Viva Health For USA Employees · Health & Dental Plan? No, if you are a new employee you may select...

USA-ViVa Guidebook 2017

For Employees

Access to exclusive University of South Alabama providers.

you deserve.

you demand.

Coverage

Choices

2017

USA Viva Health & Dental Plan will offer value to employees and their dependents with a low cost benefit plan that provides access to select medical providers concentrating on improved medical outcomes and preventive health.

Enrollment in USA Viva Health & Dental Plan will be during Open Enrollment which begins on Tuesday, November 1, 2016, and ends on Wednesday, November 30, 2016.

Viva Health, located in Birmingham, AL, is affiliated with the UAB Medical System. Viva administers narrow network health plans with many large employers across the state of Alabama.

USA Viva Health & Dental Plan is a narrow network plan consisting of USA Health medical providers and select providers from the VIVA network. VIVA working with USA Health will ensure access to primary care and all medical specialties. To assist with primary care, a Telehealth program will be included providing telephone and internet access to a physician for minor medical concerns resulting in less cost for the employee, time saved and convenience. Out-of-network services will only be available for emergency care and when approved by Viva’s medical director.

The employee cost sharing will be the lowest of the plans offered by the University:

Single - $108.00* Family - $350.00**Includes the non-tobacco wellness incentive of $50

USA Viva Health & Dental Plan will save the employee $240 for single coverage and $816 for family coverage annually, as compared to the USA Health & Dental Plan’s Standard Plan. In addition, the benefits provided by the plan include no deductibles or copay amounts required for hospital and physician services as well as several other services. The pharmacy benefit will be administered by Express Scripts, Inc., and the dental benefit will be administered by Southland National with plan benefits the same as those provided with the USA Health & Dental Plan’s Standard Plan.

Enrollment in the USA Viva Health & Dental Plan will be on a voluntary basis to all benefits-eligible employees.

USA Viva Health & Dental Plan representatives will be at the Employee Benefits Fair on Thursday, November 3, 2016, and on Friday, November 4, 2016, to answer your questions and to assist with enrollment.

Beginning January 1, 2017, the University of South Alabama in coordination with USA Health will offer employees the opportunity to participate in a new health and dental plan, USA Viva Health & Dental Plan!

May I join any of the three plans offered by the University: Base Plan, Standard Plan, USA-Viva Health & Dental Plan? No, if you are a new employee you may select between the Standard Plan and the USA-Viva Health & Dental Plan. Only employees hired before January 1, 2013, are eligible for the Base Plan.

Does the USA-VIVA Health & Dental Plan offer dental benefits? Yes, the USA-Viva Health & Dental Plan offers the exact same dental benefits that are offered in both the Base Plan and Standard Plans.

If I join the USA-VIVA Health & Dental Plan can I switch back to the Base Plan or Standard Plan?Yes, but only to the Standard Plan and only during the annual open enrollment month (generally in November) for coverage starting January 1st of the following year. You may not switch plans during the year unless you have a change in your residence and you reside outside the state of Alabama. If you are able to change from the USA-Viva Health & Dental Plan you may only join the Standard Plan; you may not transfer back to the Base Plan.

Will my doctor be covered under the USA-Viva Health & Dental Plan?The USA-Viva Health & Dental Plan’s network is limited to physicians from USA along with a select few additional specialists affiliated with other hospitals. The provider directory can help you determine if your physician(s) are in the network. You can also call Viva at 800-294-7780 or [USA micro site url] or go to the web site for the provider listing at www.aldkdlajfj.com to verify your physician’s status. Remember, medical providers that are not Network Providers are not eligible for benefits.

Under the USA-Viva Health & Dental Plan, if my Network Physician refers me to a Non-Network medical provider will that be covered by the Plan?No, generally no out-of-network medical providers will qualify for benefits. The only time a Non-Network medical provider will qualify for benefits is when Viva Health’s medical director has approved the medical expense or service for payment of benefits in advance of the medical procedure or expense.

What should I consider when deciding whether to join the USA-Viva Health & Dental Plan?You should consider that only a limited network of medical providers will qualify for coverage. This may not be the best plan if you have a chronic illness and are currently receiving medical care from multiple

providers and specialists. In that case, you will want to verify that the medical providers you use are Network Providers and are listed in the provider directory. If they are not Network Providers, you should elect to remain with the Standard Plan option or the Base Plan option.

Why are the benefits better and the cost less for the USA-Viva Health & Dental Plan?The medical providers on the USA-Viva Health & Dental Plan have agreed to accept a lower fee for services, resulting in lower costs for you. These medical providers also work to achieve better medical outcomes through quality of care, which also reduces costs. The USA-Viva Health & Dental Plan benefits are better for medical services but the pharmacy and dental benefits are the same as the Standard Plan benefit.

Who selects the medical providers for the USA-Viva Health & Dental Plan?Viva Health, Inc. has the sole responsibility for selecting medical providers to be included as Network Providers. Viva Health, Inc. monitors these providers for access and quality of care as well as medical outcomes to ensure the highest level of medical care. Viva Health, Inc. has the sole authority to add and remove providers from the listing of Network Providers.

How do I join the USA-Viva Health & Dental Plan?You must complete an enrollment form and file it with the University’s Human Resources Department. When you file that form you will attest that you understand:1. that the USA-Viva Health & Dental Plan is

a limited network plan that does not provide benefits for out-of-network medical providers except for emergency medical care (and then only after proper notification) and services prior approved by Viva Health’s medical director;

2. that it is your responsibility to ensure that medical care is provided by a Network Provider; and

3. that you may not change from the USA-Viva Health & Dental Plan except during open enrollment for coverage effective January 1st of the following year unless if you have a change of residence and reside outside the state of Alabama (see the change-in-status event rule described in your Member Handbook).

Effective Dates: January 1, 2017 – December 31, 2017 Attachment A to Certificate of Coverage

USA.2017 09/2016

The Plan’s services and benefits, with their copayments, coinsurance, and some of the limitations, are listed below. Please remember that this is only a brief listing. For further information, plan guidelines, and exclusions, please see the Summary Plan Description. As a member of this plan, you have a limited

provider network that includes the physicians associated with the University of South Alabama Health System. It also includes access to the entire VIVA HEALTH network of dermatology, endocrinology, durable medical equipment, ancillary services, urology, and rheumatology providers. These providers can be found in

our provider directory, by calling Member Services, or by using our online provider search. Please keep this Attachment A for your records. BENEFITS COVERAGE

CALENDAR YEAR OUT-OF-POCKET MAXIMUM: The most a Member will pay per Calendar Year for qualified medical, mental, and substance abuse services, prescription drugs, and specialty drugs. The maximum includes deductibles, copayments, and coinsurance paid by the Member for qualified services but does not include premiums or out-of-network charges over the maximum payment allowance. See the Summary Plan Description for details.

COVERAGE: INDIVIDUAL FAMILY MEDICAL: $1,850 $3,700 PHARMACY: $5,000 $10,000 TOTAL: $ 6,850 $13,700

PREVENTIVE CARE: Well Baby Care (Children under age 3) Routine Physicals (One per Calendar Year for ages 3+) Covered Immunizations OB/GYN Preventive Visit (One per Calendar Year) Preventive Prenatal Care (As defined in the Summary Plan Description) Other preventive items and services (See the Summary Plan Description for more

information)

$0 Copayment per visit; 100% Coverage

OTHER PRIMARY CARE SERVICES: Medical Physician Services Illness and Injury Hearing Exams X-Ray and Laboratory Procedures


SPECIALTY CARE: Medical Physician Services Illness and Injury OB/GYN Services X-Ray and Laboratory Procedures


URGENT CARE CENTER SERVICES: Medical Physician Services Illness and Injury


TELEHEALTH SERVICES: $0 Copayment per consultation; 100% Coverage VISION CARE: One routine vision exam per Calendar Year Other eye care office visits


ALLERGY SERVICES: Physician Services Testing & Treatment

$0 Copayment per service; 100% Coverage

DIAGNOSTIC SERVICES: (Including but not limited to CT Scan, MRI, PET/SPECT, ERCP) $0 Copayment per service; 100% Coverage OUTPATIENT SERVICES: Surgery and Other Outpatient Services


HOSPITAL INPATIENT SERVICES: Physician Services Semi-Private Room


MATERNITY SERVICES: Physician Services (Prenatal, delivery, and postnatal care) Maternity Hospitalization


Newborn care and other services covered only for enrolled child of employee or employee’s spouse. Eligible child must be enrolled within 30 days of birth or adoption. No coverage for children of employee’s dependent child.

EMERGENCY ROOM SERVICES: Must be Medically Necessary to be covered at 100%. Members can use participating urgent care facilities in urgent but non-emergency situations.


EMERGENCY AMBULANCE SERVICES: (Must be Medically Necessary) 80% Coverage DURABLE MEDICAL EQUIPMENT AND PROSTHETIC DEVICES: (Orthotic devices limited to two pairs every 12 months)


SKILLED NURSING FACILITY SERVICES: (Limited to 60 days per Calendar Year) 80% Coverage DIABETIC SUPPLIES: For Diabetic Supplies call VIVA HEALTH. Injectable and oral diabetic medications covered under prescription drug rider.

$0 Copayment; 100% Coverage

REHABILITIATION SERVICES: Physical, Speech, and Occupational Therapy (Limited to 60 visits each per Calendar Year. Cardiac Rehabilitation is limited to 36 visits per episode.)

$0 Copayment per visit/admission; 100% Coverage

HOME HEALTH CARE SERVICES: (Limited to 60 visits per Calendar Year) $0 Copayment per visit; 100% Coverage HOSPICE SERVICES: (Limited to 180 days per lifetime) $0 Copayment per visit; 100% Coverage CHIROPRACTIC SERVICES: (Limited to 60 visits per Calendar Year) $0 Copayment per visit; 100% Coverage TEMPOROMANDIBULAR JOINT DISORDER (TMJ) PHASE I TREATMENT: $0 Copayment per service; 100% Coverage

Effective Dates: January 1, 2017 – December 31, 2017 Attachment A to Certificate of Coverage

USA.2017 09/2016

BENEFITS COVERAGE SLEEP DISORDERS: $0 Copayment per visit/service; 100% Coverage TRANSPLANT SERVICES: $0 copayment per service; 100% Coverage MENTAL HEALTH & SUBSTANCE USE DISORDER SERVICES1: Inpatient Services (limited to 30 days for mental health and 30 days for

substance use disorder per calendar year and a lifetime limit of 60 days each) Outpatient Services2 (limited to 60 combined mental health and substance

use disorder outpatient visits per member each year)

$0 Copayment per visit/service; 100% Coverage

1Certain diagnoses are excluded from coverage. Treatment at a residential facility is not a covered service. See your Summary Plan Description for details. 2Limited to treatment in an outpatient facility or free-standing substance use disorder facility only.

PRESCRIPTION DRUG PROGRAM, Administered by Express Scripts, Inc. (ESI) The University of South Alabama’s prescription drug program for the VIVA HEALTH plan is administered through Express Scripts, Inc. (ESI). Claims for prescription drugs and any complaints regarding the prescription drug program must be submitted to ESI rather than to VIVA HEALTH. Contact ESI Customer Service at 1-855-687-3857 if you have questions regarding your prescription drug coverage. ESI has an extensive network of pharmacies that will accept this coverage. You must present your ESI identification card to the pharmacy at the time you fill your prescription. All drugs must be FDA-approved legend drugs prescribed by a physician and dispensed by a

licensed pharmacist. Prescription drug benefits are provided for participating pharmacies only. A participating pharmacy is a pharmacy contracted with ESI. Some prescriptions require prior authorization and specialty medications may be restricted to purchase from Accredo pharmacy.

Prescription Drug Card:

Non-Maintenance Prescriptions Up to a 30 day supply at retail.

Maintenance Prescriptions up to a 90 day supply; one copay for each 30 day supply.

Home Delivery requires only two copays for a 90-day supply with no shipping fee. Additional information may be obtained at 1-800-698-3757 or www.Express-Scripts.com.

Specialty Drug refills are limited to the first two after which they must be purchased from ESI Specialty Pharmacy Accredo or the individual must pay 100% of the cost.

Benefits are not provided for fertility drugs.

Express Scripts Participating Pharmacy Network:

Separate $100 prescription drug deductible per member per calendar year; maximum of 3 per family ($300). Each prescription purchased from a Participating Pharmacy will be covered at 100% after the deductible with the following copays:

Tier Type Copay per 30 day supply3

1 Generic $10 2 Preferred Brand Name $50 3 Non-Preferred Brand Name $75 4 Specialty 50%

3Out-Of-Pocket Maximum: The benefit increases to 100% of the allowed amount after the annual out-of-pocket maximum is met. The out-of-pocket limit is $5,000 for the individual and $10,000 for the family.

Insulin, needles, and syringes purchased on the same day will have one copay; otherwise each has a separate copay.

Contraceptives are covered at 100% for all FDA approved contraceptives prescribed by a physician.

Non-Participating Pharmacy:

Not covered.

No benefits for prescriptions purchased at a non-Participating Pharmacy.

DENTAL BENEFITS, Administered by Southland Dental The Dental Plan allows you to seek treatment from any licensed dentist. Please refer to the Southland Dental Member Handbook for covered benefits, limitations, and exclusions. The Dental Plan is included in the health plan premium for VIVA HEALTH and is offered by Southland Dental. There is no additional cost for this plan.

For questions regarding the dental plan or to receive a new ID card, please contact Southland Dental Customer Service at 1-800-476-3010.

Type I Diagnostic/Preventive Services Routine oral exams, Fluoride treatments (children under 19), Cleanings, X-Rays (limitations

may apply), Sealants, Space Maintainers, and Prophylaxis

100% coverage of Maximum Plan Allowance

Type II Basic Services Fillings, Surgical Extractions, Palliative Services, and General Anesthesia


Type III Major Services Major Restorative (crowns, bridges, and dentures), Denture Repair, Endodontics (root

canals), and Periodontics


Maximum Dental Benefit: $1,000 Calendar Year limit. $25 per person/$75 per family per calendar year deductible applies to Basic and Major Services. Please refer to the dental schedule of benefits, limitations, and exclusions for full benefit descriptions. Time served on a prior carrier’s dental plan with your current employer

may be credited toward the Southland Dental plan’s waiting periods

VIVA HEALTH Customer Service: (205) 558-7474 or 1-800-294-7780 Visit our Website at www.vivahealth.com

Eligible Dependent: To be eligible to enroll as a Covered Dependent, a person must be listed on the enrollment application completed by the Subscriber, reside in the state of Alabama or with the Subscriber (exceptions apply), and meet additional qualifying criteria. For exceptions and additional qualifying criteria, please refer to the Summary Plan Description.

Pre-Existing Condition Policy: No pre-existing condition exclusions or waiting period. Nondiscrimination Notice: VIVA HEALTH complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin,

age, disability, or sex. Language Assistance Services: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-294-7780 (TTY: 711).

注意如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-294-7780 TTY：

Wellness Benefits

Preventserv2016R2 | 08/2016

This schedule outlines preventive services and items that VIVA HEALTH will pay at 100% for its non-grandfathered “Wellness” plans. Many of the services are provided as part of an annual physical, which is covered at 100%. In some cases, an office visit or facility copayment or coinsurance may apply if the preventive service or item is billed separately from the visit. A copayment or coinsurance may also apply if the primary purpose of your visit is not routine, preventive care. All services must be performed by a provider in your network. This list does not apply to all VIVA HEALTH plans. Please refer to your Certificate of Coverage to determine the terms of your health plan.

PREVENTIVE SERVICE FREQUENCY Well Baby Visits (Age 0-2) Routine screenings, tests, and immunizations

As recommended per guidelines1

As recommended per guidelines Well Child Visits (Age 3-17) (Must be part of the annual well child visit for coverage at 100%) Routine screenings, tests, & immunizations HIV screening and counseling Obesity screening Hepatitis B virus screening Sexually transmitted infection counseling Skin cancer behavioral counseling (Beginning at age 10)

One per year at PCP2

As recommended per guidelines As recommended per guidelines As recommended per guidelines As recommended per guidelines Annually As recommended per guidelines

Routine Physical (Age 18+) (Must be part of your annual physical or OB/GYN visit for coverage at 100%) Alcohol misuse screening and counseling Blood pressure screening Cholesterol screening Depression screening Diabetes screening Hepatitis B and C virus screening HIV screening and counseling Obesity screening Sexually transmitted infection counseling Syphilis screening Skin cancer behavioral counseling (Up to age 24)

One per year at PCP Annually Annually As recommended per guidelines Annually As recommended per guidelines As recommended per guidelines As recommended per guidelines As recommended per guidelines Annually As recommended per guidelines As recommended per guidelines

Well Woman Visit (Adolescents & Adults) (Must be part of your annual physical or OB/GYN visit for coverage at 100%) Pap smear/cervical cancer screening Chlamydia screening Contraception counseling Domestic violence screening and counseling Gonorrhea screening HPV DNA testing Depression Screening

One per year at PCP or OB/GYN Annually As recommended per guidelines Annually Annually As recommended per guidelines Women 30+, every three years Annually

Maternity Care (Pregnant Women) Prenatal and Postpartum Services (Up to 6 visits per pregnancy for the following services):

Anemia screening Bacteriuria screening Chlamydia screening Depression screening Gestational diabetes mellitus screening

Gonorrhea screening Hepatitis B screening HIV screening Rh incompatibility screening

Syphilis screening

Breast feeding counseling Breast pump purchase3

Tobacco counseling

As recommended per guidelines

As recommended per guidelines One at 12-16 weeks’ gestation One per pregnancy for at-risk women One per pregnancy and one postpartum First prenatal visit if high-risk; after 24 weeks of

gestation for all women One per pregnancy for at-risk women First prenatal visit One per pregnancy First prenatal visit for all women; repeated testing at

24-28 weeks’ gestation if at-risk One per pregnancy Two per pregnancy One electric pump selected by VIVA HEALTH every 4 years Three per pregnancy for women who smoke

Wellness Benefits

Preventserv2016R2 | 08/2016

PREVENTIVE SERVICE FREQUENCY Contraception (Females) o

Oral contraceptives4,5 o Select generics only; Prescription required Implant (Implanon) One every three years; Performed in physician’s office Injection (Depo-Provera shot) o One every three months I.U.D. o One every three years; Performed in physician’s office Diaphragm or cervical cap o One per year Over the counter contraceptives (Females)5 o Generic only; Prescription required; Quantity limits apply

based on method Sterilization o One procedure per lifetime Contraceptive patch o Three per month Contraceptive vaginal ring o One per month

Osteoporosis screening (All women age 65+ and at-risk women of all ages) As recommended per guidelines Screening mammography (Women age 40+) One per year BRCA risk assessment and genetic counseling/testing (At-risk women) Per medical/family history Colorectal cancer screening (Age 50-75) o

Fecal occult blood testing or One per year Sigmoidoscopy or One every five years Screening colonoscopy One every 10 years

Abdominal aortic aneurysm screening (Men age 65-75 w/ smoking history) Lung cancer screening (Very heavy smokers age 55-80)

One per lifetime One per year, as recommended per guidelines

Dental caries prevention (Infants and children from birth through age 5) Four per year at physician’s office Routine immunizations (Not travel related); Includes, but not limited to: As recommended by CDC

Influenza (Age 6 months-adult) One per year HPV (Starting age 11-12) 3 doses per lifetime Pneumococcal As recommended by PCP Zoster (Shingles) (Age 60+) o One per lifetime

For a full list of covered immunizations, please visit www.vivahealth.com or call VIVA HEALTH Customer Service at 1-800-294-7780 and ask a representative to mail you a copy. Diet counseling (Adults with high cholesterol or other risks for heart or diet-related chronic disease) Obesity counseling (Clinically obese children and adults: BMI > 30) Tobacco use counseling and interventions

Three visits per year with PCP Six visits per lifetime with PCP Two visits per year with PCP or specialist

PHARMACY BENEFITS4 FREQUENCY Aspirin to prevent heart disease (Men ages 45-79; Women ages 55-79) Low-dose (81 mg) aspirin to prevent preeclampsia (High-risk pregnant women after 12 weeks of gestation) Folic acid supplements (Women 55 & younger) Iron supplements (12 months & younger) Oral contraceptives (Females) Over the counter contraceptives (Females)5

Oral fluoride supplements (6 years & younger) Vitamin D (At-risk 65+) Tobacco cessation products6

Breast cancer preventive drugs (Women)7

Generic only Generic only Generic only For babies at risk for anemia Select generics only Generic only

For children whose water source is fluoride deficient Generic only; for those at increased risk for falls Up to 12 weeks without Prior Authorization for generic Zyban, generic nicotine patch, gum and lozenge, and nicotine inhaler or nasal spray; up to 24 weeks without Prior Authorization for varenicline tartrate (Chantix)

Tamoxifen and raloxifene (generic only)

1“As recommended per guidelines” means as recommended by your physician and in accordance with guidelines issued under the Affordable Care Act. 2PCP means personal care provider or primary care physician and is generally an internist, family practitioner, general practitioner, pediatrician, and

sometimes an obstetrician/gynecologist. 3To order a breast pump, member must be within 30 days of due date or actively breastfeeding. Call MedSouth Medical Supplies at 1-800-423-8677. Exceptions to limits may apply based on medical necessity. 4Must have prescription coverage through VIVA HEALTH to access this benefit. Prescription required for coverage, even for over-the-counter products. Quantity limits may apply. 5Exceptions may

apply based on medical necessity. 6Prior Authorization must be obtained in order to access additional courses of treatment covered at 100%. 7Must complete and return to VIVA HEALTH an exception form to be eligible to receive at $0 copayment. Go to www.vivaprovider.com/Resources/Forms.aspx

to download the form, or call Customer Service.

Southland Member GuideUsing Your Southland Dental PlanPlease Read This Important Information Before Using Your BenefitsWelcome to The Southland Benefit Solutions Family! This guide explains some of your new dental plan’s more important features. Please read this in order to gain a better understanding of how to best utilize your dental benefits.

Finding A Provider Our provider directory is available at www.SouthlandBenefit.com. Click the “Locate a Provider” tab in the top menu bar, select the DentaNet network, and you will be presented with a range of search options.

Deductibles Your deductible is $25 per individual and a maximum of 3 per family within a plan year ($75 max per year). This cost is waived for Type I services at In-Network Providers.

In-Network Benefits When visiting an in-network provider, covered dental services are based on the maximum allowable charge (MAC) schedule, a set of negotiated rates within our network. Using an in-network provider eliminates balance-billing, maximizes your benefits, and reduces out-of-pocket expenses.

Out-of-Network Claims When visiting an out-of-network provider, covered dental services are based on a MAC schedule. Using an out-of-network provider may result in balance-billing and greater out-of-pocket expenses.

ID Cards and Your Contract Number

After enrollment, each employee is issued an ID card and contract number. Your contract number is used to access benefits, eligibility, authorizations, and claims for you and your dependents. Additional or replacement cards can be requested through customer service or the Southland member portal located on our website.

Creating Your Online Account

To create your account visit www.southlandbenefit.com and click on the “View Your Account” tab on the top menu bar. Select the “Create ID Now!” button to begin the process. Select “participant”, click continue, and you will be guided through the process.

www.SouthlandBenefit.com P.O. Box 1250, Tuscaloosa, AL 35401

(205) 343-1250 (800) 476-3010

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MEMBERSHIP CONDITIONS

I am aware of and accept the following VIVA HEALTH, Inc. membership conditions:

1. I understand that the USA Viva Health & Dental Plan is a limited network plan and the service area is defined as the state of Alabama.

2. 2. I authorize the release and use of all my medical records or information necessary to process claims or in any way determine benefits due. Medical information can also be used to execute the obligations imposed on Viva Health, Inc. by state or federal status, as well as for the Quality Assurance or Peer Review programs conducted by Viva Health, Inc. or its designated agents.

3. I authorize my employer to deduct premium contributions, if any, from my wages or salary with the understanding that my employer acts as my agent in all dealings with the Plan where not prohibited by statute or regulation.

4. I have read and understand the membership information available in the enrollment materials including the description of exclusions and limitations. I will abide by the Group Health Policy and Certificate of Coverage applicable to the plan in which I enrolled, and will be responsible for ensuring my (our) dependents follow instructions and abide by conditions listed therein.

5. I understand any service not provided by a participating physician or authorized by Viva Health, Inc. will not be covered and will be my responsibility.

6. I understand that the USA Viva Health & Dental Plan is a limited network plan that does not provide benefits for out-of-network medical providers except in the case of emergency medical care and then only after proper notification. I understand that it is my responsibility to ensure that medical care is provided by a Network Provider. I understand that I may not change from the USA Viva Health & Dental Plan except during open enrollment for coverage effective January 1 of the following year.

7. I understand that if I am currently a USA Health & Dental Base Plan participant and I voluntarily elect to participate in the USA Viva Health & Dental Plan; and should I elect later to change from the USA Viva Health & Dental Plan, I understand that I may only re-enroll in the USA Health & Dental Standard Plan.

TOBACCO USE CERTIFICATION

The USA Viva Health & Dental Plan is committed to helping you achieve your best health. The Wellness Incentive is available to all employees. If you think you might be unable to meet the standard under this Wellness Program, you may qualify for an opportunity to earn the same reward by different means. Contact the USA Human Resources Department for additional information.

Have you or your spouse used tobacco products within the last six (6) months? ___ YES ___ NO

Further, I attest that everything in the application is true.

Printed name______________________________ Employee J#__________________

Signature: _____________________________________ Date: ________________________

Guide to the Benefits Debit Card — FSA

www.DiscoveryBenefits.com

FLEXIBLE SPENDING AT YOUR FINGERTIPS

Fewer out-of-pocket expenses at time of service No waiting for reimbursementMerchant is paid directly at the point of sale

How It Works• Use the Discovery Benefits debit card to pay for eligible

services and products. Payments are automatically withdrawn from your reimbursement account, so there are fewer out-of-pocket costs. Merchants with the Inventory Information Approval System (IIAS) can provide all IRS-required information right at the point of sale. Your debit card will also work at pharmacies and drug stores that meet the IRS’ 90% rule. Documentation needs to be provided for purchases made at a 90% merchant. An IIAS and 90% merchant list can be located on our website at www.DiscoveryBenefits.com/IIAS.

• PIN numbers can be set up for your benefits debit card. In order to set up a PIN number, please call Discovery Benefits’ automated response system at 866-451-3399 — option 1 to identify that you are a participant, option 1 to identify which plan and option 3 to select PIN. Please have your card available for reference to expedite the process.

Documentation/Receipts• Due to IRS regulations, certain debit card transactions

need to be substantiated. Substantiating means validating a transaction to ensure the debit card was used for IRS-approved items/services within the allowed time frame. If documentation is required for a debit card transaction, you will receive email notifications to log in to your account to view receipt reminders. The receipt reminder will display the documentation required and your next steps. Note: If you do not have an email address on file, a receipt reminder will be mailed.

• Debit card use will be put on a temporary hold if documentation is not received within the designated time period. You will be asked to pay back the plan or offset the ineligible amount with documentation for eligible out-of-pocket expenses incurred within the same plan year. The benefits debit card will be reactivated as soon as the appropriate documentation or repayment is received.

Increased use of funds, less chance to forfeit at year endCard is valid for three years

Revised 7/01/16

Guide to the Benefits Debit Card — FSA, continuedWhen Documentation is Not Needed • Co-payments tied to the account holder’s health plan: These

amounts need to be communicated to Discovery Benefits by your employer.

• Purchases made at merchants using the Inventory Information Approval System (IIAS): These merchants will approve eligible expenses at the point of purchase. When using your debit card at these merchants, swipe your debit card for the entire purchase. The items that are eligible expenses will be approved, and the merchant will ask for a secondary form of payment for ineligible items. To find a full list of merchants utilizing IIAS, visit our website at www.DiscoveryBenefits.com/IIAS.

• Recurring expenses that match the same provider and dollar amount for previously substantiated transactions (e.g., orthodontia claims, maintenance prescription drugs/services).

When Documentation is Needed• Debit card transactions that do not meet the above criteria

will need additional documentation due to IRS regulations. If documentation is required for a debit card transaction, you will receive email notifications to log in to your account to view receipt reminders. The receipt reminder will display the documentation required and your next steps. Note: If you do not have an email address on file, a receipt reminder will be mailed.

Documentation Requirements• Documentation for medical expenses, which is required

by the IRS, includes a receipt/statement containing: name of the provider, date(s) of service, type(s) of service and amount (after insurance, if applicable). Explanation of Benefits (EOB) provided by insurance providers are ideal for substantiating claims. • When submitting a receipt for a co-payment amount,

please be sure the co-payment description is on the receipt. In some cases, you will need to ask for a receipt at the point of service. If “co-payment” is not clearly identified, have the provider write “co-payment” on the receipt and sign it.

• Documentation for dependent care expenses, which is required by the IRS, includes a receipt containing: name of provider, date(s) of service, type(s) of service and dollar amount. Note: The daycare provider’s signature on the receipt reminder will replace the need to submit a receipt.

Unacceptable forms of documentation include the following:• Provider statements that only indicate the amount paid,

balance forward or previous balance• Credit card receipts• Missing or vague medical practitioner’s notes• Bills for prepaid dependent care/medical expenses where

services have not yet occurred

How to Submit DocumentationDocumentation can be uploaded by logging in to your account at www.DiscoveryBenefits.com or by using the mobile app feature. If you choose to fax your documentation, please include the receipt reminder. Processing time is two business days; if further action is required, you will be notified in writing. Documentation is processed on a Central Timezone basis.

Contact Information

Participant Services Hours of Operation

6 a.m. to 9 p.m. CST (M-F)

Participant Services Toll-Free Phone Number

866-451-3399

Toll-Free Fax Number 866-451-3245

Participant Services Email Address

[email protected] (This email is for inquiries only. Please do not submit documentation to this address.)

Mailing Address

Discovery Benefits PO Box 2926 Fargo, ND 58108

Note: Some items pictured above may require a prescription or doctor’s note to be FSA eligible.

Have a Medical FSA balance and want to avoid submitting receipts?

Learn how to easily manage your account,

spend down your balance and find a full list of merchants that utilize IIAS at our

website.

www.DiscoveryBenefits.com

Flexible Spending Account (FSA) Data Collection Worksheet

Revised 6/27/16

www.DiscoveryBenefits.com ∙ 866-451-3399

Please complete and submit this worksheet to your employer. This is an internal document used by your employer for data collection purposes. Worksheets returned to Discovery Benefits cannot be processed.

*=Required Fields

If you have a payroll deduction for insurance premiums, eligible premiums will be deducted before taxes are calculated. You will automatically be enrolled in this portion of your Section 125 Plan. However, if you wish, you may opt out of the Employee Premium Conversion part of the Plan by contacting your HR Department and filling out the waiver form. Note: Insurance premiums are not eligible for reimbursement with your Medical or Limited Medical Spending Account.

I authorize my employer to reduce my pay on a per-pay-period basis as indicated above. I understand my reduction is for one flex plan year and that I cannot change or revoke my election unless I experience a qualifying event in accordance with Internal Revenue Code Section 125 and submit my request within a reasonable amount of time as deemed by the IRS and my employer. I am aware of the plan’s forfeiture provision and that my Social Security and federal unemployment benefits may be reduced because of my reduced salary for tax purposes. Further, I authorize the release of any information necessary to substantiate claims submitted against my Flexible Spending Account.

Step 1: Participant Information

Step 2: Employee Premiums

Step 4: Authorization

Step 5: Refusal (Note: Only complete this step if you are NOT electing to enroll in a Flexible Spending Account)

Step 3: Enrollment and Election Information

*Employer Name (Do not abbreviate)

*Plan Type (If enrolled in an HSA, you are not eligible to enroll in the Medical FSA. However, you are eligible for both the Limited Medical FSA and Dependent Care FSA if offered through your employer.)

*Annual Election (if employer funded, note “ER” next to amount):

*Number of Pay Periods (if enrolling mid-year, please enter the number of remaining pay periods within the plan year):*Per Pay Period Amount (to be deducted each pay period):

*Date of First Payroll (mm/dd/yyyy):

*Participant Effective Date (mm/dd/yyyy):

*Pay Frequency (please check one):

Medical FSA Limit set by employer

Monthly Semi-Monthly

Bi-Weekly 24

Bi-Weekly 26

Weekly Other

$

÷

= = =

÷ ÷

$ $

Limited FSA Limit set by employer if this plan type is offered

Dependent Care Account Limit set by employer up to IRS maximum

*Participant Name (First, MI, Last)

Employee ID Number

*Social Security Number

--

- -

*Participant Mailing Address

Email Address

*Date of Birth (mm/dd/yyyy) *Hire Date (mm/dd/yyyy)

Day Telephone

*City *State *Zip

*Participant Signature

Participant Signature

*Date

Date

*Gender (M/F) *Marital Status (Married/Single)

THIS PAGE IS INTENTIONALLY LEFT BLANK

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Customer Service(205) 558-7474 or (800) 294-7780 or

[email protected]

Coverage & Value

Coverage you deserve.Value you demand.

A Product of ViVa HealtH

A Member of the Health System

www.vivahealth.com

417 20th Street North, Suite 1100 Birmingham, Alabama 35203

ViVa HealtH complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-294-7780 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務. 請致電1-800-294-7780 (TTY: 711). H0154_mcdocxxxxx CMS Accepted mm/dd/yyyy

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