Benefits At A Glance Independence Choice

Transcription

1 Benefits At A Glance Independence Choice Plan Year 2017 This information is intended to provide only an overview of the major features of Insperity s employee benefits programs. Full details are contained in the summary plan descriptions, plan documents and insurance contracts that govern each plan or program. Summary plan descriptions and plan documents are available online through the Insperity Employee Portal. They are also available upon request. Should there be a discrepancy or conflict between the information presented here and the actual plan documents and insurance contracts, the plan documents and insurance contracts will govern. Insperity reserves the right to amend or discontinue any plan or program at any time at its sole discretion. In no event should the benefits provided by Insperity be interpreted as a guarantee of continued employment. 32 Independence Choice

2 2016 Insperity. All rights reserved. Questions? Call Insperity: (hearing/speech-impaired: TRS dial 711) INDEPENDENCE Rev

3 2016 Insperity. All rights reserved. Questions? Call Insperity: (hearing/speech-impaired: TRS dial 711) INDEPENDENCE Rev

4 MEDICAL (participant costs for non-preventive care services 1 ) Participant costs when covered services received from IN-NETWORK providers. Participant costs when covered services received from OUT-OF-NETWORK providers. Not all options provide out-of-network benefits. Medical Calendar-Year Deductible This is the amount you owe for certain covered health care services before the plan begins to pay. Not all covered services require this deductible to be met. Medical + Pharmacy Combined Annual Out-of-Pocket Max. (unless otherwise noted) This is the most you must pay out of your own pocket during the calendar-year policy period before the plan begins to pay 100% of eligible expenses for covered services. INDIVIDUAL FAMILY INDIVIDUAL FAMILY Coinsurance Where a copay applies, coinsurance generally will not apply. PLAN PAYS YOU PAY THE LEGEND BELOW APPLIES ONLY IN THIS SECTION $ = Participant Copay % = Participant-paid Coinsurance after deductible is satisfied Physician Office Visit 1 Specialist Office Visit 1 Outpatient Surgery Inpatient Hospitalization Urgent Care Centers Emergency Room PHARMACY IMPORTANT: Pharmacy copays, deductibles and/or coinsurance generally APPLY towards the combined medical + pharmacy annual out-of-pocket maximum, unless otherwise noted. PER INDIVIDUAL Calendar-yr. Deductible Prescription (Rx) Copays Rx copays apply ONLY after satisfying pharmacy deductible (or HDHP medical deductible), where applicable. RETAIL COPAY TIERS MAIL ORDER COPAY TIERS NATIONWIDE Coverage options listed in this section are generally available to eligible employees nationwide, unless a state-specific set of options are listed. Choice Plus $500 $1,500 $5,000 $10,000 80% 20% $30 $60 20% 20% $50 $1,000 $3,000 $10,000 $20,000 60% 40% 40% 40% 40% 40% 40% Choice Plus $1,000 $3,000 $4,000 $8,000 80% 20% $30 $60 20% 20% $50 $2,000 $6,000 $8,000 $16,000 60% 40% 40% 40% 40% 40% 40% Choice Plus $1,500 $4,500 $6,350 $12,700 80% 20% $30 $60 20% 20% $50 $3,000 $9,000 $12,700 $25,400 60% 40% 40% 40% 40% 40% 40% Choice Plus $2,500 $7,500 $6,350 $12,700 70% 30% $35 $70 30% 30% $50 $5,000 $15,000 $12,700 $25,400 50% 50% 50% 50% 50% 50% 50% Choice Plus $6,000 $13,200 $6,600 $13, % 0% $35 $70 0% 0% $50 $12,000 $16,400 $13,200 $26,400 70% 30% 30% 30% 30% 30% 30% $500 ($600 UHC Choice Plus HDHP , A $1,500 $3,000 $3,425 $6,850 90% 10% 10% 10% 10% 10% 10% $3,000 $6,000 $6,850 $13,700 70% 30% 30% 30% 30% 30% 30% 10% UHC Choice Plus HDHP $3,000 $6,000 $6,350 $12,700 90% 10% 10% 10% 10% 10% 10% $6,000 $12,000 $12,700 $25,400 70% 30% 30% 30% 30% 30% 30% 10% UHC Choice Plus HDHP $5,000 $10,000 $6,350 $12,700 80% 20% 20% 20% 20% 20% 20% $10,000 $20,000 $12,700 $25,400 60% 40% 40% 40% 40% 40% 40% 20% CALIFORNIA Eligible California employees may choose from the UHC options listed above under Nationwide OR from those listed in this California section. UHC of California Signature Value HMO 3 None None $3,000 $6, % 0% $25 $50 $125 $250 $10 $30 $50 Specialty RX 30% (Max ) $25 $75 $125 BCA Blue Shield of California HMO 3 None None $3,000 $6, % 0% $25 $50 $150 $500 $10 $25 $40 Specialty RX 30% (Max ) $20 $50 $70 BCA Blue Shield of California Deductible HMO $1,000 $2,000 $6,050 $12,100 90% 10% $35 $50 10% 10% 10% for certain drugs $10 $30 N/A Specialty RX 30% (Max ) $20 $60 N/A KPC Kaiser Permanente HMO 3 None None $3,000 $6, % 0% $25 $50 $250 $10 $30 N/A Specialty RX 30% (Max $150) $20 $60 N/A 2016 Insperity. All rights reserved. Questions? Call Insperity: (hearing/speech-impaired: TRS dial 711) CHOICE Rev

5 MEDICAL (participant costs for non-preventive care services 1 ) Participant costs when covered services received from IN-NETWORK providers. Participant costs when covered services received from OUT-OF-NETWORK providers. Not all options provide out-of-network benefits. Medical Calendar-Year Deductible This is the amount you owe for certain covered health care services before the plan begins to pay. Not all covered services require this deductible to be met. Medical + Pharmacy Combined Annual Out-of-Pocket Max. (unless otherwise noted) This is the most you must pay out of your own pocket during the calendar-year policy period before the plan begins to pay 100% of eligible expenses for covered services. INDIVIDUAL FAMILY INDIVIDUAL FAMILY Coinsurance Where a copay applies, coinsurance generally will not apply. PLAN PAYS YOU PAY THE LEGEND BELOW APPLIES ONLY IN THIS SECTION $ = Participant Copay % = Participant-paid Coinsurance after deductible is satisfied Physician Office Visit 1 Specialist Office Visit 1 Outpatient Surgery Inpatient Hospitalization Urgent Care Centers Emergency Room PHARMACY IMPORTANT: Pharmacy copays, deductibles and/or coinsurance generally APPLY towards the combined medical + pharmacy annual out-of-pocket maximum, unless otherwise noted. PER INDIVIDUAL Calendar-yr. Deductible Prescription (Rx) Copays Rx copays apply ONLY after satisfying pharmacy deductible (or HDHP medical deductible), where applicable. RETAIL COPAY TIERS MAIL ORDER COPAY TIERS CALIFORNIA continued Eligible California employees may choose from the UHC options listed above under Nationwide OR from those listed in this California section. KPC Kaiser Permanente Deductible HMO $1,000 $2,000 $6,050 $12,100 70% 30% $35 $50 30% 30% 30% per member for certain drugs $10 $30 N/A Specialty RX 30% (Max $150) $20 $60 N/A KPC Kaiser Perm. HMO HDHP $2,600 $5,200 $5,200 $10,400 90% 10% 10% 10% 10% 10% 10% 10% $10 $30 N/A Specialty RX 30% (Max $150) $20 $60 N/A MASSACHUSETTS Coverage options listed in this section are available ONLY to eligible employees who live in Massachusetts. THP Tufts CareLink Advantage PPO $500 $1,500 $5,000 $10,000 80% 20% $30 $30 20% 20% $1,000 $3,000 $10,000 $20,000 60% 40% 20% 20% 40% 40% 40% THP Tufts CareLink Advantage PPO $1,000 $3,000 $4,000 $8,000 80% 20% $30 $30 20% 20% $2,000 $6,000 $8,000 $16,000 60% 40% 20% 20% 40% 40% 40% THP Tufts CareLink Advantage PPO $1,500 $4,000 $6,350 $12,700 80% 20% $30 $30 20% 20% $3,000 $8,000 $10,000 $20,000 60% 40% 20% 20% 40% 40% 40% THP Tufts CareLink Advantage Saver PPO HDHP , A Combined In- & Out-of-Network 90% 10% 10% 10% 10% 10% 10% $1,500 $3,000 $3,425 $6,850 70% 30% 30% 30% 30% 30% 30% 10% THP Tufts CareLink Advantage Saver PPO HDHP , A Combined In- & Out-of-Network 90% 10% 10% 10% 10% 10% 10% $3,000 $6,000 $3,425 $6,850 70% 30% 30% 30% 30% 30% 30% 10% THP Tufts Value HMO 3 None None $3,000 $6, % 0% $20 $35 $250 $10 $30 $45 $20 $60 $90 THP Tufts Advantage Deductible HMO $1,000 $2,000 $5,000 $10, % 0% $20 $35 0% 0% $15 $30 $50 $30 $60 THP Tufts Advantage Deductible HMO $2,000 $4,000 $6,350 $12, % 0% $25 $40 0% 0% $15 $30 $50 $30 $60 THP Tufts Adv. Saver HMO HDHP , A THP Tufts Adv. Saver HMO HDHP , A $1,500 $3,000 $3,425 $6,850 90% 10% 10% 10% 10% 10% 10% 10% $3,000 $6,000 $3,425 $6,850 65% 35% 35% 35% 35% 35% 35% 35% $15 $30 $50 $30 $60 $ Insperity. All rights reserved. Questions? Call Insperity: (hearing/speech-impaired: TRS dial 711) CHOICE Rev

6 HAWAII Coverage options listed in this section are available ONLY to eligible employees who live in Hawaii. BHI HMSA BCBS of Hawaii HMO 3 None None Medical- Only $2,500 4 Medical- Only $7, % 10% $20 $20 10% 10% N/A $7 $30 $30 + $45 Specialty Rx $11 $65 $65 + $135 Pharmacy-ONLY Annual Out-of-Pocket Max. 4 Individual: $3,600 Family: $4,200 KPC Kaiser Permanente HMO 3 None None $2,000 $6, % 0% $20 $20 $20 $50 per day $50 N/A $5 $20 Not covered $10 $40 Not covered UHC Options PPO 2 Combined In- & Out-of-Network 90% 10% 10% 10% 10% 10% 10% $300 $2,500 $7,500 70% 30% 30% 30% 30% 30% 30% 10% N/A $10 $15 $30 $20 $30 $60 OUT-OF AREA Indemnity options available ONLY to eligible employees who live in a ZIP code service area NOT served by a carrier network contracted with the Insperity Group Health Plan. No network limitations apply. PP1 Out-of-Area 500 $500 $1,500 $6,350 $12,700 80% 20% 20% 20% 20% 20% 20% 20% UHC PP1 Out-of-Area HDHP 1500 A UHC PP1 Out-of-Area HDHP 3000 UHC PP1 Out-of-Area HDHP 5000 $1,500 $3,000 $3,425 $6,850 80% 20% 20% 20% 20% 20% 20% 20% $3,000 $6,000 $6,350 $12,700 80% 20% 20% 20% 20% 20% 20% 20% $5,000 $10,000 $6,350 $12,700 80% 20% 20% 20% 20% 20% 20% 20% Denotes a high deductible health plan (HDHP)-type coverage option, which offers NO coverage (other than certain preventive care) until the applicable deductible is met. All Insperity HDHP-type coverage options are HSA-eligible. With HDHP coverage, Rx copays apply only after the applicable HDHP medical calendar-year deductible is met. As a result, HDHP coverage options generally do not have a separate pharmacy deductible. (See also the HDHP explanation on the next page.) 1 In-network office visits for preventive care services (as defined in the Certificate of Coverage that applies to a specific Insperity coverage option) are paid at 100% and not subject to any deductible, coinsurance or copay. Applies to all Insperity coverage options. 2 Choice Plus and PPO-type coverage options provide BOTH in- and out-of-network benefits. 3 HMO-type coverage options provide ONLY in-network benefits, and generally require participants to designate a Primary Care Physician (PCP). 4 For the HMSA BlueCross BlueShield of Hawaii HMO coverage option only, a pharmacy-only annual out-of-pocket maximum applies, which must be met separately from the medical-only annual out-of-pocket maximum before the plan will begin paying 100% of eligible pharmacy expenses. No participant out-of-pocket pharmacy expenses will apply towards the medical-only annual out-of-pocket maximum. A Denotes a high deductible health plan (HDHP) coverage option that has aggregate (non-embedded) deductibles and out-of-pocket maximums (OOPMs). For family coverage under the aggregate design, the entire family calendar-year deductible must be met before copays or coinsurance will apply for any individual family member. Only after the full family deductible is met will any family member be able to receive covered medical services or prescription drugs at copay or coinsurance levels. A family is responsible for all its members out-of-pocket covered medical expenses up to the family-level OOPM. In contrast, all other Insperity coverage options have embedded calendar-year deductibles and OOPMs. For family coverage under the embedded design, each covered family member needs to satisfy only an individual calendar-year deductible, not the entire family deductible, before the individual member can receive covered medical services or prescription drugs at copay or coinsurance levels. Individual family members are responsible for their own out-of-pocket covered medical expenses up to the individual-level OOPM. Combined individual out-of-pocket covered medical expenses for a family will never exceed the family-level OOPM Insperity. All rights reserved. Questions? Call Insperity: (hearing/speech-impaired: TRS dial 711) CHOICE Rev

7 WHAT YOU NEED TO KNOW About Group Health Plan Coverage IMPORTANT: Insperity provides Benefits At A Glance summaries solely for the education and convenience of employees and clients. Any Insperity-branded benefits summary is intended ONLY as a brief, general overview. Actual Insperity benefits are subject to the provisions and limitations of the agreements between Insperity and its insurance carriers. In the event of a conflict between the information in an Insperity-branded benefits summary and the applicable Certificate of Coverage (COC), the COC will be the controlling document. General Group Health Plan Rules In-network office visits for preventive care services (as defined in the Certificate of Coverage that applies to a specific Insperity coverage option) are paid at 100%, and are not subject to any deductible, coinsurance or copay. Applies to all Insperity options. A participant s medical calendar-year deductibles, copays and coinsurance generally apply towards satisfying the annual out-of-pocket maximum. (Certain exceptions may apply. For more information, please refer to the Certificate of Coverage that applies to your coverage option.) Except as otherwise noted for certain HDHP-type coverage options, all Insperity coverage options generally have embedded calendar-year deductibles and out-of-pocket maximums (OOPMs). For family coverage under the embedded design, each covered family member needs to satisfy only an individual calendar-year deductible, not the entire family deductible, before the individual member can receive covered medical services or prescription drugs at copay or coinsurance levels. Individual family members are responsible for their own out-of-pocket covered medical expenses up to the individual-level OOPM. Combined individual out-of-pocket covered medical expenses for a family will never exceed the family-level OOPM. Certain group health plan coverage options (at the discretion of the health insurance carrier) require all covered individuals to designate a Primary Care Physician (PCP) who has responsibility for coordinating all of the covered individual s care. Generally, whenever a medical copay applies, coinsurance will generally not apply, and the participant is not required to first satisfy any applicable medical calendar-year deductible. Coinsurance (where applicable) applies after the participant satisfies any applicable calendar-year deductible. Also, coinsurance generally will not apply where a copay applies. Generally, when services are received for mental health / substance abuse disorder services, the Physician Office Visit copay (and not the Specialist Office Visit copay) will apply. Where applicable, in addition to any Outpatient Surgery copay, physician services received are subject to the associated medical calendar-year deductible and/or coinsurance. In some instances, hospital precertification may be required for full benefits to be paid. This means you or your physician must call the toll-free number on your medical ID card at least 14 days before any hospital stay. In an emergency, you must call within 24 hours or 48 hours (as required by your specific insurance carrier) from the time you are hospitalized. If your admission is not pre-certified as specified by your insurance carrier, your benefits will be reduced. While most mail-order pharmacy programs provide a 90-day supply of maintenance medications, Kaiser Permanente provides a 100-day supply. For each coverage option available to you, specific limitations and exclusions may apply, as outlined in the option s Certificate of Coverage. Participant Responsibilities & Obligations Certain health services have notification requirements and limitations that may vary based upon coverage option, insurance provider or state mandate. It is your responsibility as a Plan participant to confirm that the services you plan to receive are covered health services and to determine what precertification and/or notification requirement or limitations may apply. Additional Key Points to Remember The benefits package you are offered is determined by your client company s selection when it contracts with Insperity. Each Insperity package that includes health benefits generally offers a selection of medical coverage options to meet your needs. The availability of certain coverage options depends on the benefits package available to you, where you live and the insurance carrier under which you elect coverage. Not all coverage options and insurance carriers under the Insperity Group Health Plan are available in all areas of the country. Your ZIP code service area determines the available coverage options. To participate in an Insperity coverage option, an eligible employee must live in a ZIP code service area that is included in that option s network. ZIP codes associated with an insurance carrier s network service areas are determined by the insurance carrier (not Insperity) and are specific to the health insurance product offerings defined in the carrier s contract with Insperity. To confirm which coverage option(s) are available to you, please call Insperity at weekdays from 7 a.m. to 7 p.m. Central time. Availability of Out-of-Area (Indemnity) Coverage An Out-of-Area (Indemnity) option is associated with certain Insperity coverage options. Where offered, the Indemnity option is available ONLY to eligible employees who live in a ZIP code service area NOT served by any Insperity insurance carrier s network. If you enroll in an option for which no network is available in your ZIP code service area, you automatically will be enrolled in the appropriate Indemnity option, IF one is offered in your ZIP code service area. In some instances, it may be possible to request enrollment in the nearest network, even though you do not live within its network service area. To receive in-network benefits in such instances, you must be willing to travel to in-network providers. Reimbursement of Out-of-Network Services (if offered) If your elected coverage option pays benefits for services received from out-of-network providers, your financial responsibility will likely be much greater if you DO receive services from an out-of-network provider rather than from an in-network provider. It is important to understand how your specific insurance carrier reimburses for non-network services. For example, UnitedHealthcare (UHC) Choice Plus and Options PPO coverage options pay benefits for non-emergency, non-network services after the deductible and on the basis of an Eligible Expense methodology defined by UHC in its Benefits Descriptions. On the other hand, Tufts PPO coverage options reimburse for covered services received from non-network providers up to the reasonable charge, which is defined as the amount the provider charges, or the amount that Tufts Health Plan determines to be reasonable, based upon nationally accepted methods and amounts of claims payment whichever is less. It is the participant s responsibility to pay any cost difference between what the non-network provider charges and what the Plan covers (i.e., what the insurance carrier pays). In addition, the cost difference, which could be substantial depending on the cost of the care received, does not apply to the out-of-pocket maximum. UnitedHealthcare coverage options only: Any services received from out-of-network providers (e.g., radiology, anesthesiology, pathology or laboratory) while a participant is being treated within an in-network facility may be subject to additional charges beyond the participant s financial responsibility for in-network charges. High Deductible Health Plan (HDHP) Coverage Options It is important to understand how an HDHP-type coverage option works and weigh carefully your health care needs before electing this type of coverage option. HDHP-type options generally do not allow for any medical expenses to be covered (other than for certain preventive care) until the applicable calendar-year deductible is met. All medical and pharmacy expenses apply toward the applicable calendaryear deductible and out-of-pocket maximum (OOPM). The full cost of these expenses are the participant s responsibility until the full applicable medical calendar-year deductible is met. Certain Insperity HDHP coverage options (marked with an A in the charts on the preceding pages) have aggregate (non-embedded) deductibles and OOPMs. For family coverage under the aggregate design, the entire family calendar-year deductible must be met before copays or coinsurance will apply for any individual family member. Only after the full family deductible is met will any family member be able to receive covered medical services or prescription drugs at copay or coinsurance levels. A family is responsible for all its members out-of-pocket covered medical expenses up to the family-level OOPM. In contrast, all other Insperity HDHP coverage options have embedded deductibles and OOPMs. For family coverage under the embedded design, each covered family member needs to satisfy only an individual calendar-year deductible, not the entire family deductible, before the individual member can receive covered medical services or prescription drugs at copay or coinsurance levels. Individual family members are responsible for their own out-of-pocket covered medical expenses up to the individual-level OOPM. Combined individual out-of-pocket covered medical expenses for a family will never exceed the family-level OOPM. All Insperity HDHP coverage options are HSA-qualified and meet IRS rules for an individual to establish a tax-advantaged personal health savings account (HSA). Visit esc.insperity.com for details. Questions? You can find detailed group health plan information online at esc.insperity.com. Or you may contact Insperity by phone at (weekdays 7 a.m. to 7 p.m. Central time) or by at contactcenter@insperity.com Insperity. All rights reserved. Rev

8 BENEFITS AT A GLANCE Dental Benefits Plan Year 2017 Insperity dental benefits are generally available to eligible employees nationwide, provided that dental coverage is included in the Insperity benefits package available to the employee. Insperity s dental benefits cover a wide range of dental procedures, including preventive and diagnostic services, basic (restorative) services, major (prosthodontic) services, and orthodontia services. There are some limitations to frequency of preventive, basic and major services per member, per year. Coverage is provided through UnitedHealthcare Dental. With Insperity dental benefits, you may use any dentist you choose. However, costs are generally lower when you use in-network providers. Dental Insurance Carrier UnitedHealthcare (UHC) myuhc.com Dental Provider Network The Insperity UnitedHealthcare Dental Provider Network is National Options PPO 30. Dental ID Card When In-Network Provider(s) Are Used When Non-Network Provider(s) Are Used Issued and mailed to the participant s home address by UnitedHealthcare. Claims for benefits are paid at negotiated rates, and coinsurance limits will also be based on these lower fees. Additionally, participants are not balance-billed for any fees over the negotiated rates. There is no reduction in benefits. Benefits will be paid at reasonable and customary (R&C) levels, which are determined from the prevailing charge for a service made by providers within the same geographic area where the service is rendered. The participant is responsible for 100% of any charges above R&C limits, subject to any limitations and a combined annual maximum benefit of $1,500 per person. Calendar-Year Deductibles INDIVIDUAL: $50 FAMILY: Maximum of 3x the Individual Deductible per family (up to $150) Calendar-Year Benefit Maximum $1,500 per person IMPORTANT: Certain dental procedures and services (as outlined below under Type of Dental Service ) may have limitations based on frequency per calendar year or other defined time interval, or age of covered participant, etc. For example (effective Jan. 1, 2013), orthodontia services will no longer apply to adults; coverage will be provided only for covered dependent children until the age of 19. Coverage Limitations It is the participant s responsibility to confirm that the services he or she plans to receive are covered dental services and to determine what limitations may apply by reviewing the Dental Certificate of Coverage (available online in the Insperity Employee Service Center TM (esc.insperity.com) under Benefits, or by contacting UnitedHealthcare Dental directly at Listed here are a couple of representative examples of some of the possible limitations that may apply: Scaling and root planning are limited to one time per quadrant per 24 months. No coverage for orthognathic surgery, jaw alignment or treatment for temporomandibular joint (TMJ). Additional limitations may be associated with the services described below. Complete details are available in the Dental Certificate of Coverage. Reimbursement of Claims Your dentist may file a claim on your behalf. If not, you pay the cost of the service when you receive it and then file a claim for reimbursement. Claim forms are available online in the Employee Service Center at esc.insperity.com, or they may be obtained by calling Insperity toll free at Type of Dental Service Preventive & Diagnostic Basic (Restorative) Major (Prosthodontic) Orthodontic What the Plan Pays 100% Deductible Waived 80% After Deductible 50% After Deductible 50% Deductible Waived Example Covered Procedures Routine Oral Exams Prophylaxis (Cleaning) Topical Application of Fluoride Diagnostic Cast Bite-Wing Dental X-rays Sealants Space Maintainers Simple Extraction Fillings Oral Surgery Palliative Emergency Treatment Apicoectomy Occlusal Guards Periodontic Services Root Canal Therapy Therapeutic Pulpotomy Inlays Crowns Bridges Dentures Denture Rebase or Reline Repair of Removable Dentures Re-cement Crowns & Bridges Repair to Fixed Bridges For dependent children only, until age 19. Including Braces, Retainers & Other Appliances That Correct Misalignments Some limitations apply. Orthodontia Lifetime Maximum... $1,500 Actual benefits are subject to the provisions and limitations of the agreements between Insperity and its benefit providers. In the event of a conflict between the information in this schedule and the Certificate of Coverage, the Certificate of Coverage will be the controlling document Insperity. All rights reserved. DENTAL

9 BENEFITS AT A GLANCE Vision Benefits Plan Year 2017 Insperity vision benefits are generally available to eligible employees nationwide, providing that vision coverage is included in the Insperity benefits package available to the employee. Vision Insurance Carrier Using Your Vision Benefits When In-Network Provider(s) Are Used When Non-Network Provider(s) Are Used Vision Service Plan (VSP) Provider Network: VSP Choice NO ID card is issued or required to visit a VSP network doctor. Simply call a VSP network doctor to schedule an appointment. Be sure to tell the doctor you are a VSP member when making your appointment. The doctor and VSP handle the rest. You may use any optometrist, ophthalmologist or optician you choose. However, you ll realize greater benefits when you use providers who participate in the VSP provider network. In most cases, the program pays 100% of most eligible vision expenses after you pay the required copay. The provider will file your claims for you. To receive reimbursement at the in-network level, please ensure you are set up in VSP s system before receiving services from a VSP provider. You pay the full cost of vision care services and supplies when you receive them. You must then file a claim within six months from the date services were received in order to be reimbursed for eligible expenses, up to the program s benefit allowance. Find a VSP Provider Log in to vsp.com via the Insperity Employee Service Center (esc.insperity.com), or call VSP at What s Covered WellVision Exam (routine) One exam every 12 months from your last date. Includes tests necessary to evaluate / monitor visual wellness. If you wear contact lenses, a separate contact lens exam (fitting and evaluation) is necessary. Please see Contact Lenses below for coverage details. WHEN YOU USE IN-NETWORK PROVIDERS You pay The Plan pays: WHEN YOU USE NON- NETWORK PROVIDERS You pay The Plan pays: $15 copay 100% $15 copay Up to $45 Glasses (Lenses & Frames) Lenses: The chart at right explains how lenses are covered. Frames: Your coverage provides an allowance of up to $130 for frame of your choice. This allowance provides coverage for a wide selection of frames. Your VSP benefit provides guaranteed savings whether you choose a frame that is covered in full or one that exceeds the Plan s allowance. If you choose a frame through a network provider valued at more than the Plan s allowance, you will receive a 20% discount on the amount over your allowance. Your doctor can help you choose the best frame for you based on your needs. * Up to $130. Single Vision Lenses: $25 copay 100% Lined Bifocal Lenses: $25 copay 100% Lined Trifocal Lenses: $25 copay 100% Lenticular Lenses: $25 copay 100% Frames (every 24 months): $25 copay 100% * Single-Vision Lenses: $25 copay Up to $30 Lined Bifocal Lenses: $25 copay Up to $50 Lined Trifocal Lenses: $25 copay Up to $65 Lenticular Lenses: $25 copay Up to Frames (every 24 months): $25 copay Up to $70 IMPORTANT: You may receive a benefit for glasses (lenses and frame) OR for contact lenses in one 12-month period, but you may not receive a benefit for both. Contact Lenses If you choose contacts lenses instead of glasses (lenses and frame), you will not be eligible to receive glasses (lenses and a frame) during the same service period. You will be eligible for a frame 12 months from the date your contact lenses were obtained. The contact lens exam is a special exam, in addition to your routine eye exam, for ensuring proper fit of your contacts and evaluating your vision with the contacts. You will be responsible for any costs exceeding the allowance. 15% discount available for in-network professional exam fees (evaluation and fitting) NO discount available when non-network providers are used. Visually Necessary Contact Lenses Coverage for visually necessary contact lenses, regardless of whether obtained from a network provider or non-network provider, is subject to review and authorization from VSP s optometric consultants before any benefits will be paid. When obtained from a network provider, visually necessary contact lenses may be covered in full when certain benefits criteria are met. Plan pays up to 100%, after a $25 copay (includes exam fees) Plan pays up to $210 after a $25 copay (includes exam fees) Elective Contact Lenses If you choose contact lenses instead of glasses, you ll receive a $125 allowance for contact lenses (materials) and the contact lens exam (fitting and evaluation). Plan pays up to $125 (includes exam fees) Plan pays up to $125 (includes exam fees) Diabetic Eyecare Program Plus Value-Added Discounts If you wear BOTH contact lenses AND prescription glasses Laser Vision Correction Services related to diabetic eye disease, glaucoma and agerelated macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details. Medical eyecare exams: $20 copay Not covered If you choose contact lenses, but also wear prescription glasses, you will benefit from a 30% discount on additional glasses and sunglasses, including lens options, from the same VSP provider on the same day as your WellVision exam. Or get a 20% discount on additional pairs of prescription glasses and sunglasses from any VSP provider within 12 months of your last WellVision exam. Additionally, you ll save 15% off the cost of your contact lens exam when you receive services from a VSP network provider. This discount does not apply to the price of your contact lenses. There are exclusive VSP member rebates and special offers on contact lenses. Visit vsp.com or ask your VSP provider for details. NOT COVERED Laser vision correction is considered elective surgery under the Insperity Vision Plan. However, if enrolled in Insperity s Vision Plan, a participant may receive discounts on laser eye surgery, including LASIK and PRK procedures. Contact VSP at to learn more. Actual benefits are subject to the provisions and limitations of the agreements between Insperity and its benefit providers. In the event of a conflict between the information in this schedule and the Certificate of Coverage, the Certificate of Coverage will be the controlling document Insperity. All rights reserved. VISION