Benefits Wise - Florida Institute of Technology · 2020-01-27 · AFLAC Group Plans 21 Additional...

Benefits Wise2020 - 2021 Plan Year April 1, 2020 - March 31, 2021

Welcome To Your Employee Benefit Program!We appreciate your commitment to our success. We’re equally committed to providing you with competitive, affordable, health and wellbeing benefits to help you take care of yourself and your family.

Please read this guide carefully as it includes a summary of your plan options and helpful tips for getting the most value from your benefits plans. We understand that you may have questions about your annual enrollment, and we’ll do our best to help you understand your options and guide you through the process.

This guide is not your only resource. Anytime you have questions about benefits or the enrollment process, you can contact your human resources representative or visit http://ICUBAbenefits.org. Although this guide contains an overview of benefits, for complete information about the plans available to you, please see the summary plan description (SPD).

New Hire Open EnrollmentThis is the time to enroll for coverage for you or any eligible family members. If you do not enroll an eligible dependent now because they have coverage through another employer, you may only add that person on our plan during next year’s Open Enrollment Period, unless you experience a qualified family status change. Please refer to the Special Enrollment section.

Once you’re enrolled in benefits, you aren’t allowed to make changes until the next annual Open Enrollment. Open Enrollment is your one chance each year to review your coverage and make changes to your benefits. It’s also your chance to enroll if you declined coverage when you first became eligible.

ContentsEligibility and Special Enrollment 3

Enrolling with ICUBABenefits.org 4

Have you Asked Emma? 4

Quick Reference: Medical Plan Perks and Additional Details 5 - 6

ICUBA Medical Plan Option – Preferred PPO Plan 7

ICUBA Medical Plan Option – Premier Copay Plan (PPO) 8

ICUBA Medical Plan Option – $4,000/$8,000 Deductible PPO Plan 9

ICUBA Prescription Plan 10

ICUBAcares Pharmacist Advocate Program 11

TELADOC 12

BlueRewards Powered by Rally 13

SurgeryPlus 14

Employee Assistance Program (EAP) 15

Spending Accounts 16

Understanding Health Care Accounts 17

Dental Benefit Options 18

Vision Benefit Options 19

Income Protection Benefit Options from Symetra 20

Voluntary Benefits 21

AFLAC Group Plans 21

Additional Benefits 23

Contacts 24

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Eligibility Requirements

EMPLOYEE Full-time employees of your institution.

DEPENDENTS

Your eligible dependents include: your legally recognized spouse or qualified domestic partner and your legal child dependent(s) including natural child, legally adopted child, stepchild, child required to be covered pursuant to a Qualifed Medical Child Support Order, child with proof of legal guardianship who resides with you, or a foster child. Dependent children may remain on the ICUBA plan until the end of the calendar year in which age 26 is attained.

WAITING PERIOD 1st of the month following or coinciding with the date of hire.

Special EnrollmentThe Health Insurance Portability and Accountability Act 1996 (HIPAA), allows a Special Enrollment period in addition to the regular Open Enrollment period. Only the following individuals may make changes outside the Open Enrollment period:

� Individuals who previously waived coverage under this program because they had othercoverage and then involuntarily lost the other coverage.

� New dependents due to marriage, birth, adoption or placement for adoption. The eligibleemployee and other dependents who previously did not elect to be covered under theemployer’s healthcare plan may also enroll at the time the new dependent is enrolled.Enrollment must occur within 30 days of date of marriage, or 30 days of a birth, adoption orplacement for adoption;

� Gain of other coverage + Enrollment time frame is 30 days.

� Enrollment must occur within 30 days of the loss of other coverage.

� A court has ordered coverage be provided for a spouse or minor child under this plan andrequest for enrollment is made within 30 days after issuance of such court order;

� If employee and/or dependent(s) become ineligible for Medicaid or the Children’s HealthInsurance Program and request coverage under our plan within 30 days of termination.

For further information on eligible qualifying events, please refer to the Plan Document or contact your Human Resources Department.

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2020 - 2021ICUBA Benefits Guide

Enrolling with ICUBABenefits.orgHow to EnrollYour enrollment can be completed online at http://ICUBAbenefits.org. Be sure to review your benefits, confirm and submit.

5Enroll in your benefit selections. When you are in an active enrollment period, click the Start Your Enrollment button located on your home page.

First you will be asked to confirm your personal information. Next, you have the option to enroll or waive coverage for the various benefits offered to you.

Please make your way through each benefit category shown below until the plan image shows green and says completed! You may “View Plan Options” to find out more about each plan and your other available options (if applicable). Once completed, select the orange continue button on the right panel to review your selections and complete your enrollment.

6Review all your benefit selections. Complete your benefit enrollment by checking the “I agree and I’m finished with my enrollment” box and click the submit button.

Finally, be sure to Save your new benefit elections.You’ll be directed to your final confirmation statement. You have the option of emailing, printing or viewing a confirmation of your elections. This will submit your elections to Human Resources for approval.

1Understand your choices

This Guide contains very useful reference material to help you prepare for your enrollment. Keep it handy so you can refer to it throughout the year.

2Review your options with your family

Make sure you include any other individuals who will be affected by your elections in the decision-making process.

3Go to http://ICUBAbenefits.org. From the log on screen, enter your username & password. If this is your first time logging on we’ve set your default login information as follows:

USERNAME: Your user name is the First Initial of yourFirst Name + Last Name + Last Four Digits of SSN (e.g. JSmith6789)

PASSWORD: Your Date of Birth (mmddyyyy).Please note: You will be asked to change your password after your initial login.

If you do not remember your password, select Forgot Password and answer your security questions. After three failed login attempts, your account will be locked and you will need to contact Human Resources or bswift at 866-524-5063.

4Upon logging in, you will be able to access your benefits information, work through enrollments and access our Single Sign-On section under My Carrier Accounts. From the top task bar or side panel you can:

� Verify your personal information. If you need to make anyupdates or changes, you may do so by contacting the Human Resources office.

� Update contact information. Please make sure your phonenumber and email address are up to date. This is how we cancontact you about exciting benefits updates and wellbeingcommunication opportunities.

� If applicable, confirm dependent eligibility based on the plandocument rules.

� Access ICUBA’s insurance carrier sites through our Single Sign-On section. Approximately 48 hours after you’ve successfullyelected your ICUBA benefits, you will gain access to theinsurance carrier portals. Upon your first connection attemptyou’ll register with the carriers, however, each subsequent visitwill make the connection automatically without needing toremember a ton of different usernames and passwords.

Have you Asked Emma?

If you’re thinking, which plan is best for me — Ask Emma! If you have questions while you are enrolling for benefits, we encourage you to use our Ask Emma decision support tool.

Emma can help you make smart, cost-effective benefits decisions to fit your individual needs by estimating your annual costs, using real-life scenarios from your personal experiences. She will ask you a few questions for a personalized “walk through” to guide you in the right direction.

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http://ICUBABenefits.org

http://ICUBAbenefits.org


Quick Reference: Medical Plan Perks and Additional DetailsSurgeryPlusThis is a surgical concierge benefit which focuses on medically necessary, non-emergent surgical cases including but not limited to knee, hip, shoulder, foot & ankle, spine, wrist & elbow, general surgery, GI, GYN, bariatric, cardiac and ENT.

We know the surgery process can be very overwhelming and stressful. With the help of SurgeryPlus, your dedicated Care Advocate will manage the entire procedure including helping you select the right surgeon, coordinating travel, scheduling appointments and managing medical expenses. SurgeryPlus takes care of it all with a distinct group of High Quality Surgeons of Excellence.

Procedures coordinated through SurgeryPlus will benefit from lower cost because the deductible and coinsurance will be waived, eliminating all out-of-pocket costs including consultation and surgical procedure. To learn more about SurgeryPlus, please call 855-200-2119 or register online at https://ICUBA.SurgeryPlus.com, access code: surgery plus. (Remember, this benefit is effective 04/01/2019!)

Deductibles Only Apply to Major Services!Please familiarize yourself with what our plan covers. Many services are free and not subject to the deductible. ICUBA Medical Plan Deductibles only apply to Major Services!

No Member Cost Share for: Annual Wellness Visits, ALL Immunizations, Allergy Injections, Venipuncture/Conveyance fees, Quest Diagnostic Labs, Primary Care Visits to a Blue Distinction Total Care Provider, Electrocardiograms, Echocardiograms, Bone Mineral Density Tests, Colonoscopies, Sigmoidoscopies, Mammograms and Ultrasounds of the Breast.

Deductible DOES NOT Apply to: Physician, Specialist & Therapy visits; Convenient Care & Urgent Care; Emergency Room & Emergency Transportation, Prescription Drugs, and Advanced Imaging (precertification required for advanced imaging).

Health Management and Care ConsultantsWe are calling because we care! Health management and care consultant services are available to ICUBA medical plan members at no additional cost. These trained health advisors and registered nurses provide tools, education and advocacy to help you manage chronic health conditions. They can assist with goal setting, help you better understand your doctor’s treatment plan and support you with referrals, transition of care and assistance addressing gaps in care. ICUBA Members with specific health challenges may receive a call from one of our Care Consultants from BCBS, Optum, ICUBAcares or Aetna. We highly recommend you take advantage of this valuable service if a health advisor calls you! Working together with an advisor to manage your health will help you live life to the fullest.

In-Network Outpatient Hospital LabsIn-Network Outpatient Hospital Labs are not subject to deductible. These laboratory tests (which are recommended through Quest Diagnostics) can be performed during an evaluation and management visit to an in-network outpatient hospital/office in places like Moffitt Cancer Center or the Mayo Clinic. Employees will only be responsible for the coinsurance.

Advanced ImagingAdvanced imaging (such as an MRI or CT scan) is not subject to the deductible. ICUBA Members are only responsible for the allowable charges up to $500. If your imaging is less than $500, you are only responsible for the cost of the image.

Please note: Prior Authorization is still required for all advanced imaging services.

Engaged Rally ICUBA Private Sweepstakes WinnersICUBA is giving away $50 Amazon Gift Cards every 14 days for participation in City Walks. When you complete a cross city challenge milestone, not only will you earn coins as you sync your tracking device, but you will be entered EVERY. SINGLE. TIME. a milestone is reached! There is no limit on entries or winners – and we did have a DOUBLE winner in 2018 - 2019! Keep moving! In addition to the Amazon winners within Rally, ICUBA also draws winners monthly for participation in all the challenges, missions and survey completions through your engagement in Rally. Learn more about the BlueRewards powered by Rally program on page 13.

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Quick Reference: Medical Plan Perks and Additional Details (continued)Teladoc rave reviews for $5!Talk to a Doctor anytime! Teladoc gives you 24/7/365 access to a U.S.-based board-certified doctor through the convenience of a phone or video chat consultations. It’s an affordable alternative to costly urgent care and ER visits when you need care now. You can find additional information about Teladoc on page 12.

Blue Distinction Total Care (BDTC)Doctors with the Blue Distinction Total Care (BDTC) recognition are dedicated to improving the quality of care for their patients. By selecting one of the BDTC providers, your cost is $0 for all medically necessary services with a family practice, internal medicine, and/or pediatric physician. These physicians specialize in care for people with chronic conditions, like diabetes, asthma, COPD and heart problems, to ensure each person receives preventive screenings and follow-up care.

BDTC designation does not necessarily mean they provide a higher standard of care than other doctors. It means these doctors take part in a quality improvement program recognized by BCBS of Florida.

Use the online Doctor and Hospital finder to locate these preferred physicians by filtering for BDTC designations. Simply log in to your member account through the single sign-on section at ICUBAbenefits.org. (If applicable: Dependents can visit the BCBS website directly at www.MyHealthToolKitFL.com.)

BlueCross BlueShield of Florida Member WebsiteICUBA health insurance members can access the BlueCross BlueShield of Florida member website through the single sign-on section in the center of your http://ICUBAbenefits.org home page. By using this website, you can view your claim information, access your Rally wellbeing tools, look up doctors in your network and so much more. Spouses will need to visit the BCBS site directly by visiting at http://MyHealthToolkitFL.com and enter his/her own name, DOB and ID number to create an account.

Download the BCBS of Florida Mobile AppNow you can enjoy the making-your-life-easier utility of the MyHealthToolkit in an app! With the app you can use your digital medical ID card from your phone and smart wallet feature, check the status of your claims, view benefits and what’s covered by your medical plan and find local providers quickly! Available for Apple and Android devices.

Free Generic Statin Prescription DrugsIf you meet certain criteria as outlined by the Affordable Care Act (ACA), you may be eligible for Free Generic Statin prescription drugs. Talk to your doctor or call the ICUBAcares Pharmacist Advocate Program to find out more!

ICUBAcares Pharmacist Advocate ProgramNow you can speak with a pharmacist directly and have your personal questions answered over the telephone. Our pharmacists are ready to answer medication management questions, assist with prior authorization, or troubleshoot your personal side effects. They’ll even coordinate with your doctor and the insurance company to advocate on your behalf! Learn more on page 11.

Aetna Behavioral Health and Substance AbuseBehavioral health and substance abuse benefits through Aetna supplement the Medical benefits provided by BCBS. A few examples of Behavioral Health services include psychologists, therapists, psychiatrists, substance abuse treatments and much more! Inpatient and outpatient services are available through this valuable benefit.

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ICUBA Medical Plan Option – Preferred PPO Plan

Preferred PPO

In-Network Out-of-Network

EMPLOYEE PAYS

Deductible (Individual/Family) $2,500/$5,000 $4,000/$10,750

Coinsurance 20% 40%

Out-of-Pocket Maximum (Individual/Family) Includes all medical copays, deductibles & coinsurance

$4,000/$8,000 $7,500/$15,000

Physician Office Visits 20% 40% after deductible

Blue Distinction Total Care(Family Practice, Internal Medicine, Pediatrics)

$0 Not Applicable

Specialist Office Visits 20% 40% after deductible

Convenient Care Clinics $10 Copay N/A

Independent Clinical Labs*(free standing facilities & office visits)

0%* 40% after deductible

Preventive Care 0% Not covered

Teladoc Visit $5 Copay Not covered

Urgent Care Center $30 Copay

Emergency Room Services 0% after $300 Copay (waived if admitted)

Ambulance $250 Copay

Hospital Inpatient 20% after deductible 40% after deductible

*Quest Diagnostic Labs is the In-Network Lab for BlueCross BlueShield of Florida.

Monthly Employee Premium Amount

Employer HRA Contribution Employer Cost Employee Premium

Employee $120.00 $558.21 $101.79Employee & Spouse $240.00 $1053.77 $351.23

Employee & Child(ren) $260.00 $891.85 $297.16

Family $260.00 $1388.27 $462.73

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ICUBA Medical Plan Option – Premier Copay Plan (PPO)

Premier Copay Plan


EMPLOYEE PAYS


Coinsurance 20% 40%


$4,000/$8,000 $7,500/$15,000

Physician Office Visits $25 Copay 40% after deductible


$0 Not Applicable

Specialist Office Visits 50% 40% after deductible













Employee $120.00 $505.04 $207.96Employee & Spouse $240.00 $1074.82 $442.18Employee & Child(ren) $260.00 $910.49 $374.51Family $260.00 $1416.23 $582.77

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ICUBA Medical Plan Option – $4,000/$8,000 Deductible PPO Plan

$4,000/$8,000 Deductible Plan


EMPLOYEE PAYS


Coinsurance 30% 50%


$5,350/$10,700 $10,700/$21,400

Physician Office Visits $35 Copay 50% after deductible


$0 Not Applicable

Specialist Office Visits $70 Copay 50% after deductible













Employee $120.00 $553.21 $101.79Employee & Spouse $240.00 $1048.57 $349.43Employee & Child(ren) $260.00 $724.50 $241.50Family $260.00 $1213.50 $404.50

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ICUBA Prescription Plan

Copayments Prescription-FIll Methods*

TierRetail: Up to a 30-day supply

90-day at RetailProgram Mail: Up to a

90-day supplyUp to a 90-day supply

Preferred generics at other network pharmacies $5 $10 $10

Non-Preferred generics $10 $20 $20

Preferred brands: brand-name medications on the Preferred Medication List (PML)

$40 $80 $80

Non-Preferred brands: brand-name medications not on the Preferred Medication List

$75* $150 $150

Preferred specialty at Briova Specialty Pharmacy $75 N/A N/A

Non-Preferred specialty at Briova Specialty Pharmacy $75 N/A N/A

*Preferred Specialty medications are eligible for copay card usage.

Pharmacy Out-of-Pocket Maximum

In-Network Rx copays will be applied toward an individual maximum out-of-pocket of $2,000/single and $4,000/family. Once you reach your out-of-pocket maximum, your prescriptions will be paid for at 100% by the plan and no cost to you ($0 copay).

If you have a question about your pharmacy benefit, call the OptumRx Customer Care Center, 24 hours a day, 7 days a week. The toll-free number is 855-811-2213 and can be found on the back of your Optum ID card.

Tobacco Cessation Benefit

Tobacco cessation medications are covered—up to two cycles each year— $0 copay when you participate in coaching or counseling options though local Area Health Education Centers, BCBS telephonic coaching or Resources for Living counseling.

Free Over the Counter Items and Diabetic Supplies

With a prescription from your provider you can receive FREE prescribed diabetic supplies including meters, lancing devices, lancets, test strips, control solution, needles, and syringes; prescribed aspirin for adults; prescribed generic folic acid and generic prenatal vitamins for pregnancy. Simply take the prescription to the pharmacy counter and your local pharmacist can assist you.

Getting Stuck?

Please be aware there are some prescriptions that require Prior Authorizations, have Quantity Limits or require a Step Therapy Program. If you should have any issues with one of these programs, please contact ICUBAcares Pharmacist Advocate Program at 1-877-286-3967 for assistance.

Definitions for your Reference

PA - Prior Authorization – Your doctor is required to provide additional information to determine coverage

QL - Quantity Limit – Medication may be limited to a certain quantity

SP - Specialty Medication – Medication is designated as specialty.

ST - Step Therapy – Trial of lower-cost

Included in Medical Plan Election

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ICUBAcares Pharmacist Advocate Program

3 Real Pharmacists

3 Real Advocates

3 Real Solutions

The ICUBAcares team can review your prescriptions and answer questions. Call for a free prescription check-up at 877-286-3967, Monday to Friday 9 a.m. – 5 p.m.!

Our ICUBAcares Pharmacist Team is ready to:

� Serve as a liaison between your doctor, the pharmacy and the insurance company — taking the burden off of you!

� Answer questions on a medication you are taking or considering — providing useful information on side effects and drug interactions.

� Discuss preferred and non-preferred tier options to save you money.

� Provide assistance for a prior authorization from your provider.

� Our ICUBAcares Pharmacist Advocates will make outbound phone calls to members identified for specific services and assistance. Our members can also call our Pharmacist Advocates directly and speak to a real pharmacist if a questions arises.

� ICUBAcares Rally Incentive: If you are a candidate for a qualified medication change, the ICUBAcares team will assist with your transition to a medication less costly to the plan and reward once complete. Call for a prescription check-up to find out more!

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101410E-103A

WHEN CAN I USE TELADOC?

• When you need care now• If your doctor is unavailable• If you’re considering the ER or

urgent care center for a non-emergency issue

• On vacation, on a business trip,or away from home

• For short-term prescriptionrefills

GET THE CARE YOU NEED

Teladoc doctors can treat many medical conditions, including:

• Cold & flu symptoms• Allergies• Bronchitis• Skin problems• Respiratory infection• Sinus problems• And more!

SHARE WITH YOUR PCP

With your consent, Teladoc is happy to provide information about your Teladoc consult to your primary care physician.

So many reasonsto use Teladoc®!

A network of doctors that can treat children

of any age

No limit onconsults, so

take your time

Secure, personal and portable electronic health record (EHR)

Prompt treatment,average call back in

16 min

Receive quality care via phone or

online video

Talk to a doctor anytime, anywhere you happen to be

Teladoc gives you 24/7/365 access to a doctor through the convenience of phone or video consults. It's an affordable option for quality medical care.

Facebook.com/Teladoc Teladoc.com/mobile

Talk to a doctor anytime for $45 or less!

Teladoc.com 1-800-Teladoc (835-2362)

© 2015 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are trademarks of Teladoc, Inc. and may not be used without written permission.Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, 7 days a week while video consultations are available during the hours of 7am to 9pm, 7 days a week.

Teladoc gives you 24/7/365 access to US board-certified doctors through the convenience of phone or video consults. It’s an affordable alternative to costly urgent care and ER visits when you need care now! With your consent, Teladoc can provide information about your Teladoc consult to your primary care physician. The Teladoc benefit is included with your election in an ICUBA Medical Plan.

Talk to a doctor anytime for a $5 copay!

When can I use Teladoc?

Teladoc does not replace your primary care physician. It is a convenient and affordable option for quality care.

� When you need care now � If you’re considering the ER or urgent care for a non-

emergency issue � On vacation, on a business trip, or away from home � For short-term prescription refills

Get the care you need

Teladoc doctors can treat many medical conditions, including:

� Cold & Flu symptoms � Allergies � Bronchitis � Urinary tract infection � Respiratory Infection � Sinus Problems � And more!

Doctor Requirements

Teladoc is simply a new way to access qualified doctors. All Teladoc doctors:

� Are practicing PCPs, pediatricians, and family medicine physicians

� Average 15 years experience � Are US board certified and licensed in your state � Are credentialed every three years, meeting NCQA

standards

Members must establish an account at www.teladoc.com prior to seeking treatment. For first time registration with Teladoc there is a single sign-on feature through BCBS MyHealthToolkit or dependents may visit www.teladoc.com directly. If you need further assistance, call 800-Teladoc, and a customer representative can walk you through the account setup.

TELADOC

12

http://www.teledoc.com

http://www.teladoc.com

BlueRewards Powered by Rally Employee health and wellbeing is one of your institutions top priorities. We look at our programs and incentives every year, making sure we are providing best-in-class tools and resources to assist you and your family in achieving an optimal level of health. We want you to be the best you — personally and professionally.

What is BlueRewards powered by Rally? � Rally is our digital health engagement experience that will help you stay engaged in improving

your health and wellbeing while incentivizing you for healthy activities along the way!

Who is Eligible? � Each employee and spouse enrolled in the ICUBA medical plan is eligible to participate in this

wellbeing incentive plan.

How do I access the Rally Wellness program Portal? � Visit http://ICUBAbenefits.org and utilize the single sign-on feature for BCBS MyHealthToolkit.

Activity Incentives

Rally Survey Gatekeeper required for Incentives 400 Coins & ICUBA Private Sweepstakes

Biometric Screenings (ask about the Physician Results Form!) $40

Wellness Exams $60

Onsite/Campus Events $10 each (up to $70)

Qualified Preventive Screening (Colonoscopy, Mammogram, PSA) $50

Qualified Medication change with ICUBAcares $50

City Challenges Unlimited Coins & ICUBA Private Sweepstakes every 14 days!

Missions Unlimited Coins & ICUBA Sweepstakes

Teladoc Registration 400 Rally Coins

Tobacco Attestation 400 Rally Coins

Clinical Rewards for Chronic Conditions 500 Rally Coins per quarter = 2,000 Coins per year

Incentive Total $270

As you work toward your goals, you will earn Rally coins and ICUBA dollars that can be redeemed through the Rally Marketplace. Coins can be used for a variety of discounts and ICUBA dollars can be used for electronic gift cards.

Remember to download

the Rally Health app!

Interested in Biometrics at your Primary Care Visit?New for this plan year, you can get your biometric screenings with your regular blood work through your annual wellness exam with a PCP. It’s easy! Covered employees and spouses can log into your portal at My.QuestForHealth.com and download the Physician Results Form. Simply download the form which contains a bar code unique to the employee or spouse and will include specific valid date ranges for completion. Take the form with you to your doctor’s office when you are reviewing the results of your blood work and have your doctor sign the Quest Physician Results Form. Then, upload your completed form to the same Quest portal. *Pro Tip: If you have an established relationship with your physician, ask if you can get your blood work ahead of your

annual wellness exam to save time and check this off your list with one visit. 13



http://My.QuestForHealth.com

PROVIDED TO YOU AS A MEMBER OF AN ICUBA MEDICAL PLAN

SurgeryPlus is a comprehensive benefit at NO ADDITIONAL COST that provides access to a premier network of high-performing surgeons for non-emergent/planned surgical procedures.

SurgeryPlus has identified the nation’s highest quality surgeons for the best possible care in an elite network, setting them apart from other under-performing surgeons.

The Same Dedicated

Care Advocate Manages the Entire

Pathway of Care For You

You Can Save Money

You Do Not Need to Enroll in SurgeryPlus

SurgeryPlus will waive your deductible and coinsurance, eliminating all out-of-pocket costs, including consultation, your surgical procedure and post-procedure appointments for up to 90 days.

If you are covered under ICUBA’s medical plan, you have been automatically enrolled in this extra benefit at no additional cost. If you are planning a procedure, call SurgeryPlus as you could save thousands of dollars.

To learn more about SurgeryPlus, contac t

Selection

Scheduling

Advocacy

Follow-up

Surgeon

Employer Direct Healthcare | 2100 Ross Avenue, Suite 550, Dallas, TX 75201 | Phone: 855.200.2119 | Fax: 855.764.0264

Recommends at Least Three Best Fitting Surgeons for Your Individualized Needs

Books Appointments, Transfers Medical Records & Manages Logistics

Listens & Anticipates All Your Needs

855.200.2119 Ensures YourComplete Satisfaction

SurgeryPlus is a comprehensive benefit at NO ADDITONAL COST included with medical that provides access to a premiere narrow network of high-performing surgeons for non-emergent, planned surgical procedures.

No Enrollment Necessary!If you are covered under ICUBA’s medical plan, you have been automatically enrolled in this extra benefit at no additional cost. If you are planning a procedure, call SurgeryPlus at 1-855-200-2119 and you could save thousands of dollars.

Save Money!If you choose to use the SurgeryPlus benefit, ICUBA will waive your deductible and coinsurance, eliminating all out-of-pocket costs, including consultation, your surgical procedure and post-procedure appointments for up to 90 days. Please keep in mind, pre-operative labs and testing will be done at your PCP or Quest and will be submitted to your current medical plan through BCBS. Additionally, follow-up care such as physical therapy, durable medical equipment and lab work will still be covered by the BCBS medical plan and necessary prescription drugs will be covered under OptumRx.

The Same Dedicated Care Advocate Manages the Entire Pathway of Care For You

Surgeon Selection: SurgeryPlus will recommend at least three of the best fitting surgeons for

your individualized needs

Scheduling: SurgeryPlus will book appointments, transfer medical records and manage

logistics

Advocacy: SurgeryPlus will listen and anticipate your surgery related needs

Follow-up: SurgeryPlus will work to ensure your complete satisfaction

To learn more about SurgeryPlus, call 855-200-2119

SurgeryPlus

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Employee Assistance Program (EAP)Aetna’s Resources for Living EAP services are available to you, all members of your household and your adult children up to the age of 26, regardless of your medical insurance coverage. Services are confidential and are available 24 hours a day, 7 days a week. This resource includes six free counseling sessions per issue per plan year.

To access services: 877-398-5816 www.resourcesforliving.com

Username: ICUBA Password: 8773985816

Plan Year: April 1 through March 31

Emotional wellbeing support Daily life assistance

Support is available 24 hours a day for in-the-moment emotional wellbeing. You can also access up to 6 counseling sessions per issue each year.

Visit with a counselor face to face, online with televideo or get in-the-moment support by phone. Services are free and confidential. Resources For Living (RFL) is here to help with a wide range of issues including:

� Relationship support � Stress management � Work/life balance � Family issues � Grief and loss � Depression � Anxiety � Substance misuse and more � Self-esteem and personal development

Competing day-to-day needs can make it tough to know where to start. Call RFL for personalized guidance. RFL will help you find resources for:

� Child care, parenting and adoption � Summer programs for kids � School and financial aid research � Care for older adults � Caregiver support � Special needs � Pet care � Home repair and improvement � Household services and more

RFL also offer carekits related to growing families, child care, caregiving and more.

Legal services

Financial services

You can get a free 30-minute consultation with a participating attorney for each new legal topic related to:

� General � Family � Criminal law � Elder law and estate planning � Divorce � Wills and other document preparation � Real estate transactions � Mediation services

Simply call RFL for a free 30-minute consultation for each new financial topic related to:

� Budgeting � Retirement or other financial planning � Mortgages and refinancing � Credit and debt issues � College funding � Tax and IRS questions and preparation

Talkspace

Talkspace in an online therapy platform that makes mental health care more convenient and accessible by connecting users with a network of 2,500+ licensed therapists. With Talkspace, you can send unlimited multimedia messages to a therapist via web browser or the Talkspace mobile app — anywhere, anytime. Talkspace is currently provided to adults who are 18 or older. Register your account at www.talkspace.com/RFL then download the app from your device’s app store. Enter your employer’s name when prompted for Organization name. 15


http://resourcesforliving.com

http://www.talkspace.com/RFL

Spending AccountsNew Flexible Spending election required each year!

MANDATORY ELECTIONS EACH YEARMORE of an FYI...

YOUR HRA IS PAIRED WITH YOUR ICUBA MEDICAL PLAN

HCFSA Health Care

Flexible Spending Account

DCFSA Dependent Care

Flexible Spending Account

HRA Health Reimbursement Account

Contributions funded by your employer

Funded by benefit eligible employees (Please note: A medical insurance election is not required to enroll

in flex spending)

Funded by your employer and provided when you enroll in an ICUBA

Medical Plan

Deducted pre-tax throughout the year Deducted pre-tax throughout the year No deductions-EMPLOYER MONEY!!

Available for immediate use 04/01/2020

Deposited each pay periodAvailable at the end of each month and

earns interest quarterly

Can be used for healthcare expenses for you & eligible dependents

Can be used for the care of dependents under the age of 13

Can be used for eligible healthcare expenses for participants enrolled in

an ICUBA medical Plan

If enrolled in an ICUBA medical plan: HCFSA funds are used before HRA

Covered expenses include: Day Care, After Care, Gap Camps

If you elect an HCFSA the Flex funds are used BEFORE the HRA funds

NEW! IRS annual individual limit:$2,750

IRS calendar year household limit:$5,000

Funds Rollover Every Year; after 36 continuous months of

enrollment in an ICUBA medical plan with IRA, you are considered vested

and the funds are yours to keep.

Use-it-or-lose-it, no annual carry over Please plan wisely!

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Understanding Health Care AccountsHealth Care Reimbursement Account

(HRA)Health Care Flexible Spending

Account (FSA)

Funding Contribution Funded by your employer.

Funded by employee pre-tax dollars. � The maximum amount you can

contribute to the Health CareSpending Account is $2,750.

� The maximum amount you cancontribute to the Dependent CareSpending Account is $5,000

� Flexible spending amounts aresubject to discrimination testing.Highly compensated employeesmay be asked to adjust flexiblespending dollars based on results.

Tax Benefits for EmployeesReimbursements are tax-free.

Employee contributions are exempt from federal and FICA tax as well as most state and local tax. Reimbursements are tax-free.

Roll Over of Funds Funds roll over at the end of each plan year indefinitely.

Have to spend funds by 6/15 and claim by 6/30 of the following plan year (Use-it-or-lose-it).

Medical Plan EnrollmentMust be enrolled in ICUBA medical plan to be eligible.

Enrollment in medical plan not required.

Dependent EligibilityOnly if covered on medical plan.

All qualified dependents are eligible, even if not enrolled in medical plan.

Availability of FundsCan withdraw up to what has been deposited.

Annual election amount available the 1st business day of the plan year for Health Care Flex Spending Account; the amount available for the Dependent Care Spending Account is the balance of the account as it accumulates through payroll deduction throughout the year.

PortabilityCan continue after 36 months of continuous participation in an ICUBA medical plan.

Available for remainder of plan year through COBRA.

Remember: Each time you use your Health Reimbursement Account (HRA) or Flexible Spending Account (FSA) debit card, you should keep your receipts. Each request for reimbursement must be substantiated before it can be reimbursed.

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Dental Benefit Options Benefits Summary

High Option PPO Preventive Plus DHMO Prepaid 250CS

Plan Year Maximum $2,000 $1,000 Unlimited

ProvidersIn- & Out-of-Network

ProvidersIn- & Out-of-Network

ProvidersNetwork Providers/

Assignment Providers

Deductible $50 Individual/ $150 Family $50 Individual/ $150 Family Not Applicable


Plan Pays In- & Out-of-Network

Patient Pays Assigned Network Provider

Benefit/Service EMPLOYEE PAYS

Preventive Services 0% 20% 0% You pay a pre-set copay

Basic Services20% after deductible

50% after deductible

20% after deductible You pay a pre-set copay

Major Services50% after deductible

70% after deductible

Discount available for In-Network only*

You pay a pre-set copay

Orthodontia (Adult and/or Child)

50%Discount available for

In-Network only*You pay a pre-set copay

Orthodontia Lifetime Maximum for each member

$2,000 Not CoveredNo Maximum, Member

pays pre-set copay

*Discount is subject to provider discretion and does not count toward the deductible or maximum out-of-pocket.


Higher Option PPO Preventive Plus DHMO 250CS

Employee Only $40.81 $19.67 $11.83

Employee + 1 $81.29 $45.72 $23.73

Employee & Family $136.71 $75.69 $36.85

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Vision Benefit Options ICUBA offers two voluntary vision plans through EyeMed. The Base Vision Plan allows you and your covered family members one routine exam every 12 months, plus lenses once every 12 months, and new frames every 24 months. The second option is the Buy-up Vision option that works the same as the basic plan but allows for new frames every 12 months and has an increased frame allowance of $130.

To view the entire provider network, please visit the EyeMed website at www.eyemed.com or contact the Vison Service Center at 866-800-5457. Please review the complete summary of benefits for full coverage details.

Base Plan

In-Network Out-of-Network Reimbursement

Exam(Once every 12 months)

$5 copay up to $35

Frames$0 copay;

$100 allowance; 20% off balance over $100; (Once every 24 mos.)

up to $50

Single Vision Lenses(Once every 12 months)

$15 copay up to $20

Contacts(Once every 12 months)

$0 copay; $100 allowance; plus balance over $100

up to $80

Monthly Employee Premium

Base Plan

Employee $3.91

Employee & Family $10.02

Download the EyeMed Members AppEyeMed gives you access to your benefit information on-the-go. Check your benefit details for eye exams, eyeglass frames, contacts, and lenses directly from your phone.

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http://www.eyemed.com

Income Protection Benefit Options from SymetraShort-Term DisabilityAll benefit eligible employees are provided Short-Term Disability coverage at no cost. You will receive 66 2/3% of weekly earnings, to a maximum benefit of $2,000 per week. The elimination period of this coverage is 14 calendar days for disability due to an injury or sickness. Short-Term Disability is provided for 11 weeks before an employee converts to Long-Term Disability.

Long-Term DisabilityAll benefit-eligible employees are provided salary continuance insurance. There are two options to choose from:

� Option A: Base Level-This plan providesa benefit of 60% of weekly earnings, toa maximum of $2,000 per month, and is provided by Florida Institute of Technology at no cost to all benefit-eligible employees.

� Option B: Buy-Up Level - This plan provides a

benefit of 67% of weekly earnings, toa maximum of $14,000 per month. You and Florida Institute of Technology share the cost of this coverage. Benefit cost is based on your age and salary level.

Life Insurance and AD&D PlanFlorida Institute of Technology provides group life insurance at no cost to all active full-time, benefit eligible employees. Employees receive one times their annual earnings. All amounts are rounded to the next higher multiple of $1,000, if not already an exact multiple thereof. Age reductions may apply.

Employee Voluntary Supplemental Life Insurance and AD&D PlanYou may purchase this coverage in $10,000 benefit units up to 5 times your annual salary not to exceed $500,000. Evidence of Insurability is required for amounts above $150,000 and must be approved by Symetra. All amounts are rounded to the next higher multiple of $10,000, if not already an exact multiple thereof. Age reductions may apply.

Dependent Voluntary Life InsuranceIn order to purchase life insurance for your spouse and/or child, you must purchase Supplemental Life coverage for yourself. The spouse value can be purchased up to 50% of employee amount in increments of $5,000, not to exceed $250,000. Evidence of Insurability is required for amounts above $50,000 and requires approval by Symetra. Child life insurance can be purchased in increments of $2,000 up to $10,000 if less than 50% of the employee coverage amount. Age reductions may apply.

This summary provides only a brief description of the coverage insured by Symetra Life Insurance Company. For a complete description, including all definitions, exclusions, limitations, and reductions in coverage, as well as information on termination of benefits, please refer to the Group Insurance Certificate you will receive when you become insured.

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Voluntary Benefits

The ICUBA BlueCross BlueShield medical plans provide great coverage for you and your family’s general health care needs. Still, everyone’s needs are slightly different. That’s where the Aflac voluntary Accident, Critical Illness and Hospital Indemnity options come in! These benefits are designed to protect your family’s finances in case of an unforeseen injury or illness.

AFLAC Group Plans Accident InsuranceThe Voluntary Accident Plan is designed to help cover the expenses associated with an accidental injury such as a medical plan deductible. Accident pays direct cash benefits for emergency treatment, hospitalizations, specific injury treatments, diagnostic exams and accidental death.

Benefit Highlights:ACCIDENT BENEFITS

Plan FeaturesEmergency Room $175Accident follow-up with physician

$50 per treatment, 6 per accident

X-ray $50Dislocation and fractures Up to $6,000Hospital Admission $1,000Ground ambulance / Air $400 / $1,200Concussion $500Physical Therapy $50 per treatment, 10 per

accident Wellness Benefit $50

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Critical Illness InsuranceThe Voluntary Critical Illness coverage is designed to pay cash in the event you or a covered family member is diagnosed with a critical illness such as cancer, heart attack, stroke, kidney failure, benign brain tumor, loss of hearing or sight do to a severe medical condition or Alzheimer’s. Critical illness helps protect your income and personal assets when out of pocket expenses increase as a result of a specified critical illness.

Benefit Highlights:

� $10,000 benefit for employees on a guaranteeissue basis (no health questions)

� No pre-existing condition limitation* Children are automatically covered at 50%

� The ability to collect 100% of enrolled benefitamount for different diagnosed illnesses andrecurrence of the same condition

� Pays a lump sum benefit tax free regardless ofany other insurance you may have

� Eligibility is employee and spouse andchildren up to the age of 26

* Children are automatically covered at 50%

Hospital Indemnity InsuranceAn unexpected or even planned stay in the hospital can be expensive as you meet your deductible and out-of-pocket obligations under the medical plan. The Hospital Indemnity plan is designed to provide financial protection by paying you a direct benefit to meet out-of-pocket expenses and extra bills that can occur. Lump sum benefits are paid directly to you based on the type of facility and number of days of confinement.

Benefit Highlights:

� Guarantee issue (no medical questions)

� No pre-existing condition limitation

� Portability is included

HOSPITAL INDEMNITY BENEFITSPlan Features Low HighHospital Confinement / Admission

$500 per confinement

$100 per day up to 31 days

$1,000 per confinement

$100 per day up to 31 days

Daily Confinement $100 per day, to a maximum of 31 days per calendar year

Hospital Intensive Care Unit Confinement

$100 or $200 per day up to 10 days

Wellness Benefit $50

Coverage is available for you, your spouse and or child(ren). Your coverage is portable which means you can take the policy with you if you leave the company.

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Paycheck Calculator

Do you want to know what your benefits will cost each paycheck? Use this handy paycheck calculator tool to help determine the exact amount. You can repeat this process for each monthly benefit cost shown in this brochure!

Equation[monthly amount] x 12 months = —— ÷ [paychecks per year] = —— total cost per paycheck

20 Pay Employees

—— x 12 months = —— ÷ 20 paychecks per year = —— total cost per paycheck (benefit amount)

26 Pay Employees

—— x 12 months = —— ÷ 26 paychecks per year = —— total cost per paycheck (benefit amount)

Additional Benefits Post-Tax Benefits Available For Employee Purchase

These are portable individual policies that you pay for with after-tax dollars. If you leave the University, you can take these policies with you. If you are interested in enrolling in these plans, please use the web links below to complete an application/expression of interest.

Veterinary Pet Insurance: Affordable pet health care coverage. You can access ANY VET, for more information: www.petinsurance.com/floridatech

Florida Institute of Technology offers four separate plans with LegalShield. Policy options include:

1. Legal Plan with Spouse or Domestic Partner

2. Identity Theft Plan (IDT) Stand Alone with Spouse or Domestic Partner

3. Identity Theft Plan (IDT) Stand Alone with SafeGuard for Minors (ages 1-17)

4. Combined Legal & IDT Plans plus Safeguard for Minors

Please visit www.fit.edu/hr/benefits/ for more information on these benefit options. Select Pre-Paid Legal Services from the drop down menu.

Our Local LegalShield Agent would be happy to meet with you and answer all of your questions. Yvette Mayo can be reached at 407-657-1940 or via email at [email protected].

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BCBS Medical InsuranceCustomer Service: 855-258-9029

24/7 Essential Advocate: 888-521-2583

Website http://myhealthtoolkitfl.com

TeladocRequest a Consult: 800-TELADOC (835-2362)

Website www.teladoc.com

SurgeryPlusSurgical Care Advocate: 855-200-2119

Aetna Behavioral Health & Resources for Living EAPCustomer Service: 877-398-5816

Option 1: Employee Assistance Program

Option 2: Behavioral Health

Website www.resourcesforliving.com

Username: ICUBA

Password: 8773985816

OptumRx Prescription DrugsHealthCare Advisor: 855-811-2213

Website www.optumrx.com

ICUBAcares Pharmacist Advocate ProgramPharmacist Help Line: 877-286-3967

Humana Dental InsuranceCustomer Service: DHMO: 800-979-4760

PPO: 800-233-4013

Website www.humanadental.com

EyeMed Vision InsuranceCustomer Service: 866-800-5457

Website www.eyemed.com (network: Insight)

ICUBA Benefits MasterCardCustomer Service: 866-377-5102

Email: [email protected]

Website http://ICUBAbenefits.org

Symetra Life and Disability (Always contact HR before Symetra!)

Customer Service: 877-377-6773

Website www.symetra.com

ContactsVisit http://ICUBAbenefits.org for a quick and easy Single Sign-On access to many of the Brand Partner websites listed below. After your initial set up, the SSO links will take you directly into each carrier with a connection!

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http://myhealthtoolkitfl.com

http://www.teladoc.com

http://www.resourcesforliving.com

http://optumrx.com

http://www.humanadental.com

http://www.eyemed.com

mailto:[email protected]


http://www.symetra.com

NOTES

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Visit our website http://ICUBAbenefits.org to learn more about all of our benefits.

This summary of benefits does not create a contract between the Institute and any employee. Details of these plans can be found in official plan documents that govern the plans. In the event of a discrepancy between the plan documents and this document,

the plan documents govern. While care has been taken to ensure the accuracy of this information, the plan documents and your

employer policies will govern in all cases. Although it is our intention to continue the plans, we reserve the right to modify,

amend or terminate the plans at any time. All rates are based on current participation and are subject to change.

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