
•
Cholesterol screening
•
Depression screening (adults, children ages 12‐18,
primary care visits only)
•
Diet behavioral counseling (included as part of
annual visit and intensive counseling by primary
care clinicians or by nutritionists and dieticians)
•
Hemoglobin A1c
•
Hepatitis B testing
•
Immunizations, including flu shots (flu shots at age
19 and above at a doctor’s office or pharmacy;
under age 19 at a doctor’s office)3
•
Obesity screening and counseling (adults and
children, in primary care settings)
•
Sexually transmitted diseases (STDs) – screenings
and counseling (adolescents, adults and pregnant
women)
•
Tobacco use screening and counseling (primary care
visits only)
•
Total cholesterol tests
PREVENTIVE HEALTH SERVICES ADULTS ONLY2
$0
•
Aspirin for the prevention of heart disease (no
coverage for over‐the-counter aspirin)3
•
Blood pressure screening (adults without known
hypertension)
•
Colorectal cancer screening, including colonoscopy,
sigmoidoscopy and fecal occult blood test
•
Diabetes screenings
•
HIV screening and counseling
PREVENTIVE HEALTH SERVICES WOMEN ONLY2
•
•
•
•
•
Breast cancer chemoprevention (counseling only for
women at high risk for breast cancer and low risk
for adverse effects of chemoprevention)
Breast cancer screening, including mammograms
and counseling for genetic susceptibility screening
Breastfeeding primary care interventions (applicable
to pregnant women and new mothers) includes
lactation classes and support at prenatal and
post‐partum visits, and newborn visits; supplies
Cervical cancer screening, including pap smears
Comprehensive lactation support, counseling, and
costs of renting breastfeeding equipment
$0
$0
CBA Blue is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Trademarks of the Blue Cross and Blue Shield
Association.
12/17/2013
PREVENTIVE HEALTH SERVICES WOMEN ONLY2
•
•
•
•
•
•
•
•
•
•
•
•
Contraceptive methods approved by the FDA,
sterilization procedures and contraceptive patient
education and counseling (contraceptives covered
with no member cost sharing include generics and
brand name drugs with no generic alternative,
including emergency contraceptives.)3
Folic acid supplements (women planning or capable
of pregnancy only)3
Gestational diabetes screening
HPV (human papillomavirus) testing
Interpersonal and domestic violence counseling and
screenings
Iron deficiency anemia (pregnant women at prenatal
visits)
Microalbuminuria test (pregnant women)
Osteoporosis screening (screening to begin at age
50 for women at increased risk)
Ovarian cancer susceptibility screening
Rh (D) incompatibility, screening (pregnant women)
Routine OB/GYN examinations
Routine outpatient prenatal and postpartum visits
PREVENTIVE HEALTH SERVICES MEN ONLY2
•
Abdominal aortic aneurysm screening (for males
65‐75 one time only, if ever smoked)
PREVENTIVE HEALTH SERVICES CHILDREN ONLY2
•
•
•
•
•
•
•
•
•
•
•
•
Autism screening (for children at 18 and 24 months
of age; primary care settings)
Behavioral assessments (children of all ages;
developmental surveillance, in primary care
settings)
Congenital hypothyroidism (screening for newborns
only)
Dental caries prevention – oral fluoride (for children
to age 5 only) Note: Coverage for fluoride is only
provided if your plan includes outpatient pharmacy
coverage3
Dyslipidemia screening (for children at high risk for
higher lipid levels)
Hearing screening (screening for newborn only,
primary care settings)
Iron deficiency prevention (primary care counseling
for children ages 6 to 12 months only)
Lead screening (children at risk)
Phenylketonuria screening (newborns before 7days
old)
Sickle cell disease, screening (screening at birth and
first newborn visit)
Tuberculosis skin testing
Vision screening (children to age 5 only)
$0
$0
$0
Association.
12/1/2014
Important Additional Information:
1
The National DCP, LLC MEC Medical Plan requires the use of the BlueCard Provider Network. In most cases,
utlization of these providers will enable you to receive benefits available under the plan. To verify that your
physician(s) participate in the BlueCard® Network, you may view an electronic directory by visiting
www.cbabluevt.com. From the members page, click on “Search the National BlueCard® Network”. You may also call
the BlueCard Program at 1-800-810-BLUE(2583), 24 hours a day, seven days a week for assistance.
2
The list of preventive care services covered under this benefit plan may change periodically based upon the
recommendation of the United States Preventive Services Task Force, the Advisory Committee on Immunization
Practices of the Centers for Disease Control and Prevention, and the Health Resources and Services
Administration. Information on the recommendations of these agencies can be found at:
https://www.healthcare.gov/what-are-my-preventive-care-benefits/
3
Certain covered services are made available to you through a Prescription Drug Program which provides you
access to a retail pharmacy network managed by Benecard. To locate a network pharmacy or access the
prescription formulary, go to www.benecardpbf.com.
Questions:
Member Services
No Matter which method of contact you prefer, you’ll be able to locate plan coverage details, find answers to
your questions and more:
Call Us
1.888.222.9206
Monday through Friday
8 am – 7pm ET
On-line
At www.cbabluevt.com, you will find links to all of the resources your plan has to offer. You may also selfregister for secure access to your plan details, view claims status and EOBs, and more.
***These Pages Summarize The Benefits Of Your Health Care Plan. Your Summary Plan Description Defines The Full Terms &
Conditions In Greater Detail. Should Any Questions Arise Concerning Benefits; The Summary Plan Description Shall Govern. ***
Association.
12/1/2014
Step Therapy Program
Step Therapy is a program designed to encourage utilization of low cost generic medication.
Step therapy is a series of steps (i.e. medications) you must try for a new condition in a specific
order, starting with the generic when available.
Exclusions
Your prescription program covers most Medically Necessary, Federal Legend, State Restricted
and Compounded Medications which by law may not be dispensed without a prescription.
Your program does not cover:
x Medications which do not require a prescription order, even if one is written
x Medications which are not considered medically necessary
x Medications which are considered “off-label use” as they are not prescribed in accordance
with FDA-approved utilization or are prescribed or dispensed in a manner contrary to normal
medical practices
x Medications administered by a physician or prescriber and those not dispensed at a
pharmacy, including medications you receive at your doctor’s office, in a hospital, clinic or
other care facility
x Medications for which the cost is recoverable under a government program, Workers’
Compensation, occupational disease law, or medications for which no charge is made to you
x Immunologicals, vaccines, allergy sera, biological sera, blood plasma and charges for the
administration or injection of medications
x Any drug labeled for “Investigational Use” or as experimental
x Drugs prescribed for cosmetic purposes
x Hair loss medications
x Vaginal contraceptives
x Legend vitamins, except for children’s and prenatal vitamins
x Needles, syringes and injection devices, except with insulin
x Male sexual dysfunction drugs are covered with restrictions
Be sure to present your BeneCard PBF ID card at a participating network pharmacy to receive a
discount off the retail price of medications that may not be covered.
BeneCard PBF logo is a mark of Benecard Services, Inc.
Effective Date: January 1, 2013
National DCP LLC, Client No. 10025 Groups
50625MP1D001 through 50625MP9F001
National DCP, LLC Prescription Drug Plan
Your Prescription Benefit Program
You are responsible to pay the retail pharmacist the co-payment per prescription according to
your medical plan.
Retail quantities will be dispensed according to your physician’s instruction written on the
prescription up to a maximum of a 34-day supply.
Please Note: If the cost of your medication is less than your calculated co-payment you will only
pay the cost of the medication.
Mail Order Co-payment
Maintenance medications can be submitted to Benecard Central Fill, the mail order facility. Your
plan allows for up to a 90-day supply with 3 refills, according to your physicians instructions.
Your co-pay amount will be twice the 30-day co-payment.
Preventive Drugs
The following drugs are covered through your prescription benefit plan at a $0 copayment.
Drug Category
Contraceptives
Aspirin for Men
Aspirin for Women
Folic Acid Supplement
Iron Supplements for Infants
Gonorrhea (Newborn Eye
Drops)
Fluoride Chemoprevention
Supplements
Age Limits
\HDUVROG
45--79 years old
55--79 years old
10--55 years old
6--12 months
old
0--7 days old
7 months--6
years old
Preferred Medication Program
The Preferred Medication List is a guide for selecting clinically and therapeutically appropriate
medications. It should not take the place of a physician’s or pharmacist’s judgment with regard
to a patient’s pharmaceutical care. Refer to www.benecardpbf.com for the most recent version
of the Preferred Medication List.