CONEJO VALLEY UNIFIED SCHOOL DISTRICT. Benefits Administration Guide School Sites

Transcription

1 CONEJO VALLEY UNIFIED SCHOOL DISTRICT Benefits Administration Guide School Sites

2 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [2] TABLE OF CONTENTS Table of Contents CONTACTS... 3 District Office...4 Blue Shield of California - HMO...4 District Health Plan/Blue Shield of California - PPO...5 District Pharmacy Plan/Envision Rx...5 Kaiser...5 Delta Dental...5 VSP...6 Standard Life Insurance Company...6 MEDICAL INSURANCE... 7 Blue Shield HMO...8 District Health Plan/Blue Shield PPO...10 Kaiser...12 DENTAL INSURANCE Delta Dental...15 VISION INSURANCE VSP...17 LIFE INSURANCE Standard Insurance Company...19

3 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [3] CONTACTS

4 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [4] District Office 1400 East Janss Road Thousand Oaks, CA Name/Title Phone Number Fax Number Lee Marseglia - Risk Manager lmarseglia@conejo.k12.ca.us (805) , x261 (805) Liz Jacobs Senior Account Clerk, Benefits ejacobs@conejo.k12.ca.us (805) x473 (805) District Benefits Website: Click on Departments > Risk Management/Health Benefits > Employee Benefits Blue Shield of California - HMO 100 North Sepulveda Blvd., 20th Floor El Segundo, CA Group Number/Purchaser ID: H Name/Title Phone Number Fax Number Customer Service Call Center (800) N/A Pharmacy/Pre-Authorizations Prime Mail Mail Order Service (800) N/A (866) N/A

5 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [5] District Health Plan/Blue Shield of California - PPO 100 North Sepulveda Blvd., 20th Floor El Segundo, CA Group Number/Purchaser ID: L01119, L01120, L Name/Title Phone Number Fax Number Customer Service Call Center (800) N/A District Pharmacy Plan/Envision Rx 2181 East Aurora Road Suite 201 Twinsburg, OH Name/Title Phone Number Fax Number Envision Help Desk General questions (800) N/A Kaiser 5805 Sepulveda Blvd., Suite 750 Van Nuys, CA Group Number/Purchaser ID: Name/Title Phone Number Fax Number Administrative support for Members Hours: 7am 7pm, seven days a week (800) N/A Delta Dental Towne Center Drive Cerritos, CA Group Number/Purchaser ID: Name/Title Phone Number Fax Number Customer Service Verify eligibility, verification of participating providers, order I.D. cards, check claim status (800) N/A

6 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [6] VSP 111 West Ocean Blvd., Suite 1625 Long Beach, CA Group Number/Purchaser ID: Name/Title Phone Number Fax Number Customer Service Questions regarding plan coverage & eligibility (800) VSP-7195 N/A Standard Life Insurance Company P.O. Box 4744 Portland, OR Group Number/Purchaser ID: Name/Title Phone Number Fax Number Life Benefits N/A Customer Service N/A

7 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [7] MEDICAL INSURANCE

8 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [8] Blue Shield HMO Plan: HMO Carrier: Blue Shield of California Policy Number: H51495 Plan Renewal Date: 7/1/2010 Eligibility: 1st of the month following date of hire Dependent Age Limit: Until age 19 or 25 if full-time student Deductible Individual Family Hospital Admission Annual Copay Maximum Individual Family Hospital Services Room & Board Surgery Emergency Physician Services Office Visit Hospital Visit Diagnostic X-Ray & Lab Extended Care Home Health (up to 100 visits/yr) Out-patient Physical Therapy Hospice N/A N/A N/A $1,000 $2,000 $50 (waived if admitted) $25 $25 per visit $25 per visit

9 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [9] Prescription Drugs Retail (30-day supply) Generic Brand Mail Order (90-day supply) Generic Brand $15 $30 $15 $30 Blue Shield HMO Mental Health Inpatient (Severe) Inpatient (Non-Severe) Outpatient (Severe) Outpatient (Non-Severe) $25 per visit $25 per visit Alcohol & Substance Abuse Inpatient Outpatient Detox Wellness Periodic Health Evaluations Routine Immunizations Vision and Hearing Screening Other Services Skilled Nursing Facility Durable Medical Equipment Ambulance Chiropractic $50 per day $25/visit, 30 max days per calendar year, limited to 100 days/calendar yr. 20% of allowed charges, max $2,000/calendar yr $5 per visit, 20 visit calendar yr. max This benefit schedule is for comparison purposes only. It is not a contract. It is not intended to be all inclusive. For complete details on exclusions and limitations, refer to the plan booklets.

10 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [10] Plan: Carrier: Policy Number: District Health Plan/Blue Shield PPO PPO Plan Renewal Date: 7/01/2010 New Hire Waiting Period: Blue Shield of California Dependent Age Limit: Until age 19 L01119, L01120, L st of the month following date of hire PPO Lifetime Maximum $2,000,000 Deductible Non-PPO Individual $350 $1,000 Family $1,050 $3,000 Annual Out of Pocket Maximum Individual $2,000 $8,000 Physician Services Office Visit Hospital Services Room & Board Surgery Emergency Prescription Drugs Deductible Retail Generic Brand Mail Order Generic Brand Member pays: 60% + $25 copay, deduct. waived if admitted $100/family/calendar year $10 up to 30-day supply $15 up to 30-day supply $10 up to 90-day supply $15 up to 90-day supply 40% 40% 40%, deduct. waived if admitted

11 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [11] District Health Plan/Blue Shield PPO Mental Health Inpatient (Facility Based) Outpatient (30 visits/yr) combined with outpatient chemical dependency visits Alcohol & Substance Abuse Inpatient (Facility Based) Outpatient (30 visits/yr) combined with outpatient non- severe mental health visits Wellness Routine Physical Exams Well Child Care (includes eye/ear screenings, immunizations & vaccinations) Vision Lenses Frames Contact Lenses Other Services Skilled Nursing Facility Durable Med. Equipment Ambulance PPO Not covered Non-PPO 40% 40% 40% 40% Member pays: 60% + $25 copay Member pays: 60% + $25 copay 40% 40% This benefit schedule is for comparison purposes only. It is not a contract. It is not intended to be all inclusive. For complete details on exclusions and limitations, refer to the plan booklets.

12 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [12] Plan: Carrier: HMO Policy Number: Kaiser Kaiser Permanente Plan Renewal Date: 7/1/2010 New Hire Waiting Period: 1st of the month following date of hire Dependent Age Limit: Until age 19 or 25 if full-time student Deductible Individual Family Hospital Admission Annual Copay Maximum Individual Family Hospital Services Room & Board Outpatient Surgery Emergency Physician Services Office Visit Hospital Visit Diagnostic X-Ray & Lab Extended Care Home Health Out-patient Physical- Therapy Hospice Alcohol & Substance Abuse Inpatient (Detox Only) Outpatient Individual session Group session Wellness Routine Physical Exam Routine Immunizations Vision and Hearing Screening N/A N/A N/A $1,500 $3,000 $50 per visit (does not apply if admitted) $25 per visit (up to 100 visits per calendar year) $25 per visit $25 per visit $5 per visit $25 per visit $25 per visit

13 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [13] Prescription Drugs Retail Generic Brand Non-Formulary Brand Mail Order Generic Brand Non-Formulary Brand Mental Health Inpatient Outpatient Individual session Group session Kaiser $10/30-day supply, $20/31 to 60-day supply, $30/61 to 100-day supply $20/30-day supply, $40/31 to 60-day supply, $60/61 to 100-day supply Not Covered $10/30-day supply, $20/31 to 100-day supply $20/30-day supply, $40/31 to 100-day supply Not Covered (up to 45 days per calendar year) $25 per visit $12 per visit Other Services Skilled Nursing Facility Durable Medical Equipment Ambulance (up to 100 days per calendar year) 20% of allowed charges, max $2,000/ calendar yr This benefit schedule is for comparison purposes only. It is not a contract. It is not intended to be all inclusive. For complete details on exclusions and limitations, refer to the plan booklets.

14 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [14] DENTAL INSURANCE

15 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [15] Delta Dental Carrier: Delta Dental/Keenan Policy Number: 1349 Plan Renewal Date: 7/1/2010 New Hire Waiting Period: First of the month following date of hire Dependent Age Limit: Until age 19 or 25 if full-time student Annual Maximum $1,500 Calendar Year Deductible Individual Family N/A N/A Preventive & Diagnostic: Office Exams 70% - 100% Cleanings 70% - 100% X-Rays 70% - 100% Basic Services Basic Restorative 70% - 100% Endodontics 70% - 100% Major Restoration Prosthodontics 50% Orthodontia Maximum 50% to $1,000 Lifetime max. per person This benefit schedule is for comparison purposes only. It is not a contract. It is not intended to be all inclusive. For complete details on exclusions and limitations, refer to the plan booklets.

16 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [16] VISION INSURANCE

17 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [17] Carrier: VSP VSP Policy Number: Plan Renewal Date: 7/1/2011 New Hire Waiting Period: Dependent Age Limit: Vision Care Services: First of the month following date of hire Until age 19 or 25 if full-time student Provider Non- Provider Every 12 months Vision Examination Covered in full $45 Reimbursement Vision Care Materials: Every 24 months Lenses: Single Vision Covered in full $45 Reimbursement Bifocal Covered in full $65 Reimbursement Frames: $115 Allowance $45 Reimbursement Contact Lenses: Every 24 months Visually Necessary Professional Fees & Materials Covered in full $210 Reimbursement Elective Professional Fees & Materials $100 Allowance $100 Allowance Covered Contact Lenses Professional Fees & Materials $50 Copay $210 Reimbursement This benefit schedule is for comparison purposes only. It is not a contract. It is not intended to be all inclusive. For complete details on exclusions and limitations, refer to the plan booklets.

18 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [18] LIFE INSURANCE

19 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [19] Carrier: Standard Insurance Company Policy Numbers: Standard Insurance Company Plan Renewal Date: 7/1/2010 Eligibility: Active Full-time employees New Hire Waiting Period: Schedule of Life Insurance Participant s Age on Date Death Occurs 1st of the month following date of hire Decreasing Term Life Under $136,800 $120,000 $103,200 $88,200 $70,200 $52,800 $34,200 $27,600 $23,400 $14,400 $8,400 Dependent Life Benefit: $1,500

20 CONEJO VALLEY UNFIED SCHOOL DISTRICT Benefits Administration Guide [20]