2015 Employee Benefits Overview Medical Prescription Coverage Wellness Program Dental Life and Accident Short-Term Disability Flexible Spending Accounts (FSAs) Long-Term Care & Universal Life Shared Leave Important Contacts
About This Guide This is a summary of the benefit choices that are available for you to enroll in or make election changes for the 2015 Plan Year. The City s annual enrollment period for active employees is Wednesday, October 1 Wednesday, October 22. Election changes may include the addition or removal of a dependent to your health or dental coverage, except when court-ordered. You will need to complete a Dependent Eligibility Certification Form and provide the required documentation to Human Resources by Friday, October 31, if you add a new dependent onto your medical and/or dental coverage. Please review and make your benefit elections for 2015 using the enrollment website at www.ebenefitsnow.com. NOTE: This overview describes the benefit plans and policies available to you as a City of Winston-Salem employee. The details of these plans are contained in the official plan documents, including some insurance contracts. This overview is not meant to contain all of the details that are included in your Summary Plan Descriptions or in your other employee benefit materials. If you have questions about the plans, or if there is a conflict between the information in this overview and the formal language of the plan, the formal wording in the plan documents will govern. The benefits highlighted and described in this overview may be changed at any time and do not represent a contractual obligation either implied or expressed on the part of the City of Winston-Salem. Highlights & Changes for 2015 The City will continue to offer both Basic and Basic Plus plans. Premium rates for medical plans will increase. Prescription copays for retail and mail-order remain unchanged. Prime Therapeutics (Prime), the pharmacy manager for BlueCross BlueShield of North Carolina (BCBSNC), will provide prescription coverage. Your BCBSNC member ID card will be used for medical and pharmacy benefits. Prescription coinsurance will apply toward the annual deductible and out-of-pocket maximum under the medical plans. BCBSNC's Step Therapy Program through Prime will allow prescriptions to be filled with a comparable, but more affordable medication initially. If it is not effective, a more costly medication can be authorized. Participants who are tobacco-free and complete all established Wellness criteria will receive a $50 monthly discount. Aetna supplemental life insurance rates will change to be based on an employee's age and the amount of coverage. Aetna's dependent life insurance rate (for spouse or children) will increase to $2.92 per month. The City will offer a Guaranteed Issue Opportunity (for employees and spouses who have never been previously declined) to purchase supplemental and spouse coverage without having to provide proof of good health or Evidence of Insurability (EOI). This means the following: Previously eligible employees will be allowed to enroll at 1X basic annual salary to a max of $300,000 without submitting an EOI form. Currently enrolled employees may increase one level, not to exceed the lesser of 3X their salary or $300,000, without submitting an EOI. Employees may enroll in spouse coverage without submitting EOI if their spouse has never been declined in the past. Based on the IRS modifications to the Medical Flexible Spending Account (FSA) "Use-it-or-lose-it" rule, the City will allow participants to roll over up to $500 in unused funds to the new plan year. Note: You will no longer have the option to incur expenses across plan years. You must enroll in the Shared Leave Program during annual enrollment to be eligible to receive Shared Leave donations. PLEASE NOTE: Biometric results* will determine the eligibility for the Wellness Premium Discount and enrollment in the Basic Plus Plan. If biometric results indicate positive for use of tobacco products, or if you waive participation in biometrics, you are only eligible to enroll in the Basic Plan at a non-wellness rate. *Biometric results are protected under HIPPA and by the City of Winston-Salem. The Human Resources Department is only provided minimal information to determine eligibility for medical plans.
BlueCross BlueShield of NC PPO Plans Medical insurance gives you peace of mind and lets you focus on what is truly important a speedy recovery. You can choose from the following affordable Provider Preferred Organization (PPO) plans: Basic PPO and Basic Plus PPO. Medical Benefits Summary Coverage Annual Deductible Basic PPO In-Network Out-of- Network Basic Plus PPO In-Network Out-of- Network Individual $1,000 $2,000 $500 $1,000 Family $2,000 $4,000 $1,000 $2,000 Out-of-Pocket Maximum (including copay and deductible) Individual $4,000 $8,000 $2,000 $4,000 Family $8,000 $16,000 $4,000 $8,000 Physician s Office Visits Primary $20 copay 60%* $20 copay 70%* Specialist $40 copay 60%* $30 copay 70%* Routine Physical $0 60%* $0 70%* Hospital Care Inpatient 80%* 60%* 90%* 70%* Outpatient 80%* 60%* 90%* 70%* Emergency Treatment Emergency Room $150 copay $150 copay $100 copay $100 copay Urgent Care $40 copay $45 copay $30 copay $35 copay Mental Health Office Visit $40 copay 60%* Inpatient 80%* inpatient) 90%* Substance Abuse Office Visit $40 copay 60%* Inpatient 80%* inpatient) 90%* Other Services Vision (basic routine) Chiropractic $0 $40 copay; 30 visits per year 60%* (vision and chiropractic) $30 copay 70%* inpatient) $30 copay 70%* $0 copay $30 copay; 30 visits per year inpatient) 70%* (vision and chiropractic) *After deductible. For a complete list of covered services, refer to the Blue Member Guide on the Employee Center website. 2015 Medical Premium Rates Basic Plan Premium Comparison Basic Plan Level of Coverage Employee Premium Monthly Premium Employee Premium w/$50 Wellness Discount* Employee Only $111 $61 Employee/Child $206 $156 Employee/Spouse $264 $214 Employee/Children $370 $320 Employee/Family $435 $385 * This premium applies to employees who are participating in the City's Wellness Program and who are tobacco-free as determined by biometric screening. Basic Plus Plan Premium Comparison Basic Plus Plan Level of Coverage Employee Premium Monthly Premium Employee Premium w/$50 Wellness Discount* Employee Only $161 $111 Employee/Child $373 $323 Employee/Spouse $450 $400 Employee/Children $622 $572 Employee/Family $727 $677 * This premium applies to employees who are participating in the City's Wellness Program and who are tobacco-free as determined by biometric screening.
Prescription Drug Program Non-specialty prescriptions can be filled at a participating retail pharmacy (such as Walgreens, CVS, Walmart, Kmart and many others). Simply present your BCBSNC member ID card at the time you get your prescription filled; or you may have to pay a higher amount than the contracted cost. If you submit a manual claim you will only be reimbursed up to the contracted cost of a prescription. For added savings, you can use the mail-order prescription program that is administered by PrimeMail and receive a 90-day supply of maintenance medications (i.e. blood pressure, birth control, allergy, etc.) for the same cost as a 60-day supply. This discount is for mail-order prescriptions only and does not apply to prescriptions filled at a retail pharmacy. Step Therapy is part of the prescription plan. It is a process whereby prescriptions are filled with an effective but more affordable medication. A more costly medication can be authorized if the alternative medication is not effective in treating the condition. Prior authorization may be required. If you have pharmacy or prescription questions, contact BCBSNC Customer Service at 1-800-672-7897. For questions regarding your mail-order prescriptions, please contact PrimeMail Member Services at 1-877-357-7463. All specialty medications are distributed by Prime Specialty Pharmacy (PSP). To begin service or to get additional information, call PSP at 1-877-627-MEDS (6337). Prescription Plan Benefits Summary Plan Basic Plan Basic Plus Plan Retail Drugs (30-Day Supply) Tier 1 Generics $10 copay $10 copay Tier 2 Preferred Brand 20% coinsurance* ($40 min. - $70 max.) 10% coinsurance* ($30 min. - $60 max.) Tier 3 Non-Preferred Brand 20% coinsurance* ($55 min. - $105 max.) 10% coinsurance* ($50 min. - $100 max.) Mail-Order Drugs (90-Day Supply) Tier 1 Generics Tier 2 Preferred Brand $20 copay $60 copay $20 copay $50 copay Tier 3 Non-Preferred Brand $100 copay $90 copay * Prescription coinsurance applies toward the annual deductible and out-of-pocket maximum under the medical plans. Wellness Premium Discounts Employees enrolled in a City medical plan are eligible to receive a $50/month Wellness Premium Discount in 2015 if they are (1) tobacco-free AND (2) meet the other program requirements described below. Biometric Screening and Tobacco-Free Status Participate in September 2014 biometric screening including nicotine testing to verify tobacco-free status. (Participants who enrolled in one of the City s medical plans with a coverage effective date of July 1, 2014 or later are not required to get a screening at this time.) If you do not complete a biometric screening, you cannot enroll in the Basic Plus Plan and are not eligible for the Wellness Premium Discount. If you are interested in being tobacco-free, you can enroll in a tobacco cessation program through Employee Medical Services or BCBSNC. Employees who successfully complete a tobacco cessation program by June 30, 2015 and remain tobacco-free may request eligibility for the wellness discount after June 30, 2015. Documentation of program completion must be provided to Human Resources by July 15, 2015. Providing incorrect information about your tobacco use status will result in disciplinary action up to and including health care premium increases and termination of employment. FDA-approved tobacco cessation medications, including prescription drugs and Over-The-Counter (OTC) medications (such as nicotine replacement therapy) are covered by Prime at 100%. Health Risk Assessment (HRA) Complete the HRA between January 1, 2015 and February 28, 2015. Failure to complete the HRA will result in the discontinuation of the Wellness Premium Discount. The HRA can be accessed through the BCBSNC website at www.bcbsnc.com. New hires and employees certified for benefits must complete the HRA within 90 days of the effective date of medical coverage. Annual Preventive Care Visit or Physical Complete your annual preventive care visit or physical by December 31, 2014. Wellness Education Classes/Seminars Complete one wellness education class or seminar by December 31, 2014. Go to the Employee Center website or contact the Wellness Coordinator at 336-748-3863 for program information. Example of Prescription Plan for 2015 with Coinsurance and Minimum & Maximum Prescribed Drug (Retail Pharmacy) Crestor Formulary/Preferred Humira Specialty/Non-Preferred Brand Drug Cost $179.00 $2,952.74 Drug Cost Basic (20%)/ Basic Plus (10%) w/ Min. & Max. 20% = $35.80 / 10% = $17.90 (Coinsurance amounts less than min.) Actual Member Cost = $40/$30 20% = $590.55 / 10% = $295.27 (Coinsurance amounts greater than max.) Actual Member Cost = $105/$100
Dental Plan The City s dental plan covers a full range of services and all dental claims are handled by Flores and Associates (www. Flores247.com). You can use the dentist of your choice. Orthodontia is only available for covered dependents under the age of 19 with a lifetime maximum benefit of $1,500. There is a one-year waiting period for orthodontia and non-preventive dental services for dependents added during annual enrollment. Monthly premiums and benefits are listed in charts below. Dental Benefits Summary Amount of Service City Share Employee Share City Paid Benefit First $300 100% 0% $300 Next $50 0% $50 deductible $0 Next $250 80% 20% $200 Next $1,200 50% 50% $600 $1,100 annual maximum benefit per covered member. Dental Premium Level of Coverage Monthly Premium Employee Only $0 Employee/Family $21 Long-Term Care and Universal Life Long-Term Care provides a variety of support for individuals who are unable to care for themselves, whether temporary or permanently to assist with daily living activities. Universal Life is an individual life insurance policy that can help provide the insurance protection you need, while also giving you the financial flexibility you want for you and your family. A representative from Mark III Brokerage will be in the Human Resources Department November 5 and 6 if you wish to enroll or make changes to Long-Term Care and Universal Life coverage. To schedule an appointment, please refer to the enrollment website at www.ebenefitsnow.com to provide availability and contact information. Life Insurance: Basic, Supplemental & Dependent Coverage Basic Life with Accidental Death & Dismemberment (AD&D) All full-time employees are eligible for City-paid Basic Life Insurance for the benefit amount of an employee s annual salary up to a maximum of $150,000. Supplemental Life with Accidental Death & Dismemberment (AD&D) All full-time employees are eligible to apply for additional voluntary life insurance coverage for up to 3X their annual salary at a maximum of $300,000 or the maximum can be increased to $400,000 with an approved Evidence of Insurability (EOI). Please note that this year only the EOI is not required if you have not previously been declined and want to enroll in coverage at 1X your basic annual salary not to exceed $300,000; or if you currently have coverage and want to increase coverage by one level not to exceed $300,000. Cost will be based on age and amount of coverage. Dependent Life You can apply for dependent life insurance for your spouse and/or dependent child(ren). The benefit amount for a covered spouse is $10,000 and $5,000 for each covered unmarried child up to age 26. If you wish to enroll your spouse during annual enrollment, an EOI must be completed if your spouse has previously been declined for coverage. Children can be enrolled without an EOI. Cost of Benefit: $2.92 per month to cover dependents. Short-Term Disability All full-time and part-time/temporary employees who are eligible for benefits may apply for Short-Term Disability. It replaces some of your income if you are sick, injured (excludes work-related illness or injury), or pregnant and cannot perform the essential functions of your job. You do not have to exhaust your accrued paid leave prior to filing a claim to receive short-term disability. An EOI application must be completed if you wish to apply for coverage or increase your current weekly benefit election. Your request must be approved by The Hartford prior to enrollment or increase to weekly benefit amount. Benefit Amount Minimum Weekly Benefit $100 Maximum Weekly Benefit (Weekly benefit amount may not need exceed 70% of your gross weekly earnings) $650 Waiting Period Accident 0 days Illness/Injury/Pregnancy 7 days Benefit Duration 26 weeks
Flexible Spending Accounts (FSAs) FSAs allow you to set aside a portion of your earnings on a taxfree basis for qualified medical or dependent care expenses. You can elect an annual allocation to deposit into a medical and/or dependent care account for qualified expenses for yourself, spouse and dependents. The account balance for medical FSAs will be available to you immediately at the beginning of the plan year. You can request a medical FSA debit card, also known as the Benny Card," for a $15 annual fee, which is deducted from your FSA balance. Qualified eligible expenses include: medical, dental, prescriptions, vision care, copayments, deductibles, hearing aids and more. Dependent care FSA expenses can be used for day care (children and adult) and after-school programs. You must enroll annually for this account. The medical FSA yearly minimum contribution is $130 and the yearly maximum is $2,500 per year. There is no yearly minimum for the dependent care FSA while the yearly maximum is $4,992 per year. Shared Leave Program It is an employee-to-employee benefit in which employees donate vacation, sick, and/or holiday time for the use by employees with catastrophic and serious medical conditions. Employees who have been employed with the City of Winston- Salem for at least 12 months are eligible for the program. To be eligible to request either catastrophic* or serious** (non-catastrophic) leave, employees must have contributed at least eight (8) vacation hours to the Shared Leave Bank during annual enrollment for the calendar year in which the leave is requested. This donation requirement will be pro-rated for part-time employees who are certified for benefits, based on the number of hours they work during a normal work week. Important Contacts Employees donating eight (8) hours of vacation time during annual enrollment are not required to maintain a balance of 40 vacation hours and 40 sick hours at the time of donation. However anyone who donates hours outside of the annual enrollment window will be required to have a balance of 40 vacation hours and 40 sick hours at the time of donation. If donating outside of the annual enrollment window, employees will have to donate in one hour increments with a minimum of eight (8) vacation hours and a matching amount of sick leave up to a maximum of 80 hours each of vacation time and 80 hours of matched sick time for a total of 160 hours that can be donated to one recipient. This is the same for using holiday time as well in which holiday time can be donated in one-hour increments with a minimum of eight (8) hours holiday time and a matching amount of sick leave up to a maximum of 80 hours each of holiday time and 80 hours of matched sick time for a total of 160 hours that can be donated to one recipient. Employees who have catastrophic medical conditions are eligible to receive donations from the Shared Leave Bank and direct donations from other employees. Employees who have serious (non-catastrophic) medical conditions are not eligible for donations from the Shared Leave Bank, but could be eligible for direct donations from other employees. *Catastrophic medical conditions are serious incapacitating and/or life threatening nonjob related medical conditions requiring an extended treatment and/or recovery period for which the employee anticipates being absent from work and for which the employee would be without income for those hours. **Serious medical conditions are non-work related medical conditions, as defined in the FMLA, which would prevent an employee from coming to work for an extended period of time and which would cause the employee to be without income for at least 160 hours. Plan Provider Contact Number Website Medical Insurance BCBSNC 1-877-258-3334 bcbsnc.com Prescription Drug Plan Prime Therapeutics / PrimeMail 1-800-672-7897 / 1-888-274-5180 bcbsnc.com / myprimemail.com Dental/Flexible Spending Flores & Associates 1-800-532-3327 flores247.com Basic and Supplemental Life Insurance Aetna 1-800-826-7448 aetna.com Universal Life Insurance Unum / Colonial 1-800-635-5597 / 1-800-325-4368 unumprovident.com / coloniallife.com Long-Term Care CNA Group LTC 1-800-266-2904 cna.com Short-Term Care The Hartford 1-800-523-2233 thehartfordatwork.com Pension Plan NC Retirement System 1-877-627-3287 nctreasurer.com 457 Deferred Compensation Plan & IRA ICMA-RC / Nationwide 1-800-669-7400 / 1-877-677-3678 icmarc.com / nrsretire.com 401(k) Plan & IRA Prudential 1-866-627-5267 ncplans.prudential.com 529 Plan College Foundation of NC 1-888-234-6400 cfnc.org Copyright 2014 Mercer LLC. All rights reserved. www.cityofws.org BP-14-301609-A