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FY12 BeneFits HandBook
taBle oF Contents
CompreHensive notiCe oF privaCY poliCY and proCedures . . . . . . . . . . . . . . . . . . . . . . . . . . .1The Plan’s Duty to Safeguard Your Protected Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1How the Plan May Use and Disclose Your Protected Health Information . . . . . . . . . . . . . . . . . . . . . . . . . .1
Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations . . . . . . . . . . . . . . . .1Other Uses and Disclosures of Your PHI Not Requiring Authorization . . . . . . . . . . . . . . . . . . . . . . . . . .2
Your Rights Regarding Your Protected Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3How to Complain about the Plan’s Privacy Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Contact Person for Information, or to Submit a Complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Organized Health Care Arrangement Designation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
aBout tHis HandBook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
BeneFits in BrieF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6UA Choice Health Care Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Flexible Spending Accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Retirement Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Other Benefits * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Other Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
introduCtion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Your Benefit Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefit Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Notice Under the Women’s Health and Cancer Rights Act of 1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Campus Human Resources Office Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Your role in ControllinG Your HealtH plan Costs . . . . . . . . . . . . . . . . . . .13
eliGiBilitY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Employee Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Enrollment Waiting Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Dependent Enrollment Time Frames . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Dependent Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Evidence of Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Continued Eligibility for a Disabled Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Major Life Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Involuntary Loss of Other Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Open Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Re-enrollment After a Lapse in Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Cost for Employee Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Cost for Dependent Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
pre-eXistinG Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Credit for Prior Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
plan Year deduCtiBle—mediCal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Individual Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Family Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
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Common Accident Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Fourth Quarter Deductible Carry Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Benefits Not Subject to the Medical Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
sCHedule oF BeneFits—mediCal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Anchorage, Fairbanks and Juneau . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Outside Anchorage, Fairbanks and Juneau . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20When You Are Outside Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Benefit Level Exception for Non-Emergent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Waived Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Provider Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
out-oF-poCket maXimums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Individual Medical Out-of-Pocket Maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Family Medical Out-of-Pocket Maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Out-of-Pocket Maximums By Plan Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Maximum Lifetime Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
preventive (Wellness) BeneFit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Wellness Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Care manaGement / HealtHCare utiliZation . . . . . . . . . . . . . . . . . . . . . . . . . .26Individual Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Appeals Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26BestBeginnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
tHe BlueCard proGram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Here’s How BlueCard helps keep costs down . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Clark County Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Non-BlueCard Claim Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28BlueCard Worldwide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Further Questions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Covered serviCes and supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Hospital Inpatient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Hospital Inpatient Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Hospital Outpatient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Skilled Nursing Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Skilled Nursing Care Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Ambulatory Surgical Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Physicians’ Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Assistant Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Multiple Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Mental Health Care Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Chemical Dependency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Chemical Dependency Treatment Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Therapeutic Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Diagnostic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Diagnostic and Screening Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Contraceptive Management and Sterilization Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Prescription Contraceptives Dispensed by a Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Contraceptive Management and Sterilization Services Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
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Mastectomy and Breast Reconstruction Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Covered Transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Transplant Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Transplant Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Rehabilitation Therapy, Chronic Pain Care, and Neurodevelopmental Therapy . . . . . . . . . . . . . . . . . . . .34Rehabilitation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Inpatient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35Outpatient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35Chronic Pain Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35Neurodevelopmental Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Rehabilitation Therapy, Chronic Pain Care, and Neurodevelopmental Therapy Limitations . . . . . . . . .35Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Home Health Care Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Hospice Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Hospice Care Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37Licensed Ambulance Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Special Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Home Medical and Respiratory Equipment/Medical Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Home Medical and Respiratory Equipment/Medical Supplies Limitations . . . . . . . . . . . . . . . . . . . . . .38Prosthetic Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Prosthetic Devices Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39Blood Transfusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39PKU Dietary Formula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39Obstetric Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39Routine Newborn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Newborn Hearing Exams and Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Chiropractors’ Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41Health Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41Nicotine Dependency Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Nutritional Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41Skilled Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Skilled Nursing Care Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41Temporomandibular Joint (TMJ) Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42Orthognathic Surgery (Jaw Augmentation or Reduction) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42Obesity Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Non-Surgical Weight Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42Surgical Treatment of Morbid Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42Obesity Treatment Benefit Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
disease manaGement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
pHarmaCY proGram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45Maximum Medication Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45Special Features of the Pharmacy Network Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45Drug Utilization Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45Generic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46High Performance Step Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46Approved Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47Prescription Drug Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47Refills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47Maintenance Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
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Out-of-Pocket Maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48Pharmacies Outside Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48Non-Participating Retail Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48Coordination of Benefits for Prescription Drug Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48Ordering From CVS Caremark Mail Service Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49CVS Caremark Specialty Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Pharmacy Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
dental Care BeneFits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51Estimate of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51Alternative Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52Plan Year Deductible (750 and High Deductible Health Plans only) . . . . . . . . . . . . . . . . . . . . . . . . . . . .52Covered Dental Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52Type A—Preventive Care Expenses (not subject to dental deductible) . . . . . . . . . . . . . . . . . . . . . . . . . . .52Type B—Basic Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53Type C—Major Dental Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Dental Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54Orthodontia (Available on 500 Plan Only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Orthodontia Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
vision Care BeneFits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56Covered Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56Extra Discounts and Savings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56Using Non-VSP Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Vision Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
audio Care BeneFits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59Covered Services and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Audio Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
HoW to suBmit a Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60Automatic Claims Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60Manual Claims Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60Air or Surface Transportation Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61Submission of Pharmacy Drug Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61Claims Filing Timelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62Claims Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62Denied Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62Your Questions, Complaints and Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62
When You Have Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62When You Have a Complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63When You Have an Appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63Appeals Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Coordination oF BeneFits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65Terms You Should Know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65Order of Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66Right of Recovery/Facility of Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66Third Party Liability (Subrogation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
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termination oF BeneFits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68Termination of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68Certificate of Group Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68Plan Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
CoveraGe Continuation (CoBra) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69Leave of Absence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70Medicare Supplement Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
eXtended BeneFits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71Continued Eligibility for a Disabled Enrollee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71Surviving Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
General limitations and eXClusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73What Your Program Does Not Cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
General provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76Enrollee Cooperation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76Notice of Other Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76Evidence of Medical Necessity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76Notice of Information Use and Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76Right to and Payment of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77Right of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77Venue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77Workers’ Compensation Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77Intentionally False or Misleading Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77Limitations of Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
FleXiBle spendinG aCCounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79Plan Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79Major Life Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80Termination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80Use It or Lose It Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80Medical Flexible Spending Account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81Eligible Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81Dependent Care Flexible Spending Account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82How to Submit a Claim for Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
Medical FSA Claim Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83Dependent Care FSA Claim Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
Questions Regarding Your Plan? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83COBRA Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
emploYee assistanCe proGram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84How to Use the Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
disaBilitY BeneFits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85Definition of Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85
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Monthly Benefit Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86Monthly Earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86Benefit Offsets (Income from Other Sources) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86Rehabilitation/Return to Work Incentive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87Limitation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87Long Term Disability Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88Long Term Disability Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88Termination of Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88Conversion Privilege . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88
liFe insuranCe BeneFits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89
BasiC liFe insuranCe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Travel Accident Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Disability Waiver of Premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91Portability or Conversion Privilege . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
supplemental liFe insuranCe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92Payment of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93Disability Waiver of Premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93Portability or Conversion Privilege . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93
aCCidental deatH and dismemBerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95AD&D Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95
retirement plans and options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96Social Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
universitY oF alaska optional retirement plan . . . . . . . . . . . . . . . . . . . . . .97Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97Vesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97Your Investment Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97Forms of Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98
vii
Your Choices Of Investment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98Fidelity Investments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98Lincoln National . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98TIAA-CREF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98VALIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99Default Investment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
Choosing a Fund Sponsor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99Distributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
universitY oF alaska pension plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100Vesting and Distributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100Investment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100
state retirement plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
TRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101PERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Contribution Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101TRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101PERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Vesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
Defined Contribution Plan Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102Defined Benefits Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
taX-deFerred annuitY (tda) plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103Disclaimer Of Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103Payment of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104
otHer BeneFits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105Educational Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105Holidays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105Annual Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106Sick Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106Leave of Absence Without Pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107Other Leaves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107Medical Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107Family Medical Leave (FML) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107Leave Share Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108Parental Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108Jury Duty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108Military Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109
GlossarY oF terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110
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NOTES
1
Comprehensive Notice Of Privacy Policy And Procedures
THIS NOTICE IS REQUIRED BY FEDERAL REGULATIONS AND DESCRIBES HOW MEDICAL INFORMA-TION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFOR-MATION. PLEASE REVIEW IT CAREFULLY.
This Notice is provided to you on behalf of:
• UniversityofAlaskaHealthCarePlan• UniversityofAlaskaPharmacyPlan• UniversityofAlaskaVisionPlan• UniversityofAlaskaMedicalFlexibleSpendingAccount
Theseplanscomprisewhatiscalledan“AffiliatedCoveredEntity,”andaretreatedasasingleplanforpurposesofthisNoticeandtheprivacyrulesthatrequireit.ForpurposesofthisNotice,we’llrefertotheseplansasasingle“Plan.”
tHe plan’s dutY to saFeGuard Your proteCted HealtH inFormation
Individuallyidentifiableinformationaboutyourpast,present,orfuturehealthorcondition,theprovisionofhealthcaretoyou,orpaymentforthehealthcareisconsidered“ProtectedHealthInformation”(“PHI”).ThePlanisre-quiredtoextendcertainprotectionstoyourPHI,andtogiveyouthisNoticeaboutitsprivacypracticesthatexplainshow,whenandwhythePlanmayuseordiscloseyourPHI.Exceptinspecifiedcircumstances,thePlanmayuseordiscloseonlytheminimumnecessaryPHItoaccomplishthepurposeoftheuseordisclosure.
ThePlanisrequiredtofollowtheprivacypracticesdescribedinthisNotice,thoughitreservestherighttochangethosepracticesandthetermsofthisNoticeatanytime.Ifitdoesso,andthechangeismaterial,youwillreceivearevisedversionofthisNoticeeitherbyhanddelivery,e-maildelivery,maildeliverytoyourlastknownaddress,orsomeotherfashion.ThisNotice,andanymaterialrevisionsofit,willalsobeprovidedtoyouinwritinguponyourrequest(askyourHumanResourcesrepresentative,orcontactthePlan’sPrivacyOfficial,describedbelow),andwillbepostedontheUniversityofAlaska’sbenefitswebsite.
Youwillalsoreceiveotherprivacynotices,fromcompaniesthatprovidebenefitplanservicestotheUniversityofAlaska.ThosenoticeswilldescribehowtheyuseanddisclosePHI,andyourrightswithrespecttothePHItheymaintain.
HoW tHe plan maY use and disClose Your proteCted HealtH inFormation
The Plan uses and discloses PHI for a variety of reasons. For its routine uses and disclosures it does not require your authorization,butforotherusesanddisclosures,yourauthorization(ortheauthorizationofyourpersonalrepresen-tative,e.g.apersonwhoisyourcustodian,guardian,orhasyourpower-of-attorney)mayberequired.ThefollowingoffersmoredescriptionandexamplesofthePlan’susesanddisclosuresofyourPHI.
uses and disClosures relatinG to treatment, paYment, or HealtH Care operations
• Treatment:ThePlanispermittedtodiscloseyourPHIforpurposesofyourmedicaltreatment.Thus,itmaydis-closeyourPHItodoctors,nurses,hospitals,emergencymedicaltechnicians,pharmacistsandotherhealthcareprofessionalswherethedisclosureisforyourmedicaltreatment.
2
• Payment:ThePlanispermittedtodiscloseyourPHIforpurposesofpaymentofyourclaims.Thus,itmaydiscloseyourPHItodoctors,nurses,hospitals,emergencymedicaltechnicians,pharmacistsandotherhealthcareprofessionalswherethedisclosureisforpaymentfunctions.ThePlanmayalsoshareyourPHIwithotherplans,incertaincases.Forexample,ifyouarecoveredbymorethanonehealthcareplan,wemayshareyourPHIwiththeotherplanstocoordinatepaymentofyourclaims.
• Healthcareoperations:ThePlanmayuseanddiscloseyourPHIinthecourseofits“healthcareoperations.”Forexample,itmayuseyourPHIinevaluatingthequalityofservicesyoureceived,ordiscloseyourPHItoanaccountantorattorneyforauditpurposes.Insomecases,thePlanmaydiscloseyourPHItoinsurancecompa-niesforpurposesofobtainingvariousinsurancecoverage.
otHer uses and disClosures oF Your pHi not requirinG autHoriZation
ThelawprovidesthatthePlanmayuseanddiscloseyourPHIwithoutauthorizationinthefollowingcircumstances:
• TothePlanSponsor:ThePlanmaydisclosePHItotheemployer(suchasUniversityofAlaska)whosponsorsormaintainsthePlanforthebenefitofemployeesanddependents.However,thePHImayonlybeusedforlimitedpurposes,andmaynotbeusedforpurposesofemployment-relatedactionsordecisionsorinconnectionwithanyotherbenefitoremployeebenefitplanoftheemployer.PHImaybedisclosedto:thehumanresourcesoremployeebenefitsdepartmentforpurposesofenrollmentsanddisenrollments,census,claimresolutions,andothermattersrelatedtoPlanadministration;payrolldepartmentforpurposesofensuringappropriatepayrolldeductionsandotherpaymentsbycoveredpersonsfortheircoverage;informationtechnologydepartment,asneededforpreparationofdatacompilationsandreportsrelatedtoPlanadministration;financedepartmentforpurposesofreconcilingappropriatepaymentsofpremiumtoandbenefitsfromthePlan,andothermattersre-latedtoPlanadministration;internallegalcounseltoassistwithresolutionofclaim,coverageandotherdisputesrelatedtothePlan’sprovisionofbenefits.
• Requiredbylaw:ThePlanmaydisclosePHIwhenalawrequiresthatitreportinformationaboutsuspectedabuse,neglectordomesticviolence,orrelatingtosuspectedcriminalactivity,orinresponsetoacourtorder.ItmustalsodisclosePHItoauthoritiesthatmonitorcompliancewiththeseprivacyrequirements.
• Forpublichealthactivities:ThePlanmaydisclosePHIwhenrequiredtocollectinformationaboutdiseaseorinjury,ortoreportvitalstatisticstothepublichealthauthority.
• Forhealthoversightactivities:ThePlanmaydisclosePHItoagenciesordepartmentsresponsibleformonitor-ingthehealthcaresystemforsuchpurposesasreportingorinvestigationofunusualincidents.
• Relatingtodecedents:ThePlanmaydisclosePHIrelatingtoanindividual’sdeathtocoroners,medicalexamin-ersorfuneraldirectors,andtoorganprocurementorganizationsrelatingtoorgan,eye,ortissuedonationsortransplants.
• Forresearchpurposes:Incertaincircumstances,andunderstrictsupervisionofaprivacyboard,thePlanmaydisclosePHItoassistmedicalandpsychiatricresearch.
• Toavertthreattohealthorsafety:Inordertoavoidaseriousthreattohealthorsafety,thePlanmaydisclosePHIasnecessarytolawenforcementorotherpersonswhocanreasonablypreventorlessenthethreatofharm.
• Forspecificgovernmentfunctions:ThePlanmaydisclosePHIofmilitarypersonnelandveteransincertainsituations,tocorrectionalfacilitiesincertainsituations,togovernmentprogramsrelatingtoeligibilityanden-rollment,andfornationalsecurityreasons.
• UsesandDisclosuresRequiringAuthorization:Forusesanddisclosuresbeyondtreatment,paymentandopera-tionspurposes,andforreasonsnotincludedinoneoftheexceptionsdescribedabove,thePlanisrequiredtohaveyourwrittenauthorization.Yourauthorizationscanberevokedatanytimetostopfutureusesanddisclo-sures,excepttotheextentthatthePlanhasalreadyundertakenanactioninrelianceuponyourauthorization.
• UsesandDisclosuresRequiringYoutohaveanOpportunitytoObject:ThePlanmaysharePHIwithyourfam-ily,friendorotherpersoninvolvedinyourcare,orpaymentforyourcare.ThePlanmayalsosharePHIwiththesepeopletonotifythemaboutyourlocation,generalcondition,ordeath.However,thePlanmaydiscloseyourPHIonlyifitinformsyouaboutthedisclosureinadvanceandyoudonotobject(butifthereisanemer-gencysituationandyoucannotbegivenyouropportunitytoobject,disclosuremaybemadeifitisconsistent
3
withanypriorexpressedwishesanddisclosureisdeterminedtobeinyourbestinterests;youmustbeinformedandgivenanopportunitytoobjecttofurtherdisclosureassoonasyouareabletodoso).
Your riGHts reGardinG Your proteCted HealtH inFormation
Youhavethefollowingrightsrelatingtoyourprotectedhealthinformation:
• Torequestrestrictionsonusesanddisclosures:YouhavetherighttoaskthatthePlanlimithowitusesordisclosesyourPHI.ThePlanwillconsideryourrequest,butisnotlegallyboundtoagreetotherestriction.TotheextentthatitagreestoanyrestrictionsonitsuseordisclosureofyourPHI,itwillputtheagreementinwrit-ingandabidebyitexceptinemergencysituations.ThePlancannotagreetolimitusesordisclosuresthatarerequiredbylaw.
• TochoosehowthePlancontactsyou:YouhavetherighttoaskthatthePlansendyouinformationatanalterna-tiveaddressorbyanalternativemeans.ThePlanmustagreetoyourrequestaslongasitisreasonablyeasyforittoaccommodatetherequest.
• ToinspectandcopyyourPHI:Unlessyouraccessisrestrictedforclearanddocumentedtreatmentreasons,youhavearighttoseeyourPHIinthepossessionofthePlanoritsvendorsifyouputyourrequestinwriting.ThePlan,orsomeoneonbehalfofthePlan,willrespondtoyourrequest,normallywithin30days.Ifyourrequestisdenied,youwillreceivewrittenreasonsforthedenialandanexplanationofanyrighttohavethedenialre-viewed.IfyouwantcopiesofyourPHI,achargeforcopyingmaybeimposeddependingonyourcircumstanc-es.Youhavearighttochoosewhatportionsofyourinformationyouwantcopiedandtoreceive,uponrequest,priorinformationonthecostofcopying.
• TorequestamendmentofyourPHI:IfyoubelievethatthereisamistakeormissinginformationinarecordofyourPHIheldbythePlanoroneofitsvendors,youmayrequest,inwriting,thattherecordbecorrectedorsupplemented.ThePlanorsomeoneonitsbehalfwillrespond,normallywithin60daysofreceivingyourre-quest.ThePlanmaydenytherequestifitisdeterminedthatthePHIis:(i)correctandcomplete;(ii)notcreatedbythePlanoritsvendorand/ornotpartofthePlan’sorvendor’srecords;or(iii)notpermittedtobedisclosed.Anydenialwillstatethereasonsfordenialandexplainyourrightstohavetherequestanddenial,alongwithanystatementinresponsethatyouprovide,appendedtoyourPHI.Iftherequestforamendmentisapproved,thePlanorvendor,asthecasemaybe,willchangethePHIandsoinformyou,andwillattempttotellothersthatneedtoknowaboutthechangeinthePHI.
• Tofindoutwhatdisclosureshavebeenmade:Youhavearighttogetalistofwhen,towhom,forwhatpurpose,andwhatportionofyourPHIhasbeenreleasedbythePlananditsvendors,otherthaninstancesofdisclosureforwhichyougaveauthorization,orinstanceswherethedisclosurewasmadetoyouoryourfamily.Inad-dition,thedisclosurelistwillnotincludedisclosuresfortreatment,payment,orhealthcareoperations.Thelistalsowillnotincludeanydisclosuresmadefornationalsecuritypurposes,tolawenforcementofficialsorcorrectionalfacilities,orbeforethedatethefederalprivacyrulesappliedtothePlan.Youwillnormallyreceivearesponsetoyourwrittenrequestforsuchalistwithin60daysafteryoumaketherequestinwriting.Yourre-questcanrelatetodisclosuresgoingasfarbackassixyears.Therewillbenochargeforuptoonesuchlisteachyear.Theremaybeachargeformorefrequentrequests.
HoW to Complain aBout tHe plan’s privaCY praCtiCes
IfyouthinkthePlanoroneofitsvendorsmayhaveviolatedyourprivacyrights,orifyoudisagreewithadecisionmadebythePlanoravendoraboutaccesstoyourPHI,youmayfileacomplaintwiththepersonlistedinthesectionimmediatelybelow.YoualsomayfileawrittencomplaintwiththeSecretaryoftheU.S.DepartmentofHealthandHumanServices.Thelawdoesnotpermitanyonetotakeretaliatoryactionagainstyouifyoumakesuchcomplaints.
4
ContaCt person For inFormation, or to suBmit a Complaint
IfyouhavequestionsaboutthisNoticepleasecontactthePlan’sPrivacyOfficialorDeputyPrivacyOfficial(s)(seebelow).IfyouhaveanycomplaintsaboutthePlan’sprivacypracticesorhandlingofyourPHI,pleasecontactthePrivacyOfficialoranauthorizedDeputyPrivacyOfficial.
Privacy Official
ThePlan’sPrivacyOfficial,thepersonresponsibleforensuringcompliancewiththisNotice,is:
DonaldSmithChiefHumanResourceOfficer(Interim)
(907)450-8200
ThePlan’sDeputyPrivacyOfficialis:
ErikaVanFleinDirectorofBenefits(907)450-8227
orGaniZed HealtH Care arranGement desiGnation
ThePlanparticipatesinwhatthefederalprivacyrulescallan“OrganizedHealthCareArrangement.”ThepurposeofthatparticipationisthatitallowsPHItobesharedbetweenthemembersoftheArrangement,withoutauthoriza-tionbythepersonswhosePHIisshared,forhealthcareoperations.Primarily,thedesignationisusefultothePlanbecauseitallowstheinsurerswhoparticipateintheArrangementtosharePHIwiththePlanforpurposessuchasshoppingforotherinsurancebids.
ThemembersoftheOrganizedHealthCareArrangementare:
• UniversityofAlaska• PremeraBlueCrossBlueShieldofAlaska• CVSCaremark• FringeBenefitsManagementCompany,adivisionofWageWorks• VSP
Effective Date
TheeffectivedateofthisNoticeis:December1,2011.
5
ABOUT THIS HANDBOOK
ThishandbooksummarizesbenefitprogramscurrentlyprovidedbytheUniversityofAlaska.Formalagreementsandrules,includingbutnotlimitedtoplandocuments,Regents’PolicyandUniversityRegulation,determinetheactualbenefitsthatwillbeprovidedtoemployees.Iftheprovisionsofthissummaryconflictwithsuchdocuments,theformalagreementsandruleswillgovern.
Themethodofdeliveryorthecompanythroughwhichabenefitprogramisprovidedmaychangefromtimetotime.Specificservicesmaynotbeduplicatedorofferedbythenewbenefitvendor.
Alaskainsuranceregulationsalsoplacecertainstipulationsonthemannerinwhichinsurance-relateddisputesmaybeaddressedandsettled.Asaresult,eachvendorhasanestablisheddisputeresolutionprocedure.Inaddition,be-causesomeproductsarefullyunderwrittenand/orinsuredbyavendor,thesoleremedyforanyandalldisputeswillrestexclusivelywiththatbenefitvendor.
ThisHandbookiscurrentasofJuly1,2011.UpdatestotheHandbookaremadeasneededtoclarifyorcorrectinfor-mation.ThemostrecentversionoftheHandbookcanbefoundontheUniversityofAlaska’sbenefitswebsiteatthefollowingaddress:
http://www.alaska.edu/benefits/
YourHandbookcontainsthefollowingsections:
Benefits in Brief Chart—aquickoverviewofyourvariousbenefitsandhowtheyinterrelate.
Introduction—basicinformationaboutthebenefitprogramsoftheUniversity.
Health Care—descriptionofyourcomprehensiveMedical,Dental,PharmacyandAudiobenefits,includinginfor-mationabouteligibilityandenrollment.
Pharmacy—descriptionofyourprescriptiondrugbenefit,includingretail,mailorderandspecialtypharmacy.
Vision Care—description of the Vision Care Plan as provided by VSP
Employee Assistance Program (EAP)—descriptionofthebenefitsavailabletoemployeesandtheirdependents.
Disability—explainshowtheLongTermDisabilityplancanreplaceapercentageofyourincomeintheeventyoucannotworkbecauseofamedicaldisability.
Life Insurance Benefits—summarizesLifeInsurancecoverage,optionalSupplementalLifeInsurancebenefits,andvoluntaryAccidentalDeathandDismembermentbenefits.
Retirement Benefits—outlinesthestate-affiliatedretirementplans-TheTeachers’RetirementSystem(TRS),andPublicEmployees’RetirementSystem(PERS).AlsooutlinestheUniversityofAlaskaOptionalRetirementPlan(ORP),theUniversityofAlaskaPensionPlan,andvoluntaryTax-DeferredAnnuities.
Other Benefits—providesinformationabouttheUniversity’sregulationsandproceduresconcerningleaves,sabbati-cals,holidays,andeducationalbenefits.
If you have any questions about your benefits, please contact the human resources office at your local campus.
6
BENEFITS IN BRIEF
Medical Care Deductible
Coinsurance (afterthedeductible)
Out-of-PocketMaximum(afterthedeductible)
Dental Care ($2,000maxi-mumbenefitper covered individual per year)
Preventiveservices100%Basicexpenses 80%Majorexpenses 50%$25annualdeductibleonbasicandmajorexpenses
Pharmacy Local retail andmailorderbenefits;non-networkbenefitsalsoavailable
Vision Care $10copayforexam,$25copayforglasses(lensesandframes),nocopayforcontacts.Examevery12months,lensesandframesORcontactsevery24months.Non-VSPproviderbenefitslimitedtoallowances.
$1,250perindividual$3,000perfamily
80%forin-networkservices,60%forout-of-network
$3,750perperson,$8,000perfamilyforin-networkservices;Out-of-NetworkServicesdonotapplytothemaximumout-of-pocketlimit.
Preventiveservices 80%Basicexpenses 80%Majorexpenses 50%$50annualdeductibleonbasicandmajorexpenses
Preventiveservices100%Basicexpenses 80%Majorexpenses 50%No deductibleOrthodontiaat50%upto$1,500lifetimemaximum
ua CHoiCe HealtH Care proGram
Regularemployees(andtheirdependents,ifenrolled)areeligibleafterawaitingperiodofapproximately30daysfromhiredate.Employeesmaywaivecoveragewithproofofotherinsurance.TheUniversityofAlaskaandemployeesbothcontributetothecostofthisprogram.
$750perindividual$2,250perfamily
80%forin-networkservices,60%forout-of-network
$3,500perperson,$7,000perfamilyforin-networkservices;Out-of-NetworkServicesdonotapplytothemaximumout-of-pocketlimit.
$500perindividual$1,500perfamily
80%forin-networkservices,60%forout-of-network
$3,000perperson,$6,000perfamilyforin-networkservices;Out-of-NetworkServicesdonotapplytothemaximumout-of-pocketlimit.
Plan High Deductible Plan 750 Plan 500 Plan
LocalNetworkPharmacy MailOrderPharmacy(30daysupply) (Upto90daysupply)GenericDrugs $5copay $10copayBrandName $25copay $50copayNon-preferred $50copay $100copay
Thereisa$1,000annualout-of-pocketmaximumperenrolleeforpharmacybenefits
7
FleXiBle spendinG aCCounts
Program WhoPays Eligibility BenefitsHealth Care FlexibleSpendingAccount
You Anoptionalprogramthatprovidesem-ployeestheopportunitytobereimbursedwiththeirowntax-freecontributionsforhealthcareexpensesthatarenotcoveredbythehealthcareprogram.Accountbal-ancesmustbeusedduringtheplanyear,orthemoneyisforfeited.
Regularemployeesuponenrollment(atthetimeofhire,duringopenenroll-ment,orwith“lifeevent”).
Dependent CareFlexibleSpendingAccount
You Regularemployeesuponenrollment(atthetimeofhire,duringopenenroll-ment,orwith“lifeevent”).
Anoptionalprogramthatprovidesem-ployeestheopportunitytobereimbursedwiththeirowntax-freecontributionsfordependentcareexpensesthatareneces-sarytoallowtheemployee(andhis/herspouse,ifmarried)toseekorretainemployment.Accountbalancesmustbeusedduringtheplanyear,orthemoneyisforfeited.
liFe insuranCe
Program WhoPays Eligibility BenefitsBasic Life Insurance
SupplementalLife
The University Regularemployeesfromtheinitialdayofemployment
$50,000ofgrouplifeinsurancecoverageisprovidedtoallemployees.
You Regularemployeesuponenrollment(atthetimeofhire,duringopenenroll-ment,orwith“lifeevent”).
Availableinamountsfrom$25,000to$400,000,inincrementsof$25,000,ben-efitsarepaidinalumpsumorinmonthlyinstallments.EvidenceofInsurabilityrequiredforamountsover$200,000.Foremployeesage65andover,themaxi-mumamountoflifeinsurancethattheymayelectis$25,000.Participation is optional.
Accidental Death and Dismember-ment
You Regularemployeesuponenrollment(atthetimeofhire,duringopenenroll-ment,orwith“lifeevent”).
Paysbenefitsforaccidentallossoflifeorlimb.Coverageisalsoavailablefordependents. Participation is optional.
Travel Accident
The University Regularemployeesfromtheinitialdayofemployment.
PaysbenefitsforaccidentaldeathwhiletravelingonUniversitybusiness.Cover-ageis$250,000.
8
Program WhoPays Eligibility Benefits
retirement BeneFits
PublicEmployees’RetirementSystem(PERS)and Teachers’RetirementSystem(TRS)
You contribute a percent of your salary before taxes.Contribu-tion rate is deter-minedbydateofhire. University contribution can changeannuallyasdeterminedby the State of AlaskaDivisionofRetirement.
Eligibleregularemploy-eesfrominitialdayofemployment.EmployeeshiredonorafterJuly1,2006participateinadefinedcontribution(DC)plan.Employeeshiredbe-foreJuly1,2006partici-pateinadefinedbenefitplan(DB).
RetirementbenefitbasedondateofhirewithDCmembershavingacashaccountandDBmembersgettingcreditforsalaryand service. CompletedetailsonallfeaturesofPERSand TRS are available at the State of AlaskaDivisionofRetirementandBen-efitsWebsiteatwww.state.ak.us/local/akpages/ADMIN/drb/home.htm
Optional RetirementProgram(ORP)
You contribute apercentageofyourpre-taxsalary. Univer-sity contribution is a three-year averageofTRSemployerrateifhiredbeforeJuly1,2005.IfhiredafterJuly1,2005youremployercontribution rate is12%.
Regularfull-timeandpart-timeemployeesmustchoosebetweentheORPandthestate’sretirementsystemprogramswithin30daysofbeingnoti-fiedtheyareeligibletoparticipate.
Retirementbenefitbasedontotalcon-tributionsandearnings.Contributionsareplacedinanindividualtax-deferredaccount,chosenfromawidevarietyofinvestmentoptionsprovidedbyfourfundsponsors. Participants are fully vested in theemployercontributionaccountafterthreeyears;vestingintheemployeecon-tributionaccountisimmediate.VestedaccountbalancesmayberolledovertoanotherqualifiedplanorIRAatterminationaftera45-daywaitingperiod.Youmaynottakealump-sumcashdistri-butionfromthisplan.PleaseseetheUARetirementDecisionGuideformoreinformation.
University ofAlaskaPension Plan
The University contributes7.65%ofyourfirst$42,000ingrosswages.
Eligibleemployeesfrominitialdayofemployment.Employeeshiredonoraf-terJuly1,2006mustelecttheORPtobeeligibleforUA Pension.
Retirementbenefitbasedonamountcon-tributedandinvestmentoptionselected.VestingisimmediateifhiredbeforeJuly1,2006;3-yearvestingifhiredonorafterJuly1,2006.Accountbalancemaybewithdrawnatterminationaftera45-daywaitingperiod.
Medicare You and the University.
AllemployeeshiredafterMarch31,1986.
Medicarebenefitsfordisabledemployeesandforthoseage65andover.
TaxDeferredAnnuity Plans (TDAs)
You. Allemployeesuponen-rollment.
Supplementalsavingsforretirementanddefertaxesoncurrentincome.Participa-tion is optional.
9
otHer BeneFits *Program WhoPays Eligibility BenefitsSickLeave The University Regularemployeesfrom
initialdayofemploymentPaidleaveforillness,medicalconditions,ordoctorsappointment.Leaveaccruesat4.62hoursperpayperiodforfull-timeemployees.SeetheFamilyMedicalLeave(FML)sectionformoreinforma-tion.
Leave Share Program
FellowUniver-sityEmployeesDonatefromTheir Accrued SickLeave
Regularemployeesfrominitialdayofemployment
Ifanemployeehasexhaustedalloftheirannualleaveandsickleaveasaresultofacatastrophicmedicalcrisis,theymayapplytotheleaveshareprogramiftheystillqualifyforFamilyMedicalLeave.Underthisprogramotheremployeesareallowedtodonateaportionoftheirsickleavetotheemployeeapplyingforleaveshare.
FamilyMedical Leave(ParentalLeave)
You and the University,dependingonwhetheryouusesickleave,annualleave,leavewithoutpay,orcombi-nations of the above.
Allregularemployeesmeet-inglengthofemploymentandhoursworkedrequire-ments.
Leave for serious health care condition ofyouorafamilymember,tocarefornewborninfantornewlyadoptedchildorforplacementofafosterchild,ortocareforaninjuredservicememberorforaqualifyingexigencyrelatedtoacoveredservicemember.SeetheFamilyMedicalLeave(FML)sectionformoreinforma-tion.
Annual Leave The University Regularemployees,exceptfaculty.
Vacationtimebaseduponyearsofser-viceandpart-time/full-timeemploymentstatus.Accrualforafull-timeemployeeis: First5years: 5.54hrsperpayperiod 6-10years: 6.46hrsperpayperiod Over10years: 7.38hrsperpayperiod
Holidays The University Regularemployees,exceptfaculty. Based on part/full-timeemploymentstatus.
Upto12paidholidayseachcalendaryear. One additional personal holiday is grantedtoregularclassifiedemployees.
*Ifyouareamemberofacollectivebargainingunit,yourbenefitsmaydiffer.Pleasecheckyourcollectivebargainingagreement(CBA).
10
Educational Benefits
The University
Regularemployeesandtheir dependents.
Employeesareeligibleforupto12tuition-freecoursecreditsperacademicyear.Notuitionfeeischargedforcoursestakenbyeligibledependents.(Graduatecredits,however,aretaxable.Self-supportingclassesarenotcovered.)
Leaveforuptooneyear,withthepos-sibilitytoextendtoasecondyear.
YouLeave of Absence
AllemployeeswhoaregrantedleavebytheUni-versity.
otHer BeneFits
Program WhoPays Eligibility Benefits
Long-termDisability
The University
Ifyouarehiredandactivelyatworkonthefirstdayofthemonthcoveragebeginson that day. If you are hired and actively atworkonanyotherdayofthemonth,itstartsthefirstofthefollowingmonth.Inconjunctionwithotheravailableben-efits,theprogrampays60%ofyourbasesalary,toamaximumof$3,000/month.Priortobeingeligibleforthisprogram,anemployeemusthaveexhaustedalloftheirsickleaveand/orcompletedthe90-daywaitingperiod,whicheverisgreater.
Regularemployees.
Worker’sCompensation
The University Allemployeesfrominitialdayofemployment.
Compensationforon-the-jobinjuryorillness.Providescoverageformedi-calexpenseandlossofcompensation.Injury/illnessformmustbecompletedwithin10daysaftertheinitialinjuryofillness.
11
INTRODUCTION
Your BeneFit proGram
Inrecognitionofthediversityoftheemployeepopulation,theUniversityofAlaskahasdevelopedabenefitprogramthatallowsflexibilityandchoice.Thehealthbenefitprogramprovidescoverageforyouandyourfamilynotonlyincaseofillness,butalsoincludesseveralprovisionsthatfocusonpreventivecare.TheUA Choice health care plan offersyouthreeoptions:the500Plan,the750PlanortheHighDeductibleHealthPlan(HDHP),atthreedifferentcoststoyou.Alternatively,ifyouhaveothermedicalcoverageanddon’tneedcoveragethroughtheUniversity,youcanoptout(withproofofothercoverage)andavoidpayrolldeductionsforhealthcare.
YoumayenhancewhicheverUA Choiceplanyouchoosebyselectingamedicalflexiblespendingaccount.Thebasiclifeinsurancebenefitmaybesupplementedbypurchasingtheoptionalsupplementallifeinsuranceand/oraccidentaldeathanddismembermentcoverage.Themedicalanddependentcareflexiblespendingaccountsandlifeinsuranceplansaredesignedtoallowemployeestheabilitytoincreasetheirtotalbenefitcoverage.Pleasenotethatalloptionalplansarepaidforbytheemployeeandratesaresetannually.
EmployeesmayalsoaugmenttheUniversityretirementprogrambyselectingfromanumberofTax-DeferredAn-nuityplansinwhichtheysetasidetax-deferredfundsfromtheirsalaryforincomeduringretirement.Thesefundswouldbeinadditiontoanybenefitsfromthestate-affiliatedretirementplans,theUniversity’sPensionPlanorOptionalRetirementPlan(ORP).
BeneFit Considerations
ItisimportantthatyoucarefullyevaluateeachoftheUA Choiceplansandtheoptionalplansafterconsideringyourparticularneeds.Age,familystatus,healthcarerequirements,careergoals,yearsofservice,pay,andfinancialobjec-tivesarefactorsthatneedtobeconsideredinselectingyouroptionalbenefits.
Eachyearduringtheannualopenenrollmentperiodemployeescanmakenewbenefitelectionstoreflectchangesintheirbenefitneeds.Exceptincasesofamajorlifeevent,theperioddesignatedforopenenrollmentistheonlytimethatemployeesmaymakebenefitelections.If,however,duringtheplanyearanemployeeexperiencesamajorlifeeventsuchasmarriage,divorce,birth,adoption,deathofaspouseorchild,etc.,theymaybeeligibletomakeachangeintheirbenefitelectionsaslongasthechangeisconsistentwiththelifeevent.Pleaseconsultyourregionalcampushumanresourcesofficeifyouexperienceamajorlifeeventduringtheplanyear.
12
Campus Human resourCes oFFiCe loCations
Contactyourregionalcampushumanresourcesofficeatthefollowingaddressesforquestionsaboutspecificpro-grams:
University of Alaska FairbanksHumanResources
UniversityofAlaskaFairbanksUAFAdministrativeServicesCenter
P.O.Box7578603295CollegeRoad
Fairbanks,AK99775-7860907/474-7700
University of Alaska AnchorageHumanResourceServices
101UniversityLakeBuilding3890UniversityLakeDriveAnchorage,AK99508
907/786-4608
University of Alaska SoutheastHumanResources
UniversityofAlaskaSoutheast11120GlacierHighwayJuneau,AK99801907/796-6473
Statewide AdministrationStatewideOfficeofHumanResources
UniversityofAlaskaP.O.Box755140
212ButrovichBuildingFairbanks,AK99775-5140
907/450-8200
notiCe under tHe Women’s HealtH and CanCer riGHts aCt oF 1998
Afederallawrequireshealthplansthatprovidemastectomybenefitstoalsoprovidecertainrelatedbenefitsandtotellparticipantsthattheyareavailable.EffectiveJanuary1,1999,benefitsavailableundertheUniversityofAlaska’sHealthCarePlanforcoveredindividualswhoarereceivingbenefitsforamastectomyandelectbreastreconstructioninconnectionwiththemastectomyinamannerdeterminedinconsultationwiththepatientandat-tendingphysicianinclude:
• reconstructionofthebreastonwhichthemastectomywasperformed;• surgeryandreconstructionoftheotherbreasttoproduceasymmetricalappearance;and• prosthesesandtreatmentofphysicalcomplicationsofallstagesofmastectomy,includinglymphedemas.
Thesereconstructivebenefitsaresubjecttothesameannualdeductibleandcoinsuranceprovisionsasotherplanmedicalandsurgicalbenefits(seeMastectomyandBreastReconstructionServicesunderCoveredServicesandSup-plies).
13
YOUR ROLE IN CONTROLLING YOUR HEALTH PLAN COSTS
TheUniversity’shealthcareprogramhasmanyfeaturesthathavebeendesignedtoprovideforyourhealthcareprotection.However,yourwiseandcarefuluseoftheprogramiskeytotheUniversity’sabilitytocontinuetoofferacomprehensivehealthcareprogram.
Thecostofthehealthcareplanissharedbetweenemployeesandtheuniversity,withtheuniversitycurrentlypaying83%ofthenetcost.FortheFY12planyear,theuniversity’scontributionisapproximately$59.4million,or$13,919peremployee.
Oneofthemosteffectivemeasuresthatyoucantakeinyourpersonaleffortstoassistincontrollingthecostofthehealthcareprogramistodevelopahealthylifestyle.Unlessyouareoneofthefewreallyhealth-consciousindividu-als,yourcurrentlifestyleisalmostcertainlylesshealthythanitcouldbe.Nowisthetimetomodifyit.Youwillbenefitfirstofallbyloweringyourriskofdevelopingapreventableillness.Heartdisease,cardiovasculardisease,andcanceraremajorcoststoyourhealthcareprogramandaremoreeasilypreventedthancured.Second,asyoubecomeincreasinglyfit,youwillfeelbetterandwillfindthatyouaremoreabletoenjoylife.Basicguidelinesforhealthylivingaresimple,andmedicalresearchshowsconvincinglythatfollowingtheseguidelineswillimproveyourchancesforalonger,healthierlife:
• Ifyousmokeorusetobacco,quit.Tobaccocessationprogramsareavailabletohelpyouquit.• Ifyoudrink,drinkinmoderation.• Getsomeaerobicexercise,preferablythreetofivetimeseachweek.• Eatawell-balanceddiet.• Getplentyofrest,andtrytoscheduletimeforyourself.
Tohelpemployeesimprovetheirhealthbyadoptingamorehealthylifestyle,theUniversityofAlaskahaspartneredwithWINforAlaskatoprovideonsiteandonlineseminars,information,screeningtoolsandparticipant-basedac-tivities.Thispartnershipgoesbeyondthehealthplantohelpemployeesandtheirfamiliesdevelopahealthylifestyleplanthatmeetstheirneeds.
TheUniversityhascontractedwithPremeraBlueCrossBlueShieldofAlaska,alsoreferredtoasBlueCrossinthisHandbook,forclaims processing and paymentofthemedicalanddentalplanbenefits.PharmacybenefitsareprovidedbyCVSCaremark.VisioncarebenefitsareprovidedbyVSP.PleasecontactStatewideHumanResourcesat450-8200,BlueCrossat(800)364-2982,CVSCaremarkatCaremark.comor(800)596-2178,orVSPatwww.vsp.comor(800)877-7195ifyouhaveanyquestionsregardingyourbenefitplan.
Thisplancomplieswiththe2010federalhealthcarereformlaw,calledtheAffordableCareAct(seeGlossaryofTerms).IfCongress,federalorstateregulators,orthecourtsmakefurtherchangesorclarificationsregardingtheAffordableCareActandit’simplementingregulations,thisplanwillcomplywiththemeveniftheyarenotstatedinthisHandbookoriftheyconflictwithstatementsmadeinthisHandbook.
14
ELIGIBILITY
emploYee eliGiBilitY
Regularfull-time,regularpart-time,andextendedtemporaryemployeesoftheUniversityofAlaskamayelecteitherthe500Plan,the750PlanortheHighDeductibleHealthPlanoptionsundertheUAChoiceHealthPlan,ormayelecttowaivecoveragewithverificationofothercoverage.
enrollment WaitinG period
Eligibleemployeeshavea30-dayelectionperiodinwhichtochoosetheirpreferredhealthplananddependentcoverageoptions.Thehealthplanrequiresawaitingperiodofapproximately30daysfromyourdateofhireintoabenefits-eligibleposition,orattainingextendedtemporarystatus,beforecoverageiseffective.Thiswaitingperiodisdeterminedasfollows:
Ifyousubmityourcompletedandsignedenrollmentform,showingplanelectionandeligibledependentstobeenrolled,onorbeforethe25thofthemonthduringyour30-dayelectionperiod,yourcoveragewillbeeffectivethesamedayasyourdateofhireinthefollowingmonth.Forexample,ifyouwerehiredonJanuary13,andsubmityoursignedenrollmentformstoyourregionalhumanresourcesofficebyJanuary25th,yourcoveragewouldbeef-fectiveonFebruary13.
Ifyousubmityourenrollmentformafterthe25thofthemonth,butwithinyour30-dayelectionperiod,yourcover-agewillbeeffectivethefirstofthemonthfollowingyour30-dayelectionperiod.Forexample,ifyouwerehiredonJanuary13,andsubmittedyoursignedenrollmentformstoHRonFebruary5,yourcoveragewillbeeffectiveonMarch1.
Ifyoudonotsubmitanenrollmentformand/orifyoudonotoptout(waivecoverage)withinyour30-dayelectionperiod,youwillautomaticallybeenrolledintheStandardPlanwithemployee-onlycoverage,effectivethefirstofthemonthfollowingtheendofyourelectionperiod.
Please Note:tosubmityourenrollmentformmeansithasbeenreceivedbyyourregionalhumanresourcesoffice.
Employeesrehiredafterabreakinserviceoflessthan10workingdaysfromabenefits-eligiblepositionwillbecoveredasofthedateofrehireintoabenefits-eligibleposition,withnoadditionalwaitingperiod.Breaksinserviceof10workingdaysorlongerrequirethewaitingperiodtobesatisfiedagain.
Enrollmentsbasedonalifeeventareeffectiveonthedayofthelifeevent,aslongastheenrollmentformisturnedinwithintheappropriatetimeframe.
dependent enrollment time Frames
Eligibleemployeesarenotrequiredtoenrolltheireligibledependents,butmaychoosetodosoatthetimeofinitialeligibility,openenrollmentorinthecaseofamajorlifeeventasexplainedbelow.Coveragefordependentscanonlybeelectedwithinthirty(30)daysofhire,withinthirty(30)daysafteramajorlifeevent,orduringopenenrollment,withtheexceptionofnewbornornewlyadoptedchildren,inwhichcaseyouareallowed60days.
Inthecaseofamajorlifeevent,coveragebeginsonthedateofthemajorlifeevent.CoverageforadependentelectedatopenenrollmentwillbecomeeffectiveonJuly1.
15
dependent eliGiBilitY
Employees are required to notify their regional human resources office as soon as a dependent loses eligibility status.
Tobeeligibleforcoverageasadependentunderthisprogram,thefamilymembermustfitoneofthefollowingdescriptions:
• Thelawfulspouseoftheemployee,unlesslegallyseparated Please note: ProvidedallrequirementsaremetasspecifiedbytheUniversityofAlaska,wherever“spouse”is
statedinthehealthcareplan,afinanciallyinterdependentpartnerwouldalsobeincluded.Pleasecontactyourregionalhumanresourcesofficefordetailsconcerningfinanciallyinterdependentrelationships.
• A“child”26yearsofageoryounger.However,ifachildisanemployeeoftheUniversityofAlaskawhomeetstherequirementsin“EmployeeEligibility”earlierinthissection,thechildcanonlyenrollasanemployee.Achildisconsideredoneofthefollowing:• Anaturaloffspringofeitherorboththeemployeeorspouse• Alegallyadoptedchildofeitherorboththeemployeeorspouse• Achildforwhomtheemployeehasbeengrantedcourt-appointedlegalguardianship;theremustbeacourt
ordersignedbyajudge,whichgrantsguardianshipofthechildtotheemployeeorspouseoftheemployeeasofaspecificdate.Whenthecourtorderterminatesorexpires,thechildisnolongeraneligiblechild
• Achildforwhomtheemployeeorspouseisunderadomesticrelationsordertoprovidemedicalbenefitsasdirectedbyadivorcedecree,amedicalchildsupportorderorothercourt-ordereddependentcoverage
• Afosterchildlivingwiththeemployee• Achild“placed”withtheemployeeforthepurposeoflegaladoptioninaccordancewithstatelaw;placed
foradoptionmeansassumptionandretentionbytheemployeeofalegalobligationfortotalorpartialsup-port of a child in anticipation of adoption of such child.
evidenCe oF eliGiBilitY
TheUniversityofAlaskarequiresevidenceofeligibilityforallenrolleddependents.Supportingdocumentsincludebirthcertificate,marriagelicense,finaladoptionpaperwork,taxreturnsshowingclaimeddependents,qualifiedmedicalchildsupportorders,legalguardianshippapers,etc.Seeyourregionalhumanresourcesofficeformoreinformationonsupportingdocumentation.
Continued eliGiBilitY For a disaBled CHild
Coveragemaycontinuepastthelimitingageof26foradependentchildwhocannotsupporthimselforherselfbecauseofadevelopmentalorphysicaldisability.Thechildwillcontinuetobeeligibleifallthefollowingrequire-mentsaremet:
• Thechildbecamedisabledbeforereachingthelimitingageof26.• Thechildisincapableofself-sustainingemploymentbyreasonofdevelopmentaldisabilityorphysicalhandi-
cap,andischieflydependentupontheemployeeforeconomicsupportandmaintenance.• Theemployeeremainscoveredunderthisprogram.• Theemployee’scostfordependentcoveragecontinuestobepaid.• Within30daysofthechildreachingthelimitingage,theemployeemusthavecompletedandhaveonfilewith
BlueCrossa“RequestforCertificationofHandicappedDependent”statusform.• TheemployeehascontinuedtoprovideBlueCrosswithproofofthechild’sdisabilityanddependentstatus
whenrequested.BlueCrosswillnotaskforproofmoreoftenthanonceayearafterthetwo-yearperiodfollow-ingthechild’sattainmentofthelimitingage.
Blue Cross must approve the request for certification before coverage can continue.
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major liFe event
Outsideoftheannualopenenrollmentperiod,anemployeemaychangeanenrollmentelection(i.e.,addordeletedependents,changelevelofcoverage)onlyiftherehasbeenamajorlifeevent.Thefollowingareconsideredmajorlife events:
• Marriageordivorceoftheemployee• Deathoftheemployee’sspouseoradependent• Birthoradoptionofachildbytheemployee• Terminationofemployment(orthecommencementofemployment)oftheemployee’sspouse• Switchingfrompart-timetofull-timeemploymentstatusorfromfull-timetopart-timestatusbytheemployee
ortheemployee’sspouse• Takingofanunpaidleaveofabsencebytheemployeeortheemployee’sspouse• Asignificantchangeinthehealthcoverageoftheemployeeortheemployee’sspouseattributabletothe
spouse’semployment• Gainorinvoluntarylossofhealthcarecoverageofyourdependent
Changes(additionordeletionofdependents)willbelimitedtothosethatarebothonaccountofamajorlifeeventandareconsistentwiththatmajorlifeevent.Enrollmentchangesaresubjecttotheothertermsandlimitationsofthisprogram.
Aneligibleemployeewhopreviouslyelectednottoenrolladependent(s)intheplanwhensuchcoveragewasprevi-ouslyoffered,mayenrollthedependent(s)intheplanatthesametimeanewlyacquireddependentisenrolled.
involuntarY loss oF otHer CoveraGe
Ifadependentdidnotenrollinthisprogramwhenfirsteligible,thedependentmaylaterenrolloutsideoftheannualopenenrollmentperiodifeachofthefollowingrequirementsaremet:
• yourdependentwascoveredundergrouphealthcoverageorahealthinsuranceprogramatthetimecoverageundertheUniversityofAlaska’sprogramwaspreviouslyoffered;
• youdeclinedcoverageforyourdependentunderthisprogramatthetimethiscoveragewasoffered,and• yourdependent’scoverageundertheothergrouphealthcoverageorhealthprogramwasterminatedasaresult
of:• lossofeligibilityforthecoverage(including,butnotlimitedto,asaresultoflegalseparation,divorce,
death,takinganunpaidleaveofabsence,terminationofemployment,orreductioninhoursofemploy-ment);
• terminationofemployercontributionstowardsuchcoverage,or• yourdependentwascoveredunderCOBRAatthetimecoverageunderthisprogramwaspreviouslyoffered
andCOBRAcoveragehasbeenexhausted.• thereisasignificantchangeinthehealthcoverageofyourspouseattributabletotheiremployment.
WhentheUniversityofAlaskareceivesyourcompletedenrollmentformandanyrequiredcontributionswithin30daysofthedatesuchothercoverageended,coverageunderthisprogramwillbecomeeffectiveonthedayaftertheothercoverageended.IftheUniversityofAlaskadoesnotreceiveyourcompletedenrollmentformwithin30daysofthedatepriorcoverageended,referto“OpenEnrollment”below.
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enrollment
Aftertimelyenrollment,coveragewillbecomeeffectiveonthefollowingdates:
• Fortheemployeeandenrolledfamilymembers,seethesectiononEnrollmentWaitingPeriod• Foraspouseandeligiblechildrenacquiredthroughmarriage,onthedateofmarriage• Foraspouseandeligiblechildrenwhohavehadalossofothercoverage,thedayafterothercoverageended• Foranewbornchild,onthechild’sdateofbirth• Foranadoptedchild,onthedatethechildisplacedwiththeemployeeforthepurposeoflegaladoption• Forachildcoveredunderacourt-appointedlegalguardianshiporder,thedatethecourtgrantslegalguardian-
shiptotheemployeeorspouse• Forachildcoveredunderadomesticrelationsordertoprovidemedicalbenefitsasdirectedbyadivorcedecree,
the date of the order• Forafosterchild,onthedatethechildisplacedintheemployee’shome
open enrollment
Aneligibledependentwhoisnotenrolledwhenfirsteligibleorwhofailstomaintaincontinuouscoveragemayen-rollonlyduringtheUniversity’sannualopenenrollmentperiod.Toenroll,properapplicationmustbemadeduringtheopenenrollmentperiodandcoveragewillbecomeeffectiveatthebeginningofthenewplanyear(July1).
re-enrollment aFter a lapse in CoveraGe
Ifyourcoverageisreinstatedafteralapseoftime,thedateyourcoveragebeginsagainbecomesyoureffectivedate.Alltermsandconditionsofthehealthcareprogram,includingpre-existingconditions,willapplyatthetimeofrein-statement.PleaseseethesectiononEnrollmentWaitingPeriodformoreinformation.
Cost For emploYee CoveraGe
Employeesarerequiredtoshareinthecostoftheirhealthcarecoverage.Thecostforemployeecoverageisdeter-minedannually.
Cost For dependent CoveraGe
Employeesarerequiredtoshareinthecostofcoveringdependentsonthehealthcareplan.Thecostfordependentcoverageisdeterminedannually.Ifyouhavequestionsastothecurrentcostofdependentcoverage,pleasecontactyourregionalhumanresourcesoffice.
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PRE-EXISTING CONDITIONS
Apre-existingconditionisanycondition,regardlessofcause,forwhichanymedicaladvice,diagnosis,care,medication,ortreatmentwasrecommendedorreceivedwithinthe90dayspriortothedatetheenrollee’scoveragebecomeseffective.However,thehealthcareplanwillprovideupto$1,000inbenefits,afteranyrequireddeductiblehasbeensatisfied,foreachconditionthatwouldotherwisebeexcludedbythispre-existingconditionslimitation.
Thereisnopre-existingconditionsexclusionforchildrenundertheageof19.
Aconditionisnolongerconsideredpre-existingifanenrolleehasbeencoveredbytheprogramfor90days,andnomedicalservicesfortheconditionhavebeenincurredorrecommendedduringthattime.
However,ifanenrolleehas incurredexpensesforaconditionduringthefirst90daysofcoverage,thentheconditionwillnolongerbeconsideredpre-existingoncethefollowingissatisfied:
• Fortheemployee,onceheorshehasbeencoveredunderthisprogramforaperiodof6consecutivemonths• Forthedependentage19orolder,onceheorshehasbeencoveredunderthisprogramforaperiodof12con-
secutivemonths
Thiswaitingperiodlimitationforpre-existingconditionsdoesnotapplyinthefollowingcases:
• Membersundertheageof19• Pregnancy• Childwhoiscoveredunderlegalguardianship,providedthechildhasbeencoveredunderthisprogramsince
thedatethecourtgrantedlegalguardianshiptotheemployeeorspouse• Fosterchild,providedthechildhasbeencoveredunderthisprogramsincethedatethechildwasplacedinthe
employee’shome• Childcoveredunderadomesticrelationsorder,providedthechildhasbeencoveredunderthisprogramsince
the date of the order• CoverageforPKUformulaforenrolleeswithPhenylketonuria• Geneticinformationinabsenceofadiagnosis
Credit For prior CoveraGe
Thewaitingperiodforpre-existingconditionsmaybereducedbyperiodsofcreditablecoverageyou’veaccruedun-derotherhealthcareprogramspriortoyoureffectivedateforthisplan.Mostmedicalhealthcarecoverageisconsid-eredcreditablecoverage.Youwillreceivecreditforpriorcreditablecoveragethatoccurredwithoutabreakincover-ageofmorethan90days.Anycoverageyouhadbeforeabreakincoveragewhichexceeds90daysisnotcreditedtowardyourwaitingperiodforpre-existingconditions.Eligibilitywaitingperiodswillnotbeconsideredcreditablecoverageorabreakincoverage.Yourprioremployerorhealthinsurancecarrierwillprovideyouwithacertificateofhealthcoverage.Ifyouhavenotreceivedacertificate,orhavemisplacedit,youhavetherighttorequestonefromaprioremployerorhealthcarrierwithin24monthsofthedateyourcoverageunderthatplanterminated.
Certificatesofpriorhealthcarecoverageshouldbesubmittedtoyourregionalhumanresourcesoffice.
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PLAN YEAR DEDUCTIBLE—MEDICAL
individual deduCtiBle
EachplanyearyoumustsatisfyadeductiblebeforeyourComprehensiveMedicalBenefitsarepayable.DeductibleamountsforeachplaninUA Choicearelistedbelow.
Whilesomebenefitshavedollarmaximums,othershavedifferentkindsofmaximums,suchasamaximumnumberofvisitsordaysofcarethatcanbecovered.Allowablechargesthatapplytoyourindividualplanyeardeductibledon’tcounttowarddollarbenefitmaximums.Butifyoureceiveservicesorsuppliescoveredbyabenefitthathasanyotherkindofmaximum,chargesforthoseservicesorsuppliesthatapplytoyourdeductiblearealsoappliedtothatbenefit’smaximum.
FamilY deduCtiBle
ThisprogramhasaComprehensiveMedicalPlanYearDeductiblelimitforfamilies.Ifthetotaldeductibleforyouandyourfamilyreachesacertainamountwithinoneplanyear,youwillnotbesubjecttoanyfurtherdeductibleforthatyear.Familydeductiblelimitsareshownbelow.Onlytheamountsusedtosatisfyeachenrolledfamilymem-ber’sdeductiblewillcontributetowardthefamily’stotaldeductible.
Plan Option Individual Deductible Family Deductible
HighDeductibleHealthPlan $1,250 $3,000750Plan $750 $2,250500Plan $500 $1,500
Common aCCident deduCtiBle
Ifyouandoneormoreofyourinsureddependents,ortwoormoreofyourinsureddependents,incurcoveredmedicalexpensesasaresultofthesameaccident,thedeductiblewillbeappliedonlyonceduringtheplanyearinwhichtheaccidentoccursandthefollowingplanyear.Inotherwords,nomatterhowmanyinsuredfamilymembersreceivetreatmentforinjuriesfromanaccident,thedeductibleistheapplicableindividualdeductible.
FourtH quarter deduCtiBle CarrY ForWard
Coveredchargesthatareappliedtowardadeductibleforservicesincurredduringthelastthreemonthsofaplanyearmaybecarriedovertoreducethedeductibleforthenextplanyear.Thisisalsotrueforthefamilydeductible.
BeneFits not suBjeCt to tHe mediCal deduCtiBle
Thefollowingbenefitsarenotsubjecttothecomprehensivemedicalplanyeardeductible:
• DiagnosticandScreeningMammography • PharmacyBenefits• WellnessProvisions(PreventiveBenefit) • AudioCare• DentalCare(seetheDentalBenefitssectionforinformationondentaldeductibles)
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SCHEDULE OF BENEFITS—MEDICAL
Thebenefitsofyourhealthcareplanarebasedonallowablechargesforcoveredservicesandsupplies.PleaserefertothedefinitionofAllowableChargeintheGlossaryofTermsatthebackofthisHandbook.
PremeraBlueCrossBlueShieldofAlaskahasdevelopedabroadnetworkofprovidersinthestateofAlaskacalledthe Alaska Heritage Network.Youmayseekcoveredservicesfromanyproviderlicensedtoprovidetheservice.However,withinAlaska,inordertoreceivethehigherlevelofbenefitsavailableunderthisprogramforcertainser-vices,youmustuseaphysician,hospitalorhospital-basedchemicaldependencytreatmentfacilityintheNetwork.Forthispurpose,a“physician”meansaproviderwhoislicensedbythestateasaDoctorofMedicineandSurgery(M.D.),DoctorofOsteopathyandSurgery(D.O.)orPodiatrist(D.P.M.).
Whenyouuseaphysician,hospital,orhospital-basedchemicaldependencytreatmentfacilityintheNetwork,youwillberesponsibleonlyforanyapplicabledeductibles,copayments,coinsurance,out-of-pocketmaximums,chargesinexcessofthestatedbenefitmaximums,andchargesforservicesandsuppliesnotcoveredunderthehealthcareprogram.Inaddition,networkproviderswillbillBlueCrossdirectlywhentheyfurnishcoveredservicestoyou.
Ifyouuseaproviderthatdoesn’thaveanetworkagreementwithBlueCross,you’llberesponsibleforamountsovertheallowablecharge.Amountsinexcessoftheallowablechargealsodon’tcounttowardtheplanyeardeductibleoras coinsurance.
anCHoraGe, FairBanks and juneau
IfyouliveinthegreaterAnchorage,FairbanksorJuneauareas,thefullnetworkofAlaskaHeritageprovidersisavailable(AlaskaHeritagePlusnetwork).Fornon-emergencyphysicianservices,hospitalservicesandhospital-basedchemicaldependencyservicesreceivedinAlaska,youmustuseAlaskaHeritagePlusnetworkproviderstoreceivethehigherlevelofbenefitsprovidedunderthisprogram.AfteryousatisfyyourPlanYearMedicalDeduct-ible,thePlanwillprovidebenefitsforcoveredservicesasfollows:
• In-networkBenefitLevel:benefitswillbeprovidedat80percentofallowablechargesforcoveredservicesandsupplies.Thisbenefitlevelisalsoprovidedfornon-networkproviderswhenBlueCrosshasgrantedabenefitlevelexceptionfornon-emergentcareasexplainedbelow.
• Out-of-networkBenefitLevel:benefitswillbeprovidedataconstant60percentofallowablecharges;out-of-pocketexpensesdonotaccruetowardsanyout-of-pocketmaximum.
Tolocateanetworkproviderinyourarea,pleaserefertotheBlueCrossHeritageNetworkDirectory of Alaska Phy-sicians and Other Providers.Ifyouhavequestions,pleasecontactBlueCrossCustomerServiceat(800)364-2982,yourregionalhumanresourcesoffice,orchecktheUniversityofAlaska’sbenefitswebsiteatwww.alaska.edu/ben-efitsorPremera.com.
outside anCHoraGe, FairBanks and juneau
IfyouliveoutsideofthegreaterAnchorage,FairbanksorJuneauareas,thenetworkproviderrequirementinthestateofAlaskaappliestohospitalsandhospital-basedchemicaldependencyprogramsinAnchorageonly.However,ifyoureceivecareoutsideofAlaska,youmustusenetworkproviderstoreceivethehigherlevelofbenefits.
21
WHen You are outside alaska
Fornon-emergencyphysician,hospitalandhospital-basedchemicaldependencyservicesreceivedinWashington,you’llreceivethehigherlevelofbenefitswhenyouuseHeritagenetworkproviders.ForthesameservicesoutsideofAlaskaandWashington,seekcarefromproviderswithpreferredagreementswiththelocalBlueCrossand/orBlueShield Licensee.
WhentravelingorifeligibledependentsareattendingschooloutsidethestateofAlaska,itisimperativethatyouusepreferredproviderstoobtainthehigherlevelofbenefitsfromyourhealthcareplan.SeeTheBlueCardProgramsectionofthisHandbookformoreinformation.
emerGenCY serviCes
Benefitsformedicalemergenciesandaccidentalinjurieswillbeprovidedatthehigherlevelwhenyouseeanycov-eredprovider.PremeraBlueCrossBlueShieldofAlaskawillpaytheallowablechargefortheseservicesandyou’llonlypayyourapplicabledeductibles,coinsurance,copays,amountsthatexceedthebenefitmaximums,amountsabovetheallowablechargefornon-networkprovidersandchargesfornon-coveredservices.
BeneFit level eXCeption For non-emerGent Care
PremeraBlueCrossBlueShieldofAlaskacurrentlyhasanextensivenetworkofprovidersintheAnchorage,Fair-banksandJuneaucommunities.However,ineachcommunitytherearespecialtieswherethenetworkisincomplete.
IfyourequiretheservicesofaphysicianorhospitalthatisnotintheAlaskaHeritagenetwork,youmustcallBlueCrossforareferral,or“benefitlevelexceptionfornon-emergencycare,”toreceivethehigherlevelofbenefits.AbenefitlevelexceptionisadeterminationbyBlueCrosstoprovidein-networkbenefitsforcoveredservicesfromanon-networkprovider.
You,yourproviderormedicalfacilitymayrequestabenefitlevelexception,butitmustbedonebeforeyoureceivetheserviceorsupply.IfyourrequestisapprovedbyBlueCross,benefitsforcoveredservicesandsupplieswillbeprovidedatthein-networkbenefitlevel.Paymentofyourclaimwillbebasedonyoureligibilityandbenefitsavailableatthetimeyougettheserviceorsupply.Youwillberesponsibleforamountsappliedtowardsyourplanyeardeductible,coinsurance,amountsthatexceedthebenefitmaximums,amountsabovetheallowablecharge,andchargesfornon-coveredservices.Ifyourrequestisdenied,in-networkbenefitswon’tbeprovided.
PleasecallPremeraBlueCrossBlueShieldofAlaskaCustomerServiceat(800)364-2982torequestabenefitlevelexceptionfornon-emergencycare.
BlueCrosswilldeterminewhetherthebenefitlevelexceptionwillbeauthorizedordenied.IfyoudonotcallBlueCrossforabenefitlevelexceptionbeforehand,orifabenefitlevelexceptionisdenied,benefitswillbeprovidedataconstant60percentofallowablechargesafteryouhavemetyourdeductible,withnomaximumout-of-pocketlimit.
PremeraBlueCrossBlueShieldofAlaska’sbenefitlevelexceptionshouldnotbeconsideredaguaranteeofpay-ment.Paymentofanyservicewillbebasedonyoureligibilityandbenefitsavailableatthetimeservicesareren-dered.
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Waived serviCes
PremeraBlueCrossBlueShieldofAlaskamayfromtimetotimeidentifyprovidersthattheydon’thaveagreementswithwhoprovidespecificservicesforwhichyou’llalwaysreceivethehigherlevelofbenefitsundertheStandardorEconomyPlanoptions.Waivedserviceswon’trequireabenefitlevelexception.Ifyou’dlikemoreinformationonwaivedservices,pleasecallCustomerServiceat(800)364-2982.
provider status
Sinceaprovider’sagreementwithPremeraBlueCrossBlueShieldofAlaskaissubjecttochangeatanytime,itisimportanttoverifyaprovider’sstatus.Thismayhelpyouavoidadditionalout-of-pocketexpenses.PleasecallCus-tomerServiceat(800)364-2982toverifyaprovider’sstatus.IfyouareoutsideAlaskaandWashington,orinClarkCounty,Washington,call(800)810-BLUE(2583)tolocateorverifythestatusofaprovider.
IfyouareseeingaproviderandtheirwrittenagreementwithBlueCrossisterminatedwhileyouarereceivingpreg-nancycareorotheractivetreatment,BlueCrosswillconsidertheproviderasiftheystillhaveanactiveagreementwithBlueCrossforthepurposeofthatcareuntiloneofthefollowingoccurs:
• Thisprogramisterminated.• Theprovider’sstatuswillchangeonthedatetheprovider’smedicallynecessarytreatmentofaterminalcondi-
tionends.“Terminal”meansthatthepatientisexpectedtolivelessthanoneyearfromthedatetheprovider’sagreementisterminated.
• Inallothercases,theprovider’sstatuswillchangeonthelastofthreedatestooccur:• Theninetiethdayafterthedatetheprovider’sagreementisterminated;• Thedatethecurrentplanyearends;or• Thedatepostpartumcareiscompleted.
23
OUT-OF-POCKET MAXIMUMS
Thisprovisionoffersextendedprotectionforyouandyourfamilybyplacingmaximumlimitsonyourout-of-pocketcostsformedicalservices(personalexpensesforcoveredandallowablecharges)whenyouuseAlaskaHeritagenetworkproviders.Onceyouhavereachedyourout-of-pocketlimit,benefitswillbeprovidedat100percentofal-lowablechargesforcoveredservicesreceivedbyyoufromnetworkprovidersduringtheremainderofthatplanyear.
IfyouliveinthegreaterAnchorage,FairbanksorJuneauareaswherethefullAlaskaHeritageprovidernetworkapplies,andyoudonotuseanetworkproviderordonotobtainabenefitlevelexceptionfornon-emergentcareforanon-networkprovider,yourout-of-pocketexpenseswillnotapplytoanymaximumout-of-pocketlimit.PleaseseetheBenefitLevelExceptionforNon-EmergentCaresectionofthisHandbook.
Please Note: The100percentbenefitleveldoesnotapplytothefollowingbenefits,whichhavetheirownspecificbenefitlevels.Expensesincurredforthesebenefitsdonotaccruetowardyourmedicalout-of-pocketmaximums,withtheexceptionofanyplanyeardeductibles:
• DentalCareBenefit• OrthognathicSurgeryServices• VisionCareBenefitthroughVSP• PharmacyDrugProgramthroughCaremark• AudioCareBenefit
Inaddition,planyeardeductibles,amountsthatexceedthebenefitmaximumsunderthisprogram,includingthelife-timemaximum,andamountsforservicesandsuppliesnotcoveredunderthisprogramdo notaccruetowardyourindividualorfamilymedicalcoinsuranceout-of-pocketmaximum.
individual mediCal out-oF-poCket maXimum
Based upon coveredandallowablecharges,theplanyearmaximumcoinsurancethatanindividualwouldpay,afterthedeductible,isshowninthetablesbelow.Duringtheplanyear,afteryoupaytheout-of-pocketmaximumforcoveredmedicalservicesfromnetworkproviders,anyfurthercoveredandallowablemedicalexpensesincurredbyyoufromnetworkproviderswouldbereimbursedat100percent(subjecttoallowablecharges)fortherestofthatplanyear.Seethefollowingtablesfordetailbyplanoption.
FamilY mediCal out-oF-poCket maXimum
Based upon coveredandallowablechargesforservicesfromnetworkproviders,theyearlymaximumcoinsuranceforafamily,aftersatisfyingthefamilydeductible,isshowninthetablesbelow.Duringtheplanyear,ifyourfamilyweretoreceivesufficientcoveredmedicalservicesfromnetworkproviderstoreachyourcoinsurancemaximum,anyfurthercoveredmedicalexpensesincurredbyyourfamilyfromnetworkproviderswouldbereimbursedat100percent(subjecttoallowablecharges)fortherestofthatplanyear.Seethefollowingtablesfordetailbyplanoption.
24
out-oF-poCket maXimums BY plan option
Themedicalout-of-pocketmaximumcoinsuranceisthemostyou’llpayforcoveredin-networkmedicalexpensesafteryourdeductibleissatisfied.Thismaximumisforcoveredin-networkmedicalexpensesonly;itdoesnotincludepharmacy,visionordentalcoinsuranceorcopays.(Thepharmacyplanhasitsownmaximumout-of-pocketlimit,seethePharmacyProgramsectionformoreinformation.)Themaximumout-of-pocketyou’llpayforcoveredandallowedin-networkexpensesisasfollows:
Individual Family High Deductible Health Plan Limit Limit
Deductible $1,250 $3,000MaximumCoinsurance $3,750 $8,000TotalOut-of-PocketChargesYou’llPay $5,000 $11,000 for the Plan Year
Individual Family 750 Plan Limit Limit
Deductible $750 $2,250MaximumCoinsurance $3,500 $7,000TotalOut-of-PocketChargesYou’llPay $4,250 $9,250 for the Plan Year
Individual Family 500 Plan Limit Limit
Deductible $500 $1,500MaximumCoinsurance $3,000 $6,000TotalOut-of-PocketChargesYou’llPay $3,500 $7,500 for the Plan Year
maXimum liFetime BeneFit
ThemaximumlifetimebenefitforanypersoninsuredundertheUniversity’shealthcareplanisunlimited.
25
PREVENTIVE (WELLNESS) BENEFIT
Oursharedgoalisahealthyandproductiveworkforce.TheUAChoicePlanincludesaPreventiveBenefitthatexpandsthemedicalcareavailabletoemployeesandtheirdependents.Itallowsyoutodecidewhatroutinetests,screeningsandimmunizationsarerightforyouandyourfamily.ThePreventiveBenefitisavailabletoyouinaddi-tiontotraditionaldiagnosticcare.
Recenthealthcarereformlegislationhasexpandedthelistofeligiblepreventiveservices.Asaguide,wehavepub-lishedalistoftheseservicesandthesuggestedappropriateageguidelinesontheUniversityofAlaska’sbenefitswebsiteatwww.alaska.edu/benefits/health-plan.Thelistisalsoonlineatwww.premera.com.
Preventivemedicalservicesarenowdefinedtoinclude:
• Evidence-baseditemsorserviceswitharatingof“A”or“B”inthecurrentrecommendationsoftheU.S.Pre-ventiveTaskForce(USPSTF).Alsoincludedareadditionalpreventivecareandscreeningsforwomennotde-scribedaboveinthisparagraphasprovidedforincomprehensiveguidelinessupportedbytheHealthResourcesandServicesAdministration.
• ImmunizationsasrecommendedbytheAdvisoryCommitteeonImmunizationPracticesoftheCentersforDis-easeControl(CDC).
• Evidence-informedinfant,childandadolescentpreventivecareandscreeningsprovidedforinthecomprehen-siveguidelinessupportedbytheHealthResourcesandServicesAdministration.
ThisPreventiveMedicalCarebenefitcoversroutineexamsandimmunizations.Othermedicalservicesthatqualifyaspreventiveasshownabovearecoveredundervariousotherbenefitsofthisplan.Forexample,colonoscopiesarenormallycoveredunderthesurgicalservicesbenefit.Whentheseservicesmeetthefederalrequirementsforpreven-tivemedicalservices,however,theplanwillprovidebenefitsforthemasstatedbelowinsteadofasdescribedinthebenefitwhichnormallycoverstheservices.
Preventivehealthservicesarecoveredat100%ofallowablecharges,withnodeductible,copayorcoinsurance.Benefitsareprovidedforroutineandpreventiveservicesperformedonanoutpatientbasis,andaren’tsubjecttoaplanyearbenefitlimit.Examplesofcoveredservicesincluderoutinephysicalexams,immunizations,well-babyandwell-childexams,physicalexamsrelatedtoschoolorsports.
Servicesthatarerelatedtoaspecificillness,injuryordefinitivesetofsymptomsarecoveredunderthenon-preven-tivemedicalbenefitsofthisplan.
Wellness limitations
Inadditionto“GeneralLimitationsandExclusions,”PreventiveMedicalCarebenefitswillnotbeprovidedfor:
• dentalexaminations,treatment,thefittingofdentalappliancesordentures,orotherservicesprovidedbyaden-tist(exceptasspecifiedunderDentalCareBenefits);
• inpatientroutinenewbornexamswhilethechildisinthehospitalfollowingbirth(theseservicesarecoveredundertheNewbornCarebenefit);
• routinevisionandhearingexaminations(exceptasspecifiedunderVisionCareBenefitsandAudioCareBen-efits);
• contraceptivedevices;• servicesthatarerelatedtoaspecificillness,injury,ordefinitivesetofsymptomsexhibitedbytheenrollee;• physicalexamsforbasiclifeordisabilityinsurance;or• work-relatedphysicalexams,work-relateddisabilityevaluationsormedicaldisabilityevaluations.
26
CARE MANAGEMENT HEALTHCARE UTILIZATION
CareManagementservicesworktohelpensurethatyoureceiveappropriateandcost-effectivemedicalcare.YourroleintheCareManagementprocessissimple,butimportant.
Thisprogram’sbenefitsdonotrequirepreauthorizationforcoverage.Youmustbeeligibleonthedatesofserviceandservicesmustbemedicallynecessary.WeencourageyoutocallCustomerServicetoverifythatyoumeettherequiredcriteriaforclaimspaymentandtohelpBlueCrossidentifyadmissionswhichmightbenefitfromcaseman-agement.
individual Case manaGement
CaseManagementworkscooperativelywithyouandyourphysiciantoconsidercare-effectiveandcost-effectivealternativestohospitalizationandotherhigh-costcaretomakemoreefficientuseofthehealthcareprogram’sbenefits.Thedecisiontoprovidebenefitsforthesealternativesiswithintheplan’ssolediscretion.YourparticipationinanalternativetreatmentplanthroughIndividualCaseManagementisvoluntary.IfanagreementisreachedwithBlueCrossforanalternativeprogram,youoryourlegalrepresentative,yourphysicianandotherproviderspartici-patinginthetreatmentplanwillberequiredtosignwrittenagreementsthatsetforththetermsunderwhichbenefitswillbeprovided.
IndividualCaseManagementissubjecttothetermssetforthinthesignedwrittenagreements.BlueCrossmayutilizeyourplanbenefitsasspecifiedinthesignedcasemanagementagreements,buttheagreementsarenottobeconstruedasawaiveroftherighttoadministerthebenefitsprovidedunderthehealthcareprograminothersitua-tions.Allpartieshavetherighttore-evaluateorterminatetheIndividualCaseManagementagreementatanytime,attheirsolediscretion.IndividualCaseManagementterminationmustbeprovidedinwritingtoallparties.Yourremainingbenefitsunderthisprogramwouldbeavailabletoyouatthattime.
appeals revieW
ShouldyouoryourphysiciandisagreewiththeCareManagementdetermination,youmayfollowtheappealproce-duresexplainedinthe“YourQuestions,ComplaintsandAppeals”sectionofthishandbook.
BestBeGinninGs
BestBeginningsprovidesmothers-to-bewithquickandeasyaccessthroughouttheirpregnancytoanursetrainedinobstetrics.TheBestBeginningsnursecanhelpanswerquestionsaboutpregnancy,prenatalcareanddelivery,andprovidemothers-to-bewithotherhelpfulinformationtoassisttheminmakinghealthychoicesduringtheirpreg-nancy.
TheemployeeandanyenrolleddependentoftheemployeemayparticipateinBestBeginnings.
Assoonasyouknowyouarepregnant,calltheBestBeginningstoll-freenumber,(888)773-6399.
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THE BLUECARD PROGRAM
PremeraBlueCrossBlueShieldofAlaska,likeallBlueCrossand/orBlueShieldLicensees,participatesinaprogramcalled“BlueCard.”EnrolleescantakeadvantageofBlueCardwhentheyreceivecoveredservicesoutsideAlaskaandWashingtonorinClarkCounty,Washingtonfromhospitals,doctors,andothermedicalcareproviderswhohavecontractedwiththelocalBlueCrossand/orBlueShieldlicensee,calledthe“HostBlue”inthissection.ThenationalBlueCardprogramisavailablethroughouttheUnitedStates,theCommonwealthofPuertoRico,andU.S.VirginIslands.
YouridentificationcardtellscontractingproviderswhichindependentBlueCrossand/orBlueShieldLicenseeisyours.ItisimportanttonotethatreceivingservicesthroughBlueCarddoesnotchangecoveredbenefits,benefitlevels,oranystatedresidencyrequirementsofyourprogram.However,whenyouuseyouridentificationcard,youwillreceivemanyoftheconveniencesyou’reaccustomedtofromPremeraBlueCrossBlueShieldofAlaska.Inmostcases,therearenoclaimformstosubmitbecausecontractingproviderswillhandleclaimsubmissionforyou.Inaddition,yourout-of-pocketcostsmaybelessasexplainedbelow.
Here’s HoW BlueCard Helps keep Costs doWn
WhenyouobtainhealthcareservicesoutsideAlaskaandWashingtonorinClarkCounty,WashingtonthroughBlueCard(excludingBlueCardWorldwide,seebelow),theamountyoupayforcoveredservicesiscalculatedonthelowerof:
• Thebilledchargesforyourcoveredservices,or• The“negotiatedprice”thattheHostBluepassesontoPremeraBlueCrossBlueShieldofAlaskaforyourcov-
ered services.ThemethodsusedtodeterminethenegotiatedpricewillvaryamongHostBluesaccordingtothetermsoftheirpro-vidercontracts.Often,thisnegotiatedpricewillconsistofasimplediscount,whichreflectstheactualpriceallowedaspayablebytheHostBlue.But,sometimes,itisanestimatedpricethatfactorsinaggregatepaymentsexpectedtoresultfromtheHostBlue’ssettlements,withholds,orothercontingentpaymentarrangementsandnon-claimstransactionswithyourhealthcareproviderorwithaspecifiedgroupofproviders.Thenegotiatedpricemayalsobeadiscountfrombilledchargesthatreflectsanaverageexpectedsavingswithyourhealthcareprovidersoraspecificgroupofproviders.Thepricethatreflectsaveragesavingsmayresultingreatervariationaboveorbelowtheactualpricethanwilltheestimatedprice.InaccordancewithnationalBlueCardpolicy,theseestimatedoraveragepriceswillalsobeadjustedfromtimetotimetocorrectforoverestimationorunderestimationofpastprices.However,theamountonwhichyourpaymentisbasedremainsthefinalpriceforthecoveredservicesbilledonyourclaim.
SomestatesmaymandateasurchargeoramethodofcalculatingwhatyoumustpayonaclaimthatdiffersfromBlueCard’susualmethodnotedabove.Ifsuchamandateisinforceonthedateyoureceivedcoveredcareinthatstate,theamountyoumustpayforanycoveredserviceswillbecalculatedusingthemethodsrequiredbythatman-date.Suchmethodsmightnotreflecttheentiresavingsexpectedonaspecificclaim.
Clark County Providers
SomeprovidersinClarkCounty,WashingtondohavecontractswithPremeraBlueCross.TheseproviderswillsubmitclaimsdirectlytoPremeraBlueCrossandbenefitswillbebasedontheallowablechargefortheserviceorsupply.
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non-BlueCard Claim suBmission
Ifahospital,doctor,orothermedicalcareproviderdoesnotcontractwiththeHostBlue,thatclaimmaynotbefiledonyourbehalf.Forinstructiononhowtofileaclaiminthissituation,refertothe“HowToSubmitAClaim”sectionofthisHandbook.
BlueCard WorldWide
IfyouareoutsidetheUnitedStates,theCommonwealthofPuertoRicoandtheUnitedStatesVirginIslands,youmaybeabletotakeadvantageofBlueCardWorldwide.BlueCardWorldwideisunlikethenationalBlueCardPro-gramincertainways.Forinstance,althoughBlueCardWorldwideprovidesanetworkofcontractinghospitals,itof-fersonlyreferralstodoctors.Whenreceivingcarefromdoctors,youwillhavetosubmitformsonyourownbehalftoobtainreimbursementfortheservicesprovidedthroughBlueCardWorldwide.
ToaccesshealthcareservicesthroughBlueCardWorldwideandtoobtainadditionalinformationaboutproviders’charges,pleasecall(800)810-BLUE(2583).
FurtHer questions?
IfyouhavequestionsorneedadditionalinformationaboutusingyourcardoutsideAlaskaorWashington,pleasecallBlueCross’CustomerServiceat(800)364-2982.TolocateapreferredproviderinanotherBlueCrossand/orBlueShieldLicenseeservicearea,call(800)810-BLUE(2583).BesuretospecifythatyourhealthcareprogramisaPPOandyouwishtolocatea“preferredprovider.”
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COVERED SERVICES AND SUPPLIES
Thissectionofyourhandbookdescribesthespecificbenefitsavailableforcoveredservicesandsupplies.Benefitsareavailableforaserviceorsupplydescribedinthissectionwhentheymeetalloftheserequirements:
• Itmustbefurnishedinconnectionwiththediagnosisortreatmentofacoveredillnessoraccidentalinjury.• Itmustbe,inthejudgmentofPremeraBlueCrossBlueShieldofAlaska,medicallynecessaryandmustbe
furnishedinamedicallynecessarysetting.Inpatientcareisonlycoveredwhenyourequirecarethatcouldn’tbeprovidedinanoutpatientsettingwithoutadverselyaffectingyourconditionorthequalityofcareyouwouldreceive.
• Itmustbeprescribedbyaphysician,asdefinedinthishandbook.• Itmustnotbeexcludedfromcoverageunderthehealthcareprogram.• Theexpensefortheserviceorsupplymustbeincurredwhileyouarecoveredunderthehealthcareprogramand
afteranyapplicablewaitingperiodrequiredunderthisprogramissatisfied.• Itmustbefurnishedbyaproviderthatiscoveredundertheapplicablebenefit.
Hospital inpatient Care
Coveredcostsincludehospitalroomandboard;intensiveandcoronarycareunits;plusservicesandsupplies,suchasdiagnosticservices,surgicaldressings,anddrugs,furnishedbyandusedwhileconfinedinahospital.Benefitsarepayableforamaximumof365daysperconfinement.
Please Note:Whencoveredinpatientdiagnosticservicesarefurnishedandbilledbyaninpatientfacility,theyareonlyeligibleforcoverageundertheapplicableinpatientfacilitybenefit.All“HospitalInpatientCare”servicesaresubjecttothehealthcareplan’sdeductiblesandout-of-pocketmaximums.
Hospital inpatient limitations
Inadditionto“GeneralLimitationsandExclusions,”hospitalinpatientcarebenefitswillnotbeprovidedforthefol-lowing:
• Hospitaladmissionsfordiagnosticpurposesonly,unlesstheservicescannotbeprovidedwithouttheuseofinpatienthospitalfacilities,orunlessyourmedicalconditionmakesinpatientcaremedicallynecessary
• Anydaysofinpatientcarethatexceedthelengthofstaythatis,inthejudgmentofPremeraBlueCrossBlueShieldofAlaska,medicallynecessarytotreatyourcondition
Hospital outpatient Care
Coveredcostsincludeemergency,procedure,operating,andrecoveryrooms;plusservicesandsupplies,suchassurgicaldressings,anddrugs,furnishedbyandusedwhileatahospitalforservicesthatarefurnishedtoanenrolleewhoisnotconfinedasafull-timeinpatient.Forbenefitinformationondiagnosticservicesdonewhileatthehospi-tal,seetheDiagnosticServicesbenefit.
PleaseNote:All“HospitalOutpatientCare”servicesaresubjecttothehealthcareplan’sdeductiblesandout-of-pocketmaximums.
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skilled nursinG FaCilitY
Thisbenefitisonlyprovidedwhenyouareatapointinyourrecoverywhereinpatienthospitalcareisnolongermedicallynecessary,butskilledcareinaskillednursingfacilityis.Yourattendingphysicianmustactivelysuperviseyourcarewhileyouareconfinedintheskillednursingfacility.
Coveredcostsincludeservicesandsupplies,includingroomandboard,furnishedbyandusedwhileconfinedinaskillednursingfacilityforupto100daysinanyoneplanyear.
skilled nursinG Care limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• Custodialcare• Carethatisprimarilyforseniledeterioration,mentaldeficiencyormentalretardation• Chemicaldependency
amBulatorY surGiCal Center
Servicesandsuppliesfurnishedbyandusedwhileatthecenter,suchassurgicaldressingsanddrugsarecovered.
pHYsiCians’ serviCes
Home,office,emergencyroom,andinpatientvisits;therapeuticinjectionsincludingallergytestingandallergyinjections;surgery;anesthesiaadministration,corneatransplantation,skingraftsandtransfusionofbloodorbloodderivativesarecovered.Alsoincludedinthisbenefitareprostateandcervicalcancerscreeningexaminations,unlesstheymeetthestandardsforpreventivemedicalservicesdescribedinthePreventiveMedicalCare(Wellness)benefit.
assistant surGeon
Benefitsareonlyprovidedforservicesofanassistantsurgeonwhenmedicallynecessary,andcannotexceed20percentoftheprimarysurgeon’sallowablecharge.
multiple surGiCal proCedures
Ifmultipleorbilateralsurgicalproceduresareperformedduringthesameoperativesession,benefitswillbeprovid-edbasedontheallowablechargeforthefirstormajorprocedure,andone-halftheallowablechargeforsecondaryprocedures.
mental HealtH serviCes
Forinpatientandoutpatientmentalhealthcareofpsychiatricconditions,includingtreatmentofeatingdisorders(suchasanorexianervosa,bulimia,oranysimilarcondition),benefitswillbeprovidedaccordingtothemedicalscheduleofbenefits.
“Outpatienttherapeuticvisit”(outpatientvisit)meansaclinicaltreatmentsessionwithamentalhealthproviderofadurationconsistentwithrelevantprofessionalstandardsasdefinedinthePhysician’s Current Procedural Termi-
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nology,aspublishedbytheAmericanMedicalAssociation.
Coveredservicesmustbefurnishedbyalegally-operatedhospital,aphysician,apsychologist,apsychologicalasso-ciate,amasterofsocialwork,alicensedfamilyandmaritaltherapistorcounselor,alicensedclinicalsocialworker,oranAdvancedNursePractitioner(A.N.P.).Seethe“GlossaryofTerms”forfurtherdefinitionofacoveredprovider.
mental HealtH Care limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforwhatare,inthejudgmentofBlueCross,thefollowingcases:
• substanceusedisorderssuchasalcoholismordrugaddiction(seebelow),sexualdysfunctions,dementia,andsleepdisorders;
• servicesfurnishedinconnectionwithobesity,eveniftheobesityisaffectedbypsychologicalfactors;• neurologicalandpsychologicaltestingandevaluationsrelatedtorehabilitationtherapy;or• testing,evaluations,andotherpsychologicalservicesrelatedtochronicpaincare.
CHemiCal dependenCY
Forinpatientandoutpatienttreatmentofchemicaldependencyconditions,includingdetoxification,theplanwillpayaccordingtothemedicalscheduleofbenefits.Coveredservicesmustbefurnishedbyastate-approvedtreatmentfacility,hospital,physician(M.D.orD.O.),psychologist,psychologicalassociate,licensedclinicalsocialworker,licensedfamilyandmaritalcounselor,oragovernment-approvedmethadoneclinic.Seethe“GlossaryofTerms”forfurtherdefinitionofacoveredprovider.
Benefitsfortherapeuticandsupportingservicesthatareprovidedtoenrolledfamilymemberstoassistinthechemi-callydependentenrollee’sdiagnosisandtreatmentareappliedtothebenefitmaximumsofthechemicallydependentenrollee.
CHemiCal dependenCY treatment limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowingsituations:
• treatmentofnondependentalcoholordruguseorabuse;• voluntarysupportgroups,suchasAlanonorAlcoholicsAnonymous;or• court-orderedservicesorservicesrelatedtodeferredprosecution,deferredorsuspendedsentencing,ortodriv-
ingrights,exceptasdeemedmedicallynecessarybyBlueCross.
Indeterminingwhetherservicesforchemicaldependencytreatmentaremedicallynecessary,PremeraBlueCrossBlueShieldofAlaskawillusethecurrenteditionofthePatient Placement Criteria for the Treatment of Sub-stance-Related Disorders,aspublishedbytheAmericanSocietyofAddictionMedicine.
tHerapeutiC nuClear mediCine
Servicesandsuppliesfurnishedinconnectionwithradium,radioisotope,andX-raytherapyarecovered.
diaGnostiC serviCes
Administrationandinterpretationofdiagnosticimagingandscans(includingX-raysandEKGs),pathology,andlaboratorytestsarecovered.Screeningtestsforprostateandcervicalcancerarecovered.
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Please Note:Whencoveredinpatientdiagnosticservicesarefurnishedandbilledbyaninpatientfacility,theyareonlyeligibleforcoverageundertheapplicableinpatientfacilitybenefit.Pleaseseethe“GeneralPreventiveBenefit”under“WellnessProvisions”forinformationonpreventivediagnosticservices.
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• Diagnosticsurgeriesandscopinsertionprocedures,suchascolonoscopiesorendoscopieswhicharecoveredunderthe“Physician’sServices”benefit,unlesstheymeetthestandardsforpreventivemedicalservicesde-scribedinthePreventiveMedicalCare(Wellness)benefit
• Allergytesting(seethe“Physician’sServices”benefit)
diaGnostiC and sCreeninG mammoGrapHY
Thisbenefitisnotsubjecttotheplanyeardeductibleorcoinsurance.Benefitsareprovidedforscreeninganddiag-nosticmammographyasfollows:
• abaselinemammogramandannualmammogramscreeningsthereafter,regardlessofage;and• asrecommendedbyaphysicianforanenrolleewithsymptoms,ahistoryofbreastcancer,orwhoseparentor
siblinghasahistoryofbreastcancer.
ContraCeptive manaGement and steriliZation serviCes
Professionalservices,includingsurgeryandimplantingorinjectingcontraceptives,andoutpatientsurgicalfacilityservicesareprovided,subjecttotheplanyeardeductibleandcoinsurance.Benefitsincludeconsultations;steriliza-tionprocedures;injectablecontraceptives;implantablecontraceptives(includingIUDsandhormonalimplants);andemergencycontraceptionmethods(oralorinjectable),whenfurnishedbyyourhealthcareprovider.
presCription ContraCeptives dispensed BY a pHarmaCY
Prescriptioncontraceptives(includingemergencycontraception)andprescriptionbarrierdevices,suchasdia-phragmsandcervicalcaps,dispensedbyalicensedpharmacyarecoveredonthesamebasisasanyothercoveredprescriptiondrug.PleaseseethePharmacyProgramsectionformoreinformation.
ContraCeptive manaGement and steriliZation serviCes limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedfornonprescriptioncontracep-tivedrugs,suppliesordevices;sterilizationreversal;testing,diagnosisandtreatmentofinfertility,includingfertilityenhancementservices,procedures,suppliesanddrugs;orcontraceptivedrugs,suppliesordevicesdispensedbyalicensedpharmacy.
masteCtomY and Breast reConstruCtion serviCes
Benefitsareprovidedformastectomynecessaryduetoillnessoraccidentalinjury.Foranyenrolleeelectingbreastreconstructioninconnectionwithamastectomy,inamannerdeterminedinconsultationwiththeattendingphysicianandthepatient,thisbenefitcovers:
• reconstructionofthebreastonwhichmastectomyhasbeenperformed;• surgeryandreconstructionoftheotherbreasttoproduceasymmetricalappearance;• prosthesis;and• physicalcomplicationsofallstagesofmastectomy,includinglymphedemas.
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transplants
AlthoughpriorapprovalbyPremeraBlueCrossBlueShieldofAlaskaisnotrequiredbeforebenefitscanbepro-vided,youoryourphysicianareencouragedtocontactBlueCrosstoseeiftheproposedtransplantwillmeettherequirementsofthisbenefit.
Covered transplants
Solidorgantransplantsandbonemarrow/stemcellreinfusionproceduresmustnotbeconsideredexperimentalorinvestigationalforthetreatmentofyourcondition.(RefertotheGlossaryofTermsforthedefinitionof“Experimen-tal/InvestigationalServices.”)PremeraBlueCrossBlueShieldofAlaskareservestherighttobasecoverageonallofthefollowing:
• Solidorgantransplantsandbonemarrow/stemcellreinfusionproceduresmustbemedicallynecessaryandmeetBlueCross’criteriaforcoverage.PremeraBlueCrossBlueShieldofAlaskareviewsthemedicalindicationsfortransplant,documentedeffectivenessoftheproceduretotreatthecondition,andfailureofmedicalalternatives.
• Thetypesofsolidorgantransplantsandbonemarrow/stemcellreinfusionproceduresthatcurrentlymeetBlueCross’criteriaforcoverageare:• heart• heart/doublelung• singlelung• doublelung• liver• kidney• pancreas• pancreaswithkidney• bonemarrow(autologousandallogenic)• stemcell(autologousandallogenic)
Forthepurposesofthisprogram,theterm“transplant”doesnotinclude:corneatransplantation,skingrafts,orthetransplantofbloodorbloodderivatives(exceptforbonemarroworstemcells).Benefitsforsuchservicesareprovidedunderotherbenefitsofthisprogram.
• Yourmedicalconditionmustmeetourwrittenstandards.PleasecallPremeraBlueCrossCustomerServiceat(800)364-2982formoreinformation.
• Thetransplantorreinfusionmustbefurnishedinanapprovedtransplantcenter.(“Approvedtransplantcen-ter”isahospitalorotherproviderthathasdevelopedexpertiseinperformingsolidorgantransplants,orbonemarroworstemcellreinfusion,andisapprovedbyBlueCross.)PremeraBlueCrossBlueShieldofAlaskahasagreementswithapprovedtransplantcentersinAlaskaandWashington,andhasaccesstoaspecialnetworkofapprovedtransplantcentersaroundthecountry.Whenevermedicallypossible,BlueCrosswilldirectyoutoanapproved transplant center that has contracted for transplant services.
• Ofcourse,ifnoneofPremeraBlueCrossBlueShieldofAlaska’scentersorthenetworkcenterscanprovidethetypeoftransplantyouneed,benefitswillbeprovidedforyourtransplantfurnishedbyanothertransplantcenter.
Please Note:Transplantsaresubjecttothehealthcareprogram’spre-existingconditionwaitingperiod.
transplant serviCes and supplies
Thisbenefitcoverstheservicesandsupplieslistedbelowforallcoveredtransplants:
• Recipient Costs—Hospitalandprofessionalservicesandsuppliesfurnishedbythetransplantcenterduringthe
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stayinwhichthetransplantisperformed.Forbonemarrowtransplants,coveredservicesincludeanychemo-therapyandradiationtherapythatisapartofthecarethatiscoveredbythisbenefit.
• Donor Costs—Covereddonorservicesincludetheselection,removal(harvesting)andevaluationofthedonororgan,bonemarroworstemcell;transportationofdonororgan,bonemarrow,andstemcells,includingthesurgicalandharvestingteams;donoracquisitioncostssuchastestingandtypingexpenses;andstoragecostsforbonemarrowandstemcellsforaperiodofupto12months.
• Transportation and Lodging Expenses—Reasonableandnecessaryexpensesfortravel,lodgingandmealsforthetransplantrecipient(whilenotconfined)andonecompanion,exceptasstatedbelow,arecoveredbutlimitedasfollows:
• thetransplantrecipientmustresidemorethan50milesfromtheapprovedtransplantcenter;• thetravelmustbetoand/orfromthesiteofthetransplantforpurposesofanevaluation,thetransplant
procedure,ornecessarypost-dischargefollow-up;• whentherecipientisnotadependentminorchild,transportation,coveredlodgingandmealexpensesfor
therecipientandonecompanionwillbereimbursedupto$80perday;• whentherecipientisadependentminorchild,transportation,coveredlodgingandmealexpensesforthe
recipientandtwocompanionswillbereimbursedupto$125perday.• Coveredtransportation,lodgingandmealexpensesincurredbythetransplantrecipientandcompanion(s)
arelimitedto$7,500pertransplant.
transplant limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• servicesandsuppliesthatarepayablebyanygovernment,foundation,orcharitablegrant,includingservicesperformedonpotentialoractuallivingdonorsandrecipients,andoncadavers;
• donorcostsforasolidorgantransplantorbonemarroworstemcellreinfusionthatisnotcoveredunderthisbenefitorforarecipientwhoisnotanenrollee;however,complicationsandunforeseeneffectsfromanenroll-ee’sorganorbonemarrowdonationwillbecoveredunderthisprogramasanyotherillness;
• donorcostsforwhichbenefitsareavailableunderothergrouporindividualcoverage;• nonhumanormechanicalorgans,unlessBlueCrossdeterminestheyarenotexperimentalorinvestigationalac-
cordingtothecriteriastatedunder“GlossaryofTerms;”• personalcareitems;• anti-rejectiondrugs,exceptthoseadministeredbythetransplantcenterduringtheinpatientoroutpatienthos-
pitalstayinwhichthetransplantisperformed.OutpatientprescriptiondrugsarecoveredunderyourPharmacyDrugBenefit.
• Plannedstorageofbloodformorethan12monthsagainstthepossibilityitmightbeusedatsomepointinthefuture.
reHaBilitation tHerapY, CHroniC pain Care, and neurodevelopmental tHerapY
Inpatientcareisonlycoveredwhenservicescannotbedoneinalessintensivesetting.
reHaBilitation tHerapY
Servicesmustbemedicallynecessarytorestoreandimproveabodilyorcognitivefunctionthatwaspreviouslynormalbutwaslostasaresultofanaccidentalinjury,illness,orsurgery.
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Inpatient Care
ServicesmustbefurnishedinaspecializedrehabilitativeunitofahospitalandbilledbythehospitalorbefurnishedandbilledbyanotherrehabilitationfacilityapprovedbyPremeraBlueCrossBlueShieldofAlaska.Thecaremustalsobepartofawrittenplanofmultidisciplinarytreatmentprescribedandperiodicallyreviewedbyaphysicianspecializinginrehabilitationmedicine.
Outpatient Care
Thefollowingservicesarecoveredwhenfurnishedandbilledbyahospital,anotherrehabilitationfacilityapprovedbyPremeraBlueCrossBlueShieldofAlaska,aphysician(M.D.orD.O.),oraphysical,occupational,orspeechtherapist:
• physical,speech,andoccupationaltherapyservices,includingcardiacrehabilitation;and• neurologicalandpsychologicaltestsandevaluationsrequiredtoprescribeanappropriatetreatmentplan.This
includesanylaterreevaluationstomakesurethatthetreatmentisachievingthedesiredmedicalresults.Fortheseservices,apsychologist,psychologicalassociate,orlicensedclinicalsocialworkeriscoveredinadditionto the providers listed above.
• outpatientphysicaltherapyislimitedto45visitsperplanyear;additionalvisitsmaybeavailablebasedonmedicalnecessity;and
• massagetherapyislimitedto26visitsperyear,andmustbebilledandsupervisedbyaphysician(M.D.orD.O.),Chiropractor,orPhysicalTherapist.
Chronic Pain Care
TheInpatientandOutpatientRehabilitationTherapyBenefitsalsocoverservicesthataremedicallynecessarytotreat intractable or chronic pain.
Neurodevelopmental Therapy
Neurodevelopmentaltherapymustbemedicallynecessarytorestoreandimprovefunction,ortomaintainfunctionwhere,inthejudgmentofBlueCross,significantphysicaldeteriorationwouldoccurwithoutthetherapy.
• Inpatient Care—Servicesmustbefurnishedandbilledbyahospitalorbyanotherrehabilitationfacilityap-proved by Blue Cross.
• Outpatient Care—Thefollowingservicesarecoveredwhenfurnishedandbilledbyahospital,anotherrehabil-itationfacilityapprovedbyBlueCross,aphysician(M.D.orD.O.),orwithaphysician’sreferral,byaphysical,occupational,orspeechtherapist:• physical,speech,andoccupationaltherapyservices,includingcardiacrehabilitation,arelimitedtoamaxi-
mumof45visitsinaplanyear;and• neurologicalandpsychologicaltestsandevaluationsrequiredtoprescribeanappropriatetreatmentplan.
Thisincludesanylaterreevaluationstomakesurethatthetreatmentisachievingthedesiredmedicalresults.Fortheseservices,apsychologist,psychologicalassociate,orlicensedclinicalsocialworkeriscovered in addition to the providers listed above.
reHaBilitation tHerapY, CHroniC pain Care, and neurodevelopmental tHerapY limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowingsituations:
• nonmedicalself-help,suchas“OutwardBound”or“WildernessSurvival;”recreational,vocational,oreduca-tionaltherapy;workhardening,orexerciseprograms;
• socialorculturaltherapy;
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• acupressureorservicesofamassagetherapist,exceptassupervisedandbilledbyaphysician(M.D.orD.O.),physicaltherapist,orchiropractor;
• treatmentwhichisnotactivelyengagedinbytheill,injured,orimpairedenrollee;• gymorswimtherapy;and• custodialcare,excepthabilitativeservicesundertheNeurodevelopmentalTherapyBenefit.
Home HealtH Care
Tobecovered,thehomehealthcareservicesmustbepartofawrittenplanoftreatmentprescribed,periodicallyreviewed,andapprovedbyaphysician(M.D.orD.O.),anditmustbeginwithinsevendaysafterdischargefromahospitalasaninpatient.Intheplanofcare,thephysicianmustcertifythatconfinementinahospitalorskillednursingfacilitywouldberequiredwithouthomehealthcareservices.MedicallynecessaryhomehealthcaremustberenderedandbilledbyahomehealthagencythatisMedicare-certifiedassuchorislicensedorcertifiedassuchbythestateinwhichitoperates.
Coveredservicesincludehomecarebyoneormoreofthefollowingagencyemployeesuptoamaximumof130intermittentvisitsperenrolleeeachplanyear:
• aregisteredorlicensedpracticalnurse;• alicensedorregisteredphysicaltherapist;• acertifiedrespiratorytherapist;• aspeechtherapistcertifiedbytheAmericanSpeech,Language,andHearingAssociation;• alicensedoccupationaltherapist;• alicensedclinicalsocialworker;• amasterofsocialwork;or• ahomehealthaidewhoisdirectlysupervisedbyoneoftheaboveproviders(performingservicesprescribedin
theplanofcaretoachievethedesiredmedicalresults).
Home HealtH Care limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• socialservices;• servicesoffamilymembersorvolunteers;• nonmedicalservices,suchasspiritual,bereavement,legal,orfinancialcounseling;• normallivingexpenses,suchasfood,clothing,andhouseholdsupplies;• housekeepingservices,exceptforthoseofahomehealthaideasprescribedbytheplanofcare;• transportationservices;• chargesinexcessoftheaveragewholesalepriceshowninthePharmacist’s Red Bookforprescriptiondrugs,
insulin,andintravenousdrugsandsolutions;• over-the-counterdrugs,solutions,andnutritionalsupplements;• drugsandsolutionsreceivedwhileyouareaninpatient;• servicesprovidedtosomeoneotherthantheillorinjuredenrollee;• services,supplies,orprovidersnotinthewrittenplanofcareornotnamedascoveredinthisBenefit;• custodialcare;• dietaryassistance,suchas“MealsonWheels,”ornutritionalguidance;or• servicesprovidedduringanyperiodoftimeinwhichtheenrolleeisreceivinghospicecarebenefitsofthispro-
gram.
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HospiCe Care
Tobecovered,hospicecareservicesmustbefurnishedandbilledbyahospiceagencythatisMedicare-certifiedassuchorlicensedorcertifiedassuchbythestateinwhichitoperates,andmustbepartofawrittenplanofcareprescribedandperiodicallyreviewedbyaphysician(M.D.orD.O.).Thisphysicianmustcertifythattheenrolleeisterminallyillandthathospitalorskillednursinghomeconfinementwouldberequiredintheabsenceofthehospiceplanofcare.Theplanofcareshallalsodescribetheservicesandsuppliesforthepalliativecareandmedicallynec-essarytreatmenttobeprovidedtotheenrollee.
Benefitsareavailableforthefirstsixmonthsfromtheinitialdateofhospicecarecoveredunderthisprogram.How-ever,attheendofthesix-monthperiod,applicationsmaybemadeforanextensionifhospicecarebenefitshavenotbeenexhausted.
Thishospicebenefitcoversonlytheservicesandsupplieslistedbelow:
• Homecareuptoamaximumof$4,000forvisitsbyeachofthefollowingforintermittentcare:• registeredorlicensedpracticalnurse;• licensedphysicaltherapist;• certifiedrespiratorytherapist;• AmericanSpeech,Language,andHearingAssociation-certifiedspeechtherapist;• licensedoccupationaltherapist;• licensedclinicalsocialworker;• masterofsocialwork;or• homehealthaidewhoisdirectlysupervisedbyoneoftheaboveproviders(performingservicesprescribed
intheplanofcaretoachievethemedicallydesiredresults).• Upto10daysofinpatientcareinahospicethatisMedicare-certifiedassuchorlicensedorcertifiedassuchby
thestateinwhichitoperateswhenorderedbytheattendingphysician(M.D.orD.O.)• Upto120hoursofrespitecareforahomeboundenrolleeineachthree-monthperiodofhospicecare;thethree-
monthperiodbeginsontheinitialdateofhospicecarecoveredunderthisprogram
HospiCe Care limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• servicesprovidedtootherthantheterminallyillenrollee,includingbereavementcounseling;• pastoralandspiritualcounseling;• servicesperformedbyfamilymembersorvolunteerworkers;• homemakerorhousekeepingservices,exceptbyhomehealthaidesasorderedinthehospiceplanofcare;• supportiveenvironmentalmaterialsincluding,butnotlimitedto,handrails,ramps,airconditioners,andtele-
phones;• expensesforthenormalnecessitiesoflivingincluding,butnotlimitedto,food,clothing,andhouseholdsup-
plies;• dietaryassistance(e.g.,MealsonWheels)ornutritionalguidance;• separatechargesforreports,records,ortransportation;• legalandfinancialcounselingservices;• servicesandsuppliesnotincludedinthehospiceplanofcare,ornotspecificallysetforthasacoveredexpense;• servicesandsuppliesinexcessofthespecifiedlimitations;or• servicesprovidedduringanyperiodoftimeinwhichtheenrolleeisreceivingbenefitsunderthehomehealth
carebenefitofthisprogram.
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liCensed amBulanCe serviCe
Benefitsareprovidedformedicallynecessarytransportationtothenearestmedicalfacilityequippedtotreatyourcondition.Medicallynecessaryservicesandsuppliesprovidedbytheambulancearealsocovered.
speCial transport
Please Note: Thetravelbenefitisintendedtoallowyouaccesstohealthcareserviceswhennolocaloptionexists.
Benefitsfortransportationwillbeprovidedtothenearesthospitalequippedtofurnishspecialcaredeemedmedi-callynecessaryfortreatmentofinjuryorillnessiftheinjuryordiseaseislife-endangering,ifsurgeryisrequiredthatcannotbeperformedlocally,orifaconditionexiststhatcannotbetreatedlocally.Transportationmaybebyair,am-bulance,railroad,orcommercialairlinesonaregularlyscheduledflight.Travelinpersonalvehiclesisnotcovered.Ticketsobtainedthroughmileageplansorotherrewardsprogramsarenotcovered.
Airfareforthreeroundtripsperplanyearbythepatientwillbeallowedforanyonecondition.Ifthepatientisaminorage17oryounger,airfarewillbepaidforoneaccompanyingparentorguardianforeachtrip.
Theattendingphysicianmustcertifythenecessityofanychargesforspecialtransportation.AlthoughpriorapprovalbyPremeraBlueCrossBlueShieldofAlaskaisnotrequiredbeforebenefitscanbeprovided,youoryourphysicianareencouragedtocontactBlueCrosstoseeiftheproposedtravelwillmeettherequirementsofthisbenefit.
Home mediCal and respiratorY equipment/mediCal supplies
Durablemedicalequipmentandmedicalsuppliesareeligibleexpensesasfollows:
• Home Medical and Respiratory Equipment—Rental,nottoexceedthepurchaseprice,iscoveredwhenmedicallynecessaryandprescribedbyaphysicianfortherapeuticuseindirecttreatmentofacoveredillnessorinjury.BlueCrossmayalsoprovidebenefitsfortheinitialpurchaseofequipment,inlieuofrental.Examplesofmedicalequipmentareawheelchair,ahospital-typebed,tractionequipment,ventilators,diabeticequipmentandlightboxes.• Incaseswherethereisanalternativetypeofequipmentthatislesscostlyandservesthesamemedical
purpose,BlueCrosswillprovidebenefitsonlyuptothelesseramount.• Repairorreplacementofhomemedicalandrespiratoryequipmentmedicallynecessaryduetonormaluse
orgrowthofachildiscovered.• Medical Supplies, Orthotics And Orthopedic Appliances
• Appliancessuchasbraces,ribbelts,crutchesanddiabeticsuppliesarecovered.• Orthoticsforthefeet(shoeinserts),includingimpressioncasting,andrelatedsupplies,devices,andshoes
arecovered.Benefitsarelimitedtoaplanyearmaximumof$350.• Benefitsareprovidedforvisionhardwareforthefollowingmedicalconditionsoftheeye:cornealulcer,
bullouskeratopathy,recurrenterosionofthecornea,tearfilminsufficiency,aphakia,Sjorgren’sDisease,congenitalcataract,cornealabrasionandkeratoconus.
Home mediCal and respiratorY equipment/mediCal supplies limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• specialorextra-costconveniencefeatures;• itemssuchasexerciseequipmentorweights;• orthopedicappliancesprescribedprimarilyforuseduringparticipationinsports,recreation,orsimilaractivities;
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• whirlpools,whirlpoolbaths,portablewhirlpoolpumps,saunabaths,andmassagedevices;• over-bedtables,elevators,visionaidsandtelephonealertsystems;• structuralmodificationstoyourhomeorpersonalvehicle;or• eyeglasses,contactlensesandothervisionhardwareforconditionsnotlistedasacoveredmedicalcondition,
includingroutineeyecare(seetheVisionCaresectionforthesebenefits).
prostHetiC deviCes
Devicestoreplaceallorpartofanabsentbodylimbortoreplaceallorpartofthefunctionofapermanentlyinop-erativeormalfunctioningbodyorganarecovered.
Benefitswillonlybeprovidedfortheinitialpurchaseofaprostheticdevice,unlesstheexistingdevicecannotberepaired,orreplacementisprescribedbyaphysicianbecauseofachangeinyourphysicalcondition.
Benefitswillbeprovidedforthepurchaseofawigorhairpiecetoreplacehairlostduetoanaccidentorradiationtherapyorchemotherapyforacoveredcondition.Benefitswillbelimitedtoonewigorhairpieceperplanyear,uptoaplanyearmaximumof$350.
prostHetiC deviCes limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• electronicprostheses,penileprostheses,ordevicesdirectlyrelatedtoanorgantransplant;or• prosthetics,intraocularlenses,appliancesordevicesrequiringsurgicalimplantation,Theseitemsarecovered
undertheSurgicalServicesbenefit.ItemsprovidedandbilledbyahospitalarecoveredundertheHospitalInpa-tientCareorOutpatientCarebenefits.
Blood transFusions
Thecostofbloodandbloodderivativesarecoveredwhenmedicallynecessary.
pku dietarY Formula
Adietaryformulathatismedicallynecessaryforthetreatmentofphenylketonuria(PKU)iscovered.Thisbenefitisnotsubjecttothewaitingperiodforpre-existingconditions.
oBstetriC Care
Pregnancy,childbirth,andrelatedconditionsarecoveredthesameonthesamebasisasanyotherconditionforallfemalemembers.Coveredservicesincludescreeninganddiagnosticproceduresduringpregnancy,andrelatedgeneticcounseling,whenmedicallynecessaryforprenataldiagnosisofcongenitaldisorders.Planbenefitsarealsoprovidedformedicallynecessaryservicesandsuppliesrelatedtohomebirths.
Please Note:Attendingproviderasusedinthisbenefitmeansaphysician,aphysician’sassistant,acertifiednursemidwife(C.N.M.),alicensedmidwifeoranadvancedregisterednursepractitioner(A.R.N.P.).Iftheattendingpro-viderbillsasinglefeethatincludesprenatal,deliveryorpostpartumservicesreceivedonmultipledatesofservice,thisplanwillcoverthoseservicesasitwouldanyothersurgery.
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Planbenefitsarealsoprovidedformedicallynecessaryservicesandsuppliesrelatedtohomebirths.
Inpatienthospitalservicesandrelatedinpatientmedicalcarefollowingchildbirthasdeterminedtobenecessarybytheattendingprovider,inconsultationwiththemother,willbeprovidedupto:
• 48hoursafteravaginalbirth;or• 96hoursafteracesareanbirth.
Ifitisdeterminedthatthelengthofstaywillexceedtheabovelimitations,BlueCrossrecommendsthatthehospitalcontactCareManagementat(800)722-4714fordischargeplanningandpotentialcasemanagement.
HelpfulinformationaboutpregnancyandproperprenatalcareisavailablebycallingBestBeginnings’resourceline,(888)773-6399.Pleasesee“BestBeginnings”intheCareManagementsectionofthishandbook.
routine neWBorn Care
Benefitsforroutinehospitalnurserychargesandrelatedinpatientwell-babycareforanewborndependentchildareprovided up to:
• 48hoursafteravaginalbirth;or• 96hoursafteracesareanbirth.
Benefitsarealsoprovidedforroutinecircumcisionuptosixmonthsfollowingbirth.
Newbornchildrenborntodependentdaughtersarenoteligibleforcoverage.
Ifitisdeterminedthatthelengthofstaywillexceedtheabovelimitations,BlueCrossrecommendsthatthehospitalcontactCareManagementat(800)722-4714fordischargeplanningandpotentialcasemanagement.
Please Note:Benefitsforcareofanillbabyareprovidedunderthechild’scoverage,subjecttohisorherownComprehensiveMedicalCalendarYearDeductibleandout-of-pocketrequirements.
The University requests that you enroll your newborn as soon as possible from the date of birth. Enrollments after 60 days from date of birth will not be accepted until the next open enrollment period. Please contact your regional human resources office for assistance with enrolling your newborn.
neWBorn HearinG eXams and testinG
Thisbenefitprovidesforonescreeninghearingexamfornewbornsupto30daysafterbirth.Benefitsarealsopro-videdfordiagnostichearingtests,includingadministrationandinterpretation,forchildrenuptoage24monthsifthenewbornhearingscreeningexamindicatesahearingimpairment.
aCupunCture
Benefitsareprovidedforacupunctureserviceswhenmedicallynecessarytorelievepain,inducesurgicalanesthe-sia,ortotreatacoveredillness,injuryorcondition.Acupuncturebenefitsaren’tsubjecttoacalendaryearbenefitmaximum.
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CHiropraCtors’ serviCes
Theservicesofachiropractor(D.C.)operatingwithinthescopeofhisorherlicensearecoveredonthesamebasisasforanycoveredphysicianprovidingmedicallynecessaryservices.
Please Note:Chiropracticbenefitsarelimitedtoamaximumof26visitsperplanyear.
HealtH manaGement
Theseservicesareprovidedat100%ofallowablecharges.Benefitsforhealtheducationservicesandnicotinede-pendencyprogramsarenotsubjecttoacalendaryearmaximum.
HealtH eduCation
Benefitsareprovidedforoutpatienthealtheducationservicestomanageacoveredcondition,illnessorinjury.Examplesofcoveredhealtheducationservicesareasthma,painmanagement,childbirthandnewbornparenting,lactationandself-managementtrainingandeducationtomanagediabetes.
niCotine dependenCY proGrams
Benefitsareprovidedfornicotinedependencyprograms.Youpayforthecostoftheprogramandsendproofofpay-menttoBlueCrossalongwithareimbursementform.Theplanwillprovidebenefitsasstatedaboveinthisbenefit.Claimformsareavailableontheuniversity’sbenefitswebsiteatwww.alaska.edu/benefits,oryoucanrequestonefromBlueCrossCustomerService.
nutritional tHerapY
Benefitsfornutritionaltherapyarenotsubjecttotheplanyeardeductibleandcoinsuranceunlessservicesarepro-videdbyahospitalorhospital-basedchemicaldependencytreatmentprogramthatisnotintheBlueCrossnetwork.Out-of-networkbenefitswillbesubjecttotheplanyeardeductibleandcoinsurance.Benefitsareprovidedforoutpa-tientnutritionaltherapyservicestomanageyourcoveredcondition,illnessorinjury,includingdiabetes.Thisbenefitisnotsubjecttoaplanyearbenefitlimit.
skilled nursinG Care
ServicesofaRegisteredNurse(R.N.)oraLicensedPracticalNurse(L.P.N.)arecoveredforthepurposeofperform-ingskillednursingcare.Coveredservicesincludethefollowing:
• visitingnursingcareofnotmorethantwohoursperdayforthepurposeofperformingspecificskillednursingtasks;or
• privatedutynursingcareofgreaterthantwohoursperday,ifBlueCrossdeterminesthatvisitingnursingcareisnot adequate to treat your condition
skilled nursinG Care limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowingservices:
• allorthatpartofanynursingcarethatdoesnotrequiretheskillsofanR.N.orL.P.N.;or• anynursingcare,givenwhiletheenrolleeisaninpatientinahealthcarefacility,thatcouldsafelyandadequate-
lybefurnishedbythefacility’sgeneralnursingstaffifitwerefullystaffed.
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temporomandiBular joint (tmj) disorders
Benefitsformedicalservicesandsuppliesforthetreatmentoftemporomandibularjoint(TMJ)disordersarepro-videdonthesamebasisasanyothermedicalcondition.Thisbenefitcoversinpatientandoutpatientfacilityandprofessionalcare,includingprofessionalvisits.Coveredservicesincludethefollowing:
• Inpatientandoutpatientprofessionalservices,includingsurgery• Outpatientsurgicalfacilityservices• Inpatientfacilityservices
Medicalservicesandsuppliesarethosethatmeetallofthefollowingrequirements:
• reasonableandappropriateforthetreatmentofadisorderofthetemporomandibularjoint,underallthefactualcircumstancesofthecase;
• effectiveforthecontroloreliminationofoneormoreofthefollowing,causedbyadisorderofthetemporo-mandibularjoint:pain,infection,disease,difficultyinspeaking,ordifficultyinchewingorswallowingfood;
• notexperimentalorinvestigational,asdeterminedaccordingtothecriteriastatedunder“Definitions,”orpri-marilyforcosmeticpurposes.
ortHoGnatHiC surGerY (jaW auGmentation or reduCtion)
Whenmedicallynecessarycriteriaaremet,benefitsforupperand/orlowerjawaugmentationorreduction(orthog-nathicand/ormaxillofacial)surgeryisprovidedataconstant80percentofallowablecharges,uptoalifetimebenefitmaximumof$25,000.
oBesitY treatment
non-surGiCal WeiGHt manaGement
Benefitsfornon-surgicalweightmanagementarecoveredonthesamebasisasanyothercoveredcondition,subjecttotheapplicablebenefits,limitationsandexclusions.Non-SurgicalWeightManagementbenefitsinclude,butaren’tlimitedto,coverageofthefollowingoutpatientmedicalservices:
• Behavioralhealthvisits• Nutritional/dieticianvisits• PhysicalTherapyvisits(subjecttothe45visitsperplanyearlimit)• Physicianvisits• Prescriptiondrugs• Relatedlabanddiagnosticservices
surGiCal treatment oF morBid oBesitY
Benefitsforsurgicaltreatmentofmorbidobesityarecoveredthesameasanyothercoveredcondition,subjecttothecriterialistedbelow,applicablebenefits,limitationsandexclusions.
A benefit advisory is recommended for members considering this approach to weight loss.Forinformationonobtainingabenefitadvisory,pleasecontactPremeraCustomerServiceat(800)364-2982.
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CoverageisavailableforbariatricprocedureslistedasmedicallynecessaryinPremeraBlueCross’medicalpolicy,whenconservativemeasureshaveprovenineffective.Examplesofconservativemeasuresincludebutaren’tlimitedtocoveredservicesundertheNon-SurgicalWeightManagementbenefit,medicallysuperviseddietandexerciseprograms.Toqualifyforthesurgicaltreatmentformorbidobesitybenefit,themembermustmeetthefollowing:
• DiagnosedasmorbidlyobesewithaBodyMassIndex(BMI)greaterthanorequalto40;or• OverweightwithaBMIgreaterthan35withco-morbidities,includingbutnotlimitedto:
• CongestiveHeartFailure(CHF)• CoronaryHeartDisease• Diabetes• Hyperlipidemia• Hypertension• SleepApnea
Forspecificsurgicaltreatmentbenefitinformation,pleaseseetheHospitalInpatient,HospitalOutpatientandPhysi-cianServicesbenefits.
Thesurgicaltreatmentofmorbidobesitybenefitissubjecttoalifetimebenefitmaximumof$25,000forcoveredservices,includingbutnotlimitedtosurgery,anesthesia,facilityandotherchargesdirectlyrelatedtosurgicalcare.Medicallynecessarytreatmentofsurgicalcomplicationsdonotaccruetowardthisbenefitmaximum.
oBesitY treatment BeneFit limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowingservices:
• Proceduresortreatmentsdeemedexperimentalorinvestigational(pleaseseetheGlossaryofTerms)• Surgicalremovalofexcessabdominal,armorotherskinorliposuctionunlessmedicallynecessary• Over-the-countermedicationsforweightloss• Liquiddietorfastingprograms• Otherfoodreplacementandnutritionalsupplements• Membershipindietprograms• Healthclubs,exerciseequipment,orwholebodycalorimeterstudies• Wiringofthejaw• Vitamininjections
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DISEASE MANAGEMENT
Managinganyhealthconditionischallenging,butchronicconditionssuchasdiabetesorasthmawon’tgoaway.However,withjustafewkeylifestylechanges,youcancontrol,lessentheeffectstohelpyourselflivehealthierandfeelyourbesteachday.That’swhytheUniversityofAlaskahaspartneredwithAlere,anationallyrecognizedhealthorganization,toprovidetheAlereCareHealthManagementprogram.Alereisaleaderinpersonalhealthsupportservices.Theirpersonalizedprogramsweredesignedtohelpindividualsdeterminewhatchangestheyfeelreadytomake,setrealisticgoalsandgivethemthetoolstobesuccessful.
TheAlereCareHealthManagementProgramisaconfidential,voluntaryprogramthatcangiveyoutheextrasupportyoumayneedtobettermanageyourhealth.AndAlereCareisprovidedtoyouatnoadditionalcostaspartofyourhealthcarebenefits.
Ifyouoracovereddependentarelivingwithanyofthefollowingconditions,youmaybeeligibletoparticipateintheAlereCareprogram:
• Asthma(adultandpediatric)• Chronicobstructivepulmonarydisease(COPD)• Coronaryarterydisease• Diabetes• Heartfailure
Theprogramgivesyouaccesstoa24/7supportsystemofregisterednurses,dieticiansandotherhealtheducatorswhocanhelpyoucreateaplantomanageyourspecifichealthcondition.
Your AlereCare nurse can help you:
• Followyourdoctor’streatmentplan• Preventordecreasehealthcomplications• Understandyourmedicines• Makethemostofyourdoctorvisits• Talkaboutwhatmedicalcareandtestsmightberightforyou• Findopportunitiestomakepositivelifestylechoices
Thisinformationdoesnotreplaceyourdoctor’sadvice.Itismeanttoserveasanotherresource.Allyourinformationiskeptconfidentialandonlyusedbylicensedhealthcareprofessionals.
Ifyouareidentifiedasacandidatefortheprogram,anAlereCarespecialistwillcontactyou.Youwillalsoreceiveaprogramwelcomepacketinthemail.Youdon’thavetowaitforacall.Ifyou’dliketoparticipate,orjustlearnmoreabouttheprogram,youmaycall1-866-674-9101totalktoanAlereCarespecialistatanytime.
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PHARMACY PROGRAM
YourprescriptiondrugplanisadministeredbyCVSCaremarkandisseparatefromyourmedicalplan.PleaseuseyourCVSCaremarkIDcardwhenhavingaprescriptionfilled.YourCVSCaremarkmemberIDnumberforyouandallenrolledfamilymembersisyourUniversityofAlaskaEmployeeID.YouwillreceiveanIDcardforyouandyourspouse,ifapplicable.Ifadditionalcardsareneededforyourdependents,pleasecallCustomerCareforCVSCaremarktoll-freeat1-800-596-2178.
Thepharmacybenefitprovidescoverageformedicallynecessaryprescriptiondrugsandinsulinwhenprescribedbyaphysicianforyouruseoutsideofamedicalfacilityanddispensedbyalicensedpharmacistinparticipatingmailorderorretailpharmacieslicensedbythestateinwhichthepharmacyislocated.Forthepurposesofthisprogram,aprescriptiondrugisanymedicalsubstancethat,underfederallaw,mustbelabeledasfollows:“Caution:Federallawprohibitsdispensingwithoutaprescription.”Itdoesnotincludeanydrugslabeled,“Caution—limitedbyfederallawtoinvestigationaluse.”
Thisprogramalsoprovidescoverageforthefollowing:
• PrenatalandFluoridatedVitamins• OralContraceptiveDrugs• PrescriptionNicotineDependencyDrugs• Inhalationspacerdevicesandpeakflowmeters• Insulinneedles/syringesandotherdisposablediabeticsupplies
maXimum mediCation supplY
Whenyoupurchaseprescriptionsataparticipating(network)pharmacy,youwillreceiveamaximum30-daysupply,unlessthedrugmaker’spackaginglimitsthesupplyinsomeotherway.This30-daysupplylimitationistypicalofmostprescriptiondrugprogramsbecauseitreduceswasteandconformswithstandardphysicianprescribingpat-terns.Ifyouaretakingaprescriptionforalong-termorchroniccondition,youshouldconsiderusingCVSCaremarkMailServicePharmacy,themailservicepharmacywhichallowsyoutopurchaseuptoa90-daysupply.
speCial Features oF tHe pHarmaCY netWork proGram
TheUniversityofAlaskahascontractedwithCVSCaremarktoaccesstheirpharmacynetwork.ThesepharmacieshaveagreedtoprovideUniversityofAlaskaplanparticipantsdiscountsequaltoorgreaterthananyavailablewhenpurchasingthemedicationforcash.Thepharmacynetworkprogramalsoincludessomeimportantqualityandcost-savingfeaturessuchas:
• drugutilizationreview;• electronicsubmissionofclaims;and• reducedpricesonmostprescriptiondrugs.
druG utiliZation revieW
Yourdrugbenefitincludesaspecialcomputerizedreal-timemonitoringservice.Whenyouhaveaprescriptionfilledatanetworkpharmacy(includingtheCVSCaremarkMailServicePharmacymentionedlaterinthissection),your
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prescriptionwillbeanalyzedforcertaintypesofpotentialproblemsrelatedto:
• interactionswithotherdrugsyouaretaking;• inappropriatedrugs,basedonyourage;• unusuallyhighorlowdrugdosage;and• drugduplicationorexcessiveuse.
Thismonitoringisbasedoninformationstoredfrompreviousprescriptionsyouhavehaddispensedfromanetworkpharmacy.Ifanyofthesepotentialproblemsarise,amessageistransmittedtoyourpharmacistbeforethedrugisdispensed.Thepharmacistmayconsultwithyouandmaywanttocontactyourphysiciantoresolveanyquestionsabouttheappropriatenessofaparticulardrug.
Toreceivebenefitsforprescriptiondrugsatanetworkpharmacy,justshowyourCVSCaremarkIDcardandpayyourcopaymentfortheprescription.ThepharmacistwillelectronicallyfilethebalanceoftheclaimwithCVSCaremark.Youdon’thavetofileaclaimformandyoudon’thavetowaittobereimbursed.Ifyouarecoveredbyanadditionalprogramyoumaysubmityourreceiptforthecopaymentforreimbursementfromthesecondarycarrier.IfyoursecondarycarrierisalsoCVSCaremark,completeaCVSCaremarkPrescriptionClaimFormandsendit,alongwithyourreceiptfortheprimarycoverage,toCVSCaremark.Formsareavailablethroughtheuniversity’sbenefitsWebsiteatwww.alaska.edu/hr/forms/hr_healthforms.xml.
GeneriC druGs
Oneofthemostimportantwaysthatyoucanhelpkeepprogramcostsdownovertimeisbyutilizinggenericdrugswheneverpossible.Thegenericversionofadrugismadefromthesamechemicalcompoundasitsbrandnamecounterpart.GenericdrugsaremanufacturedaccordingtothesamestandardsasbrandnamedrugsandhavetheFDA’sapprovalforsafetyandeffectiveness,yetgenericdrugscostafractionofthepriceoftheirbrandnamecoun-terparts.Theuseofgenericdrugsoffersasimpleandsafealternativetohelpreduceyourmedicationcosts.Youcanensurethatyouwillreceivethegenericproductwhenitisavailablebyaskingyourdoctortowriteyourprescriptionforthegenericorbyindicatinggenericsubstitutionisallowed.
Underthisprogram(includingtheCVSCaremarkMailServicePharmacy)genericswillbeusedinallsituationsexceptinthefollowingcases:
• thereisnogenericequivalent;• thepharmacyisunabletoprovidethegenericequivalentatthetimetheprescriptionisfilled;or• theemployeeordependentrequeststhenamebranddrugandagreestopaythedifferenceinthecostbetween
thegenericandnamebranddrug.
HiGH perFormanCe step tHerapY
TheHighPerformanceStepTherapyprogram(alsocalledGenericStepTherapy)isdesignedtoencouragetheuseoflower-costgenericsandpreferredbrand-namedrugstohelpreducepharmacycostsforbothemployeesandtheUniversityofAlaska.
StepTherapyrequiresthatacosteffectivegenericalternativebetriedfirstbeforeanon-preferredbranddrugiscovered.Inorderforanon-preferredbrandmedicationtobecovered,theplanrequiresyoutohaveuseda30-daysupplyofagenericalternativeinthesamedrugclasswithinthelast24months,oryourmedicalproviderwillneedtogetpriorauthorizationforthenon-preferreddrugtobecovered.
Thisprogramislimitedtoacertainnumberofdrugs.Foranup-to-datelisting,checkthebenefitswebsiteatwww.alaska.edu/benefits/pharmacy-benefits.
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approved druG list
CVSCaremarkhasidentifiedalistofapprovedorpreferreddrugs,calleda“formulary,”madeupofallFDA-approvedgenericdrugsandmanybrandnamedrugs.NewlyFDA-approvedmedicationswillbesubjecttoanynon-formularycopaymentpendingareviewbythePharmacyandTherapeuticscommittee.Alistofformularydrugsisinyourpharmacybenefitbooklet,senttoyouwithyourIDcards.Periodicupdatestotheformularymayoccur.ForthemostcurrentformularyinformationpleasecallCustomerCareforCVSCaremarktoll-freeat1-800-596-2178,orvisitwww.Caremark.com/members.Drugsthatarenotontheapprovedlist(callednon-preferredbrand-namedrugs)arecoveredatthehighestcopay(pleaseseethefollowingtable).
Pleasenote:certaincategoriesofdrugsareexcluded;see“PharmacyLimitations”formoreinformationonexcludeddrugs.
presCription druG CopaYment
Eachenrolleemustpayacopayforeachseparatenewprescriptionorrefill.A“copay”isafixedup-frontdollaramountthatyou’rerequiredtopayforeachprescriptiondrugpurchase.Ifpurchasedataparticipatingpharmacy,theamountyou’llpaywillbeasfollows:
Non-PreferredPer Prescription Generic Drug Brand Name Drug Brand DrugorRefill Copayment Copayment Copayment
NetworkPharmacy $5forgenericdrugs $25forbrandname $50copayfornon-(upto30-daysupply) preferredbrandname CVSCaremarkMailService $10forgenericdrugs $50forbrandname $100copayfornon-(upto90-daysupply) preferredbrandname
Whenavailable,agenericdrugwillbedispensedinplaceofabrandnamedrug.Intheeventagenericequivalentisnotmanufactured,thebrandnamecopaymentwillapply.
If you or your doctor request a brand name drugwhenagenericequivalentisallowedbylawandavailable,inadditiontothebrandnamecopaymentyouwillberequiredtopaythedifferenceinpricebetweenthebrandnamedrugandthegenericequivalent.
reFills
Benefitsforrefillswillbeprovidedonlywhenyouhaveusedthree-fourths(75percent)ofthecurrentsupply.The75percentiscalculatedbasedonthenumberofunitsanddayssupplydispensedonthelastrefill.
maintenanCe druGs
Thepharmacyplanencouragestheuseofmailorderformaintenancedrugsbychargingahighercopayforthethirdandfuturerefillswhenfilledataretailpharmacy.Aftertworefillsataretailpharmacy,theregularcopaywillbedoubledunlessyouusetheMailServicePharmacy.Alistofmaintenancedrugscanbefoundonthebenefitswebsiteatwww.alaska.edu/benefits/pharmacy-benefits.DrugsthatcouldbedamagedbyfreezingareexemptfromtheMailServicerequirement.
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out-oF-poCket maXimum
Pharmacyplancopaysarelimitedtoanindividualout-of-pocketmaximumof$1,000perperson,perplanyear.Thisisaseparateout-of-pocketmaximumfromthemedicalplanmaximum,andisnotcombinedwithanyotherplanlimits.
pHarmaCies outside alaska
Youridentificationcardwillalsobehonoredatmorethan62,000participatingindependentandchainpharmacieslocatedintheother49states,PuertoRico,andtheDistrictofColumbiathathavecontractswithCVSCaremark.Whenyoushowyouridentificationcard,thesepharmacieswillsendtheclaiminformationdirectlytoCVSCare-mark.Youwillonlyhavetopayyourplan’sapplicablecopaymentattimeofpurchase.
If you do not show your identification cardataCVSCaremarknetworkpharmacyorifyouuseanon-participat-ingpharmacy,youwillhavetosubmittheclaimasdescribedbelowinthe“Non-ParticipatingRetailPharmacy”sec-tion.Youwillbereimburseduptotheamountchargedbyaparticipatingpharmacy,lesstheapplicablecopayment.TheCVSCaremarkPrescriptionClaimFormisavailablethroughtheuniversity’sbenefitsWebsiteatwww.alaska.edu/hr/benefits.Toconfirmthestatusofapharmacy,askthepharmacistorcallCustomerCareforCVSCaremarktoll-freeat1-800-596-2178.
non-partiCipatinG retail pHarmaCY
Ifyoufillaprescriptionatanon-participatingpharmacy,youwillbereimburseduptotheamountallowedatapar-ticipatingpharmacy,lessyourapplicablecopayment.Youwillberesponsibleforthefullretailcostoftheprescrip-tionatthetimethepharmacistissuesyourmedication;youwillnotreceivethediscountedpriceofaparticipatingpharmacy.Thisbenefitappliestoallprescriptionsfilledbyanon-participatingpharmacy,includingthosefilledviamailorotherhomedelivery.Tobereimbursed,youwillneedtosubmitaCVSCaremarkPrescriptionClaimFormtoCVSCaremarkattheaddressontheform.Formsareavailablethroughtheuniversity’sbenefitsWebsiteatwww.alaska.edu/benefits.
Coordination oF BeneFits For presCription druG Claims
TofileaclaimforcoordinationofbenefitsforsecondarycoverageyouwillneedtosubmitaCVSCaremarkPrescriptionClaimFormtoCVSCaremarkattheaddressontheform.Theformisavailablethroughtheuniver-sity’sbenefitsWebsiteatwww.alaska.edu/benefits.Besuretoincludeanyreceiptsorexplanationsofbenefitsyoureceivedfromtheprimarycoverage.
Cvs Caremark mail serviCe pHarmaCY
TheCVSCaremarkMailServicePharmacyallowsemployeesandtheirdependentstofillmaintenanceprescrip-tionsatlesscostthanthrougharetailpharmacy.Ifyoutakeprescriptionmedicationonanongoingbasisand/oryouhaveaprescriptionthatwillneeda30-daytoa90-daysupply,youcanorderthatprescription(andrefills)bymail.Uptoa90-daysupplyofcoveredmedicationsmaybepurchasedthroughthemailserviceprogram,unlessthedrugmaker’spackaginglimitsthesupplyinsomeotherway,andthecosttoyouisthecopaymentshowninthePrescrip-tionDrugCopaymenttableperprescriptionorrefill.WhenyoureceiveyourmedicationfromtheCVSCaremarkMailServicePharmacy,youwillonlyreceiveabillforyourcopaymentamount,andCVSCaremarkwillbebilleddirectly for the balance.
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orderinG From Cvs Caremark mail serviCe pHarmaCY
Theeasiestwaytogetstartedwiththemailorderbenefitistogotowww.caremark.comandloginusingyourusernameandpassword.Ifyouhaven’talreadyregisteredwiththesite,youcansetupyourusernameandpasswordquicklyandgetstartedrightaway.ClickonStartaNewPrescriptionundertheMemberQuickLinksmenu.Justfol-lowthedirectionsandchoosethemethodoforderingthatyouprefer.
Ifyouprefertophoneinyourprescription,justcall800-875-0867andhaveyourmedicationnameandyourdoctor’sinformationavailable(name,phoneandfaxnumbers).Caremarkwillcontactyourdoctortogetyourprescriptionsetup,processed,andonit’swaytoyou.
YoucanalsoorderfromtheCVSCaremarkMailServicePharmacybycompletingtheconfidentialMailServiceEnrollmentForm,foundinyourPrescriptionBenefitServicesBooklet,andmailitinthepostage-paidenvelopepro-vided.Youwillonlyneedtocompletethisformforyourfirstorder.Obtainanewprescriptionwrittenfora90-daysupplywithrefillsasneededforayear.Makesurethatyouhaveatleastatwotothreeweeksupplyofeachmedica-tiononhandbeforeyousubmityourmailserviceclaim.
YourprescriptiondrugorderwillbeprocessedandmailedtoyouviaFirstClassMailorUPS,alongwithinstruc-tionsforfutureprescriptionsand/orrefills.Refillscanbeorderedoverthephoneortheinternet.Pleaseallowupto21daysfordeliveryofyourfirstorder,and14daysforrefills.
FormoreinformationabouttheCVSCaremarkMailServicePharmacy,callCustomerCareat1-800-596-2178.
Cvs Caremark speCialtY pHarmaCY
Patientswithcomplex,chronicmedicalconditionsneedthenecessarycaremanagementtomonitortheircondition.CVSCaremarkSpecialtyPharmacyisaprogramthatprovidesthatattention,workingone-on-onewithpatients,managingtheirtreatment.CVSCaremarkSpecialtyPharmacyprovidesafullcomplementofspecializeddrugsandservicesforpatientswithhepatitisC,cancer,hemophilia,RSV,Crohn’sdisease,multiplesclerosis,rheumatoidarthritis,growthdeficiency,organtransplants,andHIV/AIDS.Ifyouaretakingmedicationsforacomplex,chronicmedicalcondition,contactCVSCaremarkSpecialtyPharmacytoll-freeat1-800-619-7610,orvisittheMemberServicessectionofwww.Caremark.com/members.
Thefirstfillofaspecialtymedicationmaybeobtainedatalocalretailpharmacy.FuturerefillsarefilledviamailservicethroughtheCVSCaremarkSpecialtyPharmacyandaresubjecttotheapplicablecopayorcoinsuranceper30-dayfill.
pHarmaCY limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• Prescriptionvitaminsandfoodsupplements,exceptforpre-natalandfluoridatedvitamins• Fertilitydrugs,regardlessoftheirintendeduse• Therapeuticdevicesorappliances(including,butnotlimitedto,hypodermicneedles,syringes,supportgar-
ments,andothernonmedicalsubstances),exceptforinsulinneedles/syringesandotherdisposablediabeticsupplies
• Anyprescriptionorrefillthatisinexcessofthequantityspecified,orthatisdispensedafteroneyearfromthedatetheprescriptionwaswritten
• Anyclaimordemandforinjuryordamagearisinginconnectionwiththemanufacturing,compounding,dis-pensing,oruseofanyprescriptiondrug
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• Over-the-counterdrugs(non-legend),otherthaninsulinandephedrine-containingproducts(e.g.emergencyallergytreatmentkits);drugsthatbylawdonotrequireaphysician’sprescription;herbal,naturopathic,orho-meopathicmedicinesordevices
• Drugsthatareprescribedordispensedforcosmeticuse• Drugsforexperimentalorinvestigationaluse
PrescriptiondrugscoveredunderthisbenefitarenoteligibleforComprehensiveMedicalBenefits.
Thispharmacyprogrambenefitisintendedtoprovidecoverageforprescriptiondrugsandinsulinwhendispensedbyapharmacy.Althoughthefollowingdrugs,services,andsuppliesarenotavailableunderthepharmacyprogram,theymaybeavailableelsewhereinthisplan:
• Immunizationagents;biologicalsera,suchasrabiesserum• Bloodorbloodplasma• Humangrowthhormonedrugs• Anyinfusiontherapydrugsorsolutions• Injectablesorotherprescriptionsrequiringparenteraladministrationoruse(otherthaninsulin)• Servicesotherthanprescriptiondrugs• Administrationorinjectionofanydrug• Drugsdeliveredoradministeredbytheprescriber• Take-homeprescriptiondrugsdispensedandbilledbyamedicalfacility
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DENTAL CARE BENEFITS
introduCtion
Benefitsareavailableunderthedentalcaresectionofthebenefitprogramforservicesandsuppliesfurnishedincon-nectionwiththediagnosisandtreatmentofacovereddentalconditionifsuchservicesandsuppliesmeetalloftheserequirements:
• Theymustnotbeexcludedfromcoverageunderthisprogram.• Theymustbefurnishedbyadentist,exceptthattheymayalsobeprovidedbyadentalhygienistorother
individualperformingwithinthescopeofhisorherlicenseasallowedbylaw.Theseservicesmustalsoberenderedunderthesupervisionandguidanceofthedentist.
• Theymustbedentallynecessary.Aserviceisdentallynecessaryif,inthejudgmentofBlueCross,itmeetsallofthefollowingrequirements:• Essentialto,consistentwith,andprovidedforthediagnosisorthedirectcareandtreatmentofadisease,
accidentalinjury,orconditionharmfulorthreateningtotheenrollee’sdentalhealth• Consistentwithstandardsofgooddentalpracticewithintheorganizeddentalcommunity• Notprimarilyfortheconvenienceoftheenrolleeortheenrollee’sdentist
Please Note:Thefactthatthecoveredserviceswerefurnished,prescribed,orapprovedbyadentistdoesnotinitselfmeanthattheservicesweredentallynecessary.
Thedeductiblesandout-of-pocketmaximumsfromthecomprehensivemedicalbenefitsectionofyourbenefitplandonotapplytothedentalcarebenefit.
YouareresponsibleforfurnishingtoBlueCrossalldiagnosticevaluativematerial,suchasstudymodels,dentalX-rays,andchartsthatBlueCrossmayrequiretodetermineavailablebenefits.Benefitswillonlybeprovidedforden-talservicesthatcanbeverifiedascoveredservicesbasedonthediagnosticmaterialBlueCrosshasbeenfurnished.BlueCrosswillnotprovidebenefitsforthosedentalserviceswhichitisunabletoverifyascoveredserviceswhenanynecessarymaterialsarenotfurnisheduponrequest.
estimate oF BeneFits
YourdentistmaysubmitanestimateofbenefitsrequesttoBlueCrossforanyproposeddentalserviceorseriesofdentalservicesforwhichthetotalchargewillexceed$500.Itisalsoimportantthatanycastorporcelainrestora-tions,prostheticappliances,orperiodontalsurgeriesbesentforanestimateofdentalbenefits.Within72hoursafterBlueCrossreceivesthefullydocumentedrequest,BlueCrosswilldeterminewhethertheservicemeetsthestandardforcoverageunderthisprogram.Estimatesarevalidforsixmonths.
BlueCrossstronglyrecommendsthatyourequestanestimateofdentalbenefitssothatbenefitquestionsarean-sweredbeforeyourcourseoftreatmentbegins.Ifyourdentistmakesamajorchangeinthetreatmentplan,heorsheshouldsubmitarevisedplan.
BlueCross’estimateisconditionedontheprovisionsofthisprogramandyoureligibilityforcoverageatthetimetheserviceisrendered.IfBlueCrossfindstheproposedtreatmenttobedentallynecessary,theywillnotreversethatdecisionunlesstheinformationonwhichtheirdecisionwasbasedislaterfoundtobemateriallyincompleteorinaccurate.Thedecisiontodeny,reduce,orendbenefitsforanotherwisecoveredservicebecausetheserviceisnotdentallynecessarywillbemadebyaBlueCrossemployeeorconsultantwhoisalicenseddentalcareprovider.
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alternative BeneFits
Todeterminebenefitsavailableunderthisprogram,BlueCrossconsidersalternativeproceduresorservicescarry-ingdifferentfeesandare,inthejudgmentofBlueCross,consistentwithacceptablestandardsofdentalpractice.Inallcaseswherethereisanalternativecourseoftreatmentthatislesscostly,BlueCrosswillonlyprovidebenefitsforthetreatmentcarryingthelesserfee.Ifyouandyourdentistdecideuponamorecostlytreatment,thenyouareresponsiblefortheadditionalchargesbeyondthoseforthelesscostlyalternativetreatment.
plan Year deduCtiBle (750 and HiGH deduCtiBle HealtH plans onlY)
CovereddentalservicesareclassifiedasTypeA,TypeB,orTypeC.TypeAcoveredservices(Preventive)arenotsubjecttoanydeductible.HoweveradeductibledoesapplytoTypeBandTypeCcoveredservices.AdeductibleistheamountofexpenseyoumustincurforTypeBandTypeCcoveredservicesandsuppliesineachplanyearbeforebenefitsarepayableunderthisprogramforthoseservicesandsupplies.Foreachenrollee,thisdeductibleamountiseither$25(forthe750Planoption),or$50(fortheHighDeductibleHealthPlanoption).Theamountcreditedtowardthedeductiblewillnotexceedtheallowablechargeforthecoveredserviceorsupply,andwillnotapplytoanyotherdeductibleunderthehealthcareprogram.The500Planoptiondoesnothaveadeductible.
Covered dental eXpenses
Dentalbenefitsareprovidedforeachenrolleeaccordingtotheplanoptionineffectatthetimeservicesarerendered,uptothedentalbenefitplanyearmaximumof$2,000.
Type Of Covered Service 500 Plan 750 Plan HDHP
Deductibles:TypeA-PreventiveCareExpenses $0 $0 $0TypeB-OtherBasicExpenses $0 $25 $50TypeC-MajorDentalExpenses $0 $25(combinedwith $50(combinedwith BasicExpenses) BasicExpenses)
Coinsurance (thepercentofallowablechargeyouareresponsiblefor):TypeA-PreventiveCareExpenses 0% 0% 20%TypeB-OtherBasicExpenses 20% 20% 20%TypeC-MajorDentalExpenses 50% 50% 50%
Thedentalbenefitsofthisprogramarebasedonallowablechargesfordentallynecessarycoveredservices.Thepercentageofanallowablechargethatyouareresponsibleforiscalledcoinsurance.Pleaserefertothe“GlossaryofTerms”sectionforadetailedexplanationofAllowableCharge.
Thedentalbenefitsavailableunderthissectionwillbeprovidedpriortoanydentalbenefitswhichmaybeavailableunderotherprovisionsofthisprogram.
tYpe a—preventive Care eXpenses (not suBjeCt to dental deduCtiBle)
• Oralexaminations(twoperyear),whichincludesprophylaxis(cleaning,scaling,andpolishingofteeth)
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• DentalX-raysfordiagnosis;alsootherx-raysnottoexceedthefollowing:• onefullmouthseriesina36-monthperiod;and• onesetofbitewings(twiceayear).
• Topicalapplicationoffluoride,forenrolleesage15oryounger• Emergencypalliativetreatment• Spacemaintainers• Sealants,forenrolleesage15oryounger
tYpe B—BasiC eXpenses
• Permanentfillings,consistingofsilveramalgam,silicate,andcompositeresins;whendentallynecessary,resinfillingswillbeallowedonlyforthefrontteeth;forothertypesoffillings,suchasgoldfoils,theallowancewillbelimitedtowhatwouldhavebeenotherwiseallowedforamalgamfillings
• Temporaryfillings• Extractions,includingsurgerytoremoveoneofthefollowing:
• teethpartlyorcompletelyimpactedintheboneofthejaw;• teeththatwillnoteruptthroughthegum;• otherteeththatcannotberemovedwithoutcuttingintobone;• therootsofatoothwithoutremovingtheentiretooth
• Oralsurgeryfordiagnosisandtreatmentofcystsandabscesses• Generalanestheticsgiveninconnectionwithcovereddentalservices• Periodontalexaminations,andtreatmentofdiseasedperiodontalstructures• Endodontictreatment,includingrootcanaltherapy• Injectionofantibioticdrugs• Repairandrecementingofcrowns,inlays,bridgework,anddentures• Treatmentsofimpactionsandgingivectomies• Reliningand/orrebasingofdentures• Tissueconditioning• Occlusalanalysis,adjustments,andguards• Dentalimplants(priorapprovalisrequired)
tYpe C—major dental eXpenses
• Inlays,onlays,goldfillings,andcrownswhen,inthejudgmentofBlueCross,amalgamorcompositeresinfill-ingswouldnotadequatelyrestoretheteeth;thiscircumstanceincludesprecisionattachmentsfordentures
• Initialinstallationofdentures(includingadjustmentsduringthefirstsix-monthperiodfollowinginstallation)andfixedbridgework(includinginlaysandcrownstoformabutments)
• Replacementinlays,onlays,crowns,dentures,andfixedbridgework,butonlywhenoneofthefollowingistrue:• thepresentinlay,onlay,crown,dentureorbridgeworkcannotbemadeserviceable,andwasseatedatleast
fiveyearspriortoreplacement;• thereplacementoradditionofteethisrequiredtoreplaceoneormoreadditionalteethextractedafterinitial
placement;• repreparationofthenaturaltoothstructure(ornaturaltoothstructureundertheexistingfixedbridgework)
isrequiredasaresultofanaccidentalinjurytothatstructure;or
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• thepresentdentureisanimmediate,temporaryoneandcannotbemadepermanent;replacementbyaper-manentdentureisneeded;andittakesplacewithin12monthsfromthedatetheimmediatetemporaryonewasfirstinstalled.
• Labialveneers• Temporaryprosthetics
dental limitations
Inadditionto“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• Anyservicesorsuppliesreceivedwhenthisbenefitisnotineffectorwhenyouarenotcoveredunderthisben-efit(includingbridges,dentures,crowns,orrootcanalsfitted,prepared,started,ororderedbeforeyoureffectivedate),exceptforprostheticdevices,crowns,orrootcanalsthatfulfillthefollowingrequirements:• werefitted,prepared,started,ororderedpriortothedateyourcoverageunderthisbenefitended;and• werecompletedorseated,anddeliveredtoyouwithin30daysafterthedateyourcoverageunderthisben-
efitended.• Servicesandsuppliestoincreaseoraltertheverticaldimension• Servicesandsuppliesprovidedbymorethanonedentistforthesamedentalprocedure• ServicesandsuppliesnotcustomaryandacceptedbythedentalprofessioninthestatesofAlaskaorWashington• ServicesandsuppliesfororthodontiaundertheStandardorEconomyPlanoptions,exceptasprovidedforac-
cidentalinjury,includingcasts,models,X-rays,photographs,examinations,appliances,braces,andretainers;however,thisexclusiondoesnotapplytoextractionsincidentaltoorthodonticservices
• Servicesandsuppliestotreatcongenitalmalformations,exceptwhenthepatientisadependentchild• Servicesandsuppliesforcosmeticoraestheticpurposes• Myofunctionaltherapy,whichmeansmuscletrainingtherapyortrainingtocorrectorcontrolharmfulhabits• Dietaryplanningforthecontrolofdentalcaries,oralhygieneinstruction,andtraininginpreventivedentalcare• Chargesforbrokenappointments• Extradenturesorotherappliances,includingreplacementsduetolossortheft• Otherthanstandardtechniquesusedinthemakingofrestorationsorprostheticappliances,suchaspersonalized
restorationsorprecisionattachments• Anydrugsandmedicines,includingvitaminsandfoodsupplements,exceptasspecifiedinthisbenefit;how-
ever,benefitsmaybeavailableforfluoridatedvitaminsunderotherbenefitsofthisprogram• Dentalservicesreceivedfromoneofthefollowing:
• Dentalormedicaldepartmentmaintainedforemployeesbyoronbehalfofanemployer• Mutualbenefitassociation,laborunion,trustee,orsimilarpersonorgroup
• Facilitychargesfordentalprocedures• Anyservicesorsuppliesconnectedwiththediagnosisortreatmentoftemporomandibularjoint(TMJ)disorders
fracturesanddislocations;howeverbenefitsmaybeavailableunderComprehensiveMedical.
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ortHodontia (availaBle on 500 plan onlY)
Benefitsareavailablefortheservicesandsuppliesdescribedinthissectionsubjecttothefollowingrequirements:
• Anexistingorthodonticconditionmustbediagnosedasconsistingofahandicappingmalocclusionwhichisabnormalandwhichcanbereducedoreliminatedbycorrectingabnormallypositionedteeth;and
• Anexpenseforanorthodonticserviceorsupplyisincurredonthedatetheserviceisreceivedorthesupplyisordered.
• Anyplanyeardeductibles,coinsuranceandbenefitmaximumsofotherbenefitsunderthisplandon’tapplytothisbenefit.
Covered services and supplies include
• diagnosticservicesandsupplies,includingexaminations,x-rays,models,andphotographs;• activetreatment,includinginitialandsubsequentnecessaryappliances;and• retentiontreatment,includingnecessaryappliances.
PremeraBlueCrossBlueShieldofAlaskareservestherighttoreviewyourdentalrecords,includingx-rays,modelsandphotographs,todetermineiftherequestedservicesandsuppliesarewithinthelimitsofthisbenefit.
Benefitsareprovidedataconstant50percentuptoalifetimemaximumof$1,500perenrollee,oruntiltheenroll-ee’stotaltreatmentplan,includingretentiontreatment,ispaid,whicheveroccursfirst.
ortHodontia limitations
Inadditionto“DentalLimitations”and“GeneralLimitationsandExclusions,”thisbenefitwillnotbeprovidedforthefollowing:
• Anyreplacementorrepairtoanyappliance• Chargesbeyondthemonthofterminationoforthodonticservicesifsuchservicesareterminatedforanyreason
beforecompletion• Furtherorthodonticservicesandsupplies,aftercompletionoftheinitialtreatmentplan,unlessthisbenefit’s
lifetimemaximumhasn’tbeenreached• Servicesrenderedbyadentalcareproviderbeyondthescopeofhisorherlicenseorcertification• Orthognathicsurgery(jawaugmentationorreduction),althoughbenefitsmaybeavailableunderthemedical
plan• Servicesprovidedbymorethanonedentalcareproviderforthesamedentalprocedure• Expensesincurredfororthodonticservicesorsupplieswhenthisbenefitisn’tineffectorwhenyou’renotcov-
eredbythisbenefit
Inallcaseswheretherearealternativetechniquesoftreatmentwhichare,inBlueCross’judgment,consistentwithacceptablestandardsofdentalpractice,butwhichcarrydifferentcharges,benefitswillbeprovidedonlyforthetechniquecarryingthelessercharge.
Theorthodontiabenefitsavailableunderthissectionwillbeprovidedpriortoanyorthodontiabenefitsthatmaybeavailable under other provisions of this plan.
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VISION CARE BENEFITS
introduCtion
VisioncoverageisprovidedthroughVSP.VSPhasanextensivenationwidenetworkofdoctorswhoagreetoprovidevisioncareandmaterialstoparticipantsatdiscountedrates.FindingaVSPnetworkdoctoriseasy—visitwww.vsp.com,selecttheMemberportal,andclickon“FindaDoctor”orcall(800)877-7195.
OnceyouareenrolledintheVSPplan,yourpersonalizedbenefitinformationisavailableonwww.vsp.com.SimplyregisteratthesitebyenteringyouremployeeIDwhereindicated,andfollowthestepstoaccessyouraccount.YouremployeeIDwillbeyourVSPidentificationnumber;youwillnotreceiveaseparateIDcard.Youcanalsocheckdetailssuchasyoureligibility,dateofyourlasteyeexamandwhichVSPnetworkdoctoryouused.AllUAChoiceplanoptionshavethesamevisionbenefit.
Covered vision serviCes
Thereisnoplanyeardeductibleorcoinsuranceforvisionbenefits.Benefitsforyouoranyofyourcovereddepen-dentsarepayableaccordingtothefollowingschedule(planyearbeginsJuly1):
TypeOfService Benefit
CompleteVisionExamination VSPdoctor:Paidinfullafter$10copay
OnceeveryPlanYear Non-VSPdoctor:Uptoa$50reimbursement afterthe$10copayLensesandFrames—Onceeveryotherplanyear VSPProvider Lensescoveredinfullafter$25copay,frameofyourchoice upto$130,plus20%offanyout-of-pocketcosts
Non-VSPProvider Reimbursementafter$25copayasfollows: Singlevisionlenses Upto$50 Bifocallenses Upto$75 Trifocallenses Upto$100 Progressivelenses Upto$75 Frames Upto$70OR Contact Lenses—Once every other plan year VSPProvider ContactLensCareprogramgivesyoua$130allowancewith nocopayevery24monthsforthecostofyourcontactsandthe contactlensexam. Currrentsoftcontactlenswearersmayqualifyforaspecial programthatincludesacontactlensexamandinitialsupplyof lenses.Askyourdoctor,orvisitvsp.com.
Non-VSPProvider Reimbursementupto$105
eXtra disCounts and savinGs
WhenyougotoaVSPnetworkdoctor,youwillreceivethefollowingdiscounts:
• Averageof35-40%savingsonallnon-coveredlensextras(suchasscratchresistantandanti-reflectivecoat-ings)
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• 30%discountwhenyoupurchaseadditionalglassesandsunglasses,includinglensoptions,fromthesameVSPdoctoronthesamedayasyourWellVisionexam,or20%offfromanyVSPdoctorwithin12monthsofyourlasteyeexam
• 15%discountoffthecostofyourcontactlensfittingandevaluationexamfromaVSPnetworkdoctor;• Anaverageof15%offtheregularpriceoflaservisioncorrection,or5%offthepromotionalprice,througha
VSPnetworkdoctor.Aftersurgery,useyourframeallowance(ifeligible)forsunglassesfromanyVSPdoctor.
Benefitsreneweveryplanyearforcoveredvisionexaminations,andeveryotherplanyearforeyeglasses(lensesandframes)orcontacts.Benefitswillbeprovidedforeithereyeglassesorcontactlensesduringthesamebenefitperiod,not both.
usinG non-vsp providers
Youmayobtaineyecareservicesfromnon-VSPproviders.Reimbursementforservicesisaccordingtothereim-bursementbenefitsstatedabove.However,VSPcannotguaranteesatisfactionorextendtheadditionaldiscounttowardsmaterialsoranyoptionsthatyoumaychoose.
Whenyouobtainservicesand/ormaterialsfromanon-VSPprovider,pleasefollowthesesteps:
• Paythenon-VSPproviderthefullamountofthebillandrequestanitemizedcopyofthebill.Thebillneedstoshowthechargesfortheeyeexamandmaterials,includinglenstype.
• LogintotheVSPwebsiteandclickthelinkfor“Out-of-NetworkReimbursement”andfollowtheinstructionstocompleteandthenprinttheonlineform,oryoucanattachasheetandincludethefollowinginformationwithyourreceipt:EmployeenameandID,patient’sname,dateofbirthandrelationshiptotheemployee.
• SendacopyoftheitemizedbillalongwiththecompletedOut-of-NetworkReimbursementFormto:VSP
POBox997105Sacramento,CA95899-7105
Pleasenotethatclaimsforreimbursementmustbefiledwithinsixmonthsofthedateofservice.Youwillbereim-bursedaccordingtothereimbursementschedule.
Coordination oF BeneFits
Ifyouhavecoverageasanemployeeandasadependent,pleaselettheVSPmemberdoctorknowatthetimeser-vicesarerendered,andprovidetheothercoverageIDnumber.Thedoctor’sofficewillfiletheclaimsonyourbehalf.
Ifyouchoosetouseanon-VSPprovider,youwillneedtopaythefullamountofthebillatthetimeofservice,andsubmityouritemizedcopyofthebillasdescribedabove,beingsuretoreferenceboththeprimaryandsecondaryIDnumbers.
vision limitations
Inadditionto“GeneralLimitationsandExclusions,”thefollowinglimitationswillapplytothisbenefit:
• visiontherapy,eyeexercise,oranysortoftrainingtocorrectmuscularimbalanceoftheeye(orthoptics),orpleoptics;
• planolenses;• expensesassociatedwithsecuringmaterialssuchaslensesandframes;
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• medicalorsurgicaltreatmentoftheeyes;or• replacementoflensesandframesfurnishedunderthisprogram(underacoveredallowance),exceptatthenor-
malintervalswhenservicesareavailable.Discountsonadditionalmaterialsareprovidedonanunlimitedbasisfortwelvemonthsfollowinganeyeexam.
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AUDIO CARE BENEFITS
introduCtion
Benefitsareavailablefortheservicesandsuppliesdescribedinthissectionthatarefurnishedinconnectionwithhearingloss.
Thedeductiblesandout-of-pocketmaximumsofthecomprehensivemedicalbenefitsinthisprogramdonotapplytothisbenefit.
Inordertoreceiveyouraudiocarebenefit,youmustbeexaminedbyoneofthefollowing:
• aphysiciancertifiedasanotolaryngologistorotologist;or• anaudiologistperformingtheexaminationatthewrittendirectionofalegallyqualifiedotolaryngologistor
otologist;theaudiologistmusteitherbelegallyqualifiedinaudiology,orholdaCertificateofClinicalCompe-tenceinAudiologyfromtheAmericanSpeechandHearingAssociationintheabsenceofanyapplicablelicens-ingrequirements.
A“coveredhearingaid”isanelectronichearingaidinstalledinaccordancewithaprescriptionwrittenduringacoveredhearingexaminationasstatedabove.
Covered serviCes and supplies
Benefitswillbeprovidedaccordingtothemedicalscheduleofbenefitsuptoamaximumbenefitof$400inaperiodofthreeconsecutiveplanyearsforthefollowing:
• oneaudiometric(hearing)examination;and• onehearingaidperear• hearingaidrentalwhiletheprimaryunitisbeingrepaired
audio limitations
Inadditionto“GeneralLimitationsandExclusions,”thehearingbenefitsofthisprogramwillnotbeprovidedforthefollowing:
• anyearorhearingexaminationtodeterminethepresenceofdiseaseorinjury,formedicalorsurgicaltreatmentorfordrugsormedicines;
• batteriesorotherancillaryequipmentotherthanthatobtaineduponpurchaseofthehearingaid;• repairs,servicing,andalterationofhearingaidequipmentpurchasedunderthisplan;• expensesincurredafteryourcoverageendsunderthisprogramunlessahearingaidwasorderedpriortothat
dateandwasdeliveredwithin30daysafterthedaycoverageended;• servicesandsuppliesthatwerereceivedpriortotheenrollee’seffectivedate;and• hearingaidsfurnishedororderedasaresultofahearingexaminationthatoccurredpriortotheenrollee’seffec-
tive date.• Hearingaidchargesinexcessofthisbenefitarenoteligibleforcomprehensivemajormedicalbenefits.
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HOW TO SUBMIT A CLAIM
automatiC Claims suBmission
GenerallyifyouuseaBlueCrossnetworkprovider,theproviderwillsubmityourclaimdirectlytoBlueCross.Onreceiptoftheclaimfromanetworkprovider,BlueCrosswillpaytheproviderdirectly—evenifyoupaythepro-viderin-fullupfrontfortheirservice.ThecontractsbetweennetworkprovidersandBlueCrossrequireallpaymentsbe sent directly to the provider.
IfyouareoutsideofAlaskaandWashingtonandhavereceivedmedicalservicesfromahospitalorotherhealthcareprovider,yourproviderofcaremustbillthelocalBlueCrossand/orBlueShieldLicenseedirectly.
BlueCrossisavailabletoanswerquestionsregardinghealthinsurancebenefitsandtheirpayment.Theycanbereached by letter at:
Premera Blue Cross Blue Shield of AlaskaPOBox327
Seattle,WA98111-0327
Oryoumayphonetollfree:
(800)364-2982
UnresolvedquestionsshouldbetakentoyourregionalhumanresourceofficeortotheStatewideOfficeofHumanResources.
manual Claims FilinG
Ifyouchoosetogotoanon-networkprovider,ortoaprovideroutsideofAlaskaandWashingtonfordentalorvi-sionservices,youhavetheoptiontomarktheclaimformfordirectpaymenttotheprovideroryourself.Ifyoudonotindicateontheclaimformthatyouwantthepaymentsenttoyou,BlueCrosswillpaybenefitstothehospital,doctor,dentist,oranyothercoveredproviderwhoservedyou.
Step 1
Completeaclaimform.Aseparateclaimformisnecessaryforeachpatientandeachprovider.ClaimformsareavailablefromBlueCross,yourregionalhumanresourcesoffice,orontheUniversityofAlaskabenefitswebpageathttp://www.alaska.edu/benefits/.
Step 2
Attachtheitemizedbill.Theitemizedbillmustcontainallofthefollowinginformation:
• Namesoftheemployeeandtheenrolleewhoincurredtheexpense• IdentificationnumbersforboththeenrolleeandtheUniversityofAlaska(theseareshownontheenrollee’s
identificationcard)• Name,address,andIRStaxidentificationnumberoftheprovider• Informationaboutotherinsurancecoverage• Dateofonsetoftheillnessorinjury
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• DiagnosisorICD-9code• Procedurecodes(CPT-4,HCPCS,ADA,orUB-92)foreachservice• Datesofserviceanditemizedchargesforeachservicerendered• Iftheservicesrenderedarefortreatmentofanaccidentalinjury,thedate,time,location,andabriefdescription
of the accident
Step 3
IfyouarealsocoveredbyMedicare,andMedicareisprimary,youmustattachacopyofthe“ExplanationofMedi-careBenefits.”
Step 4
Checkthatallrequiredinformationiscomplete.Billsreceivedwillnotbeconsideredclaimsuntilallnecessaryinformationisincluded.
Step 5
Signtheclaimforminthespaceprovided.
Step 6
Mail your claims to the following address:
Premera Blue Cross Blue Shield of AlaskaP.O.Box240609
Anchorage,Alaska99524-0609
air or surFaCe transportation Claims
Tomakeclaimforcoveredairorgroundtransportationservices,pleasefollowthesesteps:
Completeaclaimform.Aseparateclaimformisnecessaryforeachpatientandeachcarrierortransportationserviceutilized.Attachoneofthefollowingformsofdocumentation:
• Acopyoftheticketfromtheairlineorothertransportationcarrier.Theticketsneedtoindicatethenamesofthepassenger(s),datesoftravel,costofticketandtheoriginationandfinaldestinationpoints.
• Acopyofthedetaileditineraryasissuedbytheairline,transportationcarrier,travelagencyoron-linetravelwebsite.Theitinerarymustidentifythenameofthepassenger(s)thedatesoftravel,andtheoriginationandfinaldestinationpoints.
PleaseNote:Creditcardstatementsorotherpaymentreceiptsarenotacceptableformsofdocumentation.Travelinpersonal vehicles is not covered transportation.
suBmission oF pHarmaCY druG Claims
Tomakeaclaimforcoveredpharmacydrugs,pleaserefertothe“PharmacyDrugBenefit”sectionofthishandbook.
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Claims FilinG timelines
Youshouldsubmitallclaimswithin90daysofthestartofserviceorwithin30daysaftertheserviceiscompleted.BlueCrossmustreceiveclaimswithinthefollowingtimelimits:
• Within365daysofdischargeforhospitalorothermedicalfacilityexpenses,orwithin365daysofthedateonwhichexpenseswereincurredforanyotherservicesorsupplies
• ForenrolleeswhohaveMedicare,claimsmustbefiledwithintheabove-mentioned365-daytimeframeorwithin90daysoftheprocessdateshownontheExplanationofMedicareBenefits,whicheverisgreater
BlueCrosswillnotprovidebenefitsforclaimstheyreceiveafterthelaterofthesetwodates,norwillBlueCrossprovidebenefitsforclaimswhichweredeniedbyMedicarebecausetheywerereceivedpastMedicare’ssubmissiondeadline.
Claims proCedure
BlueCrosswillmakeeveryefforttoprocessclaimsasquicklyaspossible.Claimsforbenefitswillbeprocessedunderthefollowingtimeframes;
• Iftheclaimincludesalloftheinformationneededtoprocesstheclaim,BlueCrosswillprocessitwithin30calendar days of receipt.
• Ifmoreinformationisneededtoprocesstheclaim,BlueCrosswilltellyouortheproviderwhosubmittedtheclaimthattheyneedmoreinformation.Theywillmakethatrequestwithin30calendardaysofreceipt.Youoryourproviderwillhave45daysfromthenoticetoprovidetheadditionalinformation.Iftheadditionalinforma-tionisnotreceived,BlueCrosswillcontinuetonotifyyouevery45calendardaysfromtheinitialnotice,untiladecisionismadeaboutyourclaim.
• OnceBlueCrossreceivestheadditionalinformationforyourclaim,theywillprocessyourclaimwithin15daysofthedatetheyreceivetheinformation.
Whenyourclaimisprocessed,BlueCrosswillsendawrittennoticeexplaininghowtheclaimwasprocessed(an“ExplanationofBenefits,”or“EOB”).Iftheclaimisdeniedinwholeorinpart,theywillsendawrittennoticethatstatesthereasonforthedenial,andinformationonhowtorequestanappealofthatdecision.
denied Claims
BlueCrossmaydenybenefitsafteryouhavefiledaclaim.TheUniversityofAlaskahasalsograntedBlueCrossthediscretionaryauthoritytodetermineeligibilityforbenefitsandtoconstruethetermsusedinthisprogram.OnceBlueCrosshasmadeadecision,theywillsendyouan“ExplanationofBenefits”(EOB)showingbenefitsprovidedunderthisprogram.Ifyourclaimwasdenied,inwholeorinpart,theEOBwillincludethereasonsforthedenialandareferencetotheprovisionsofthisprogramonwhichitisbased,aswellasadescriptionofadditionalinformationBlueCrossmayneedandwhyitisneeded.
Your questions, Complaints and appeals
WHen You Have questions
Callyourproviderofcarewhenyouhavequestionsaboutthehealthcareservicesyoureceive.Ifyouneedmoreinformationaboutthisprogramorhaveaquestionaboutyourclaim,youmaycontactBlueCrossCustomerServiceatthefollowingnumbers:
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• University of Alaska dedicated number: 1-800-364-2982• Alaska Number: 1-800-345-6784• Hearing-impaired TTY: 1-800-842-5357(Onlycallsfromthehearing-impairedwillbeacceptedonthisline.)
PleasegiveBlueCrosstheGroupandemployeenumbersshownonyouridentificationcardwhenyoucallorwrite.BlueCrossneedsthisinformationtoidentifythetypeofcoverageyouhave.IfyouareaskingaboutaspecificclaimthatBlueCrosshasprocessed,pleasealsoincludeorhaveavailabletheEOByoureceivedfromthemforthatclaim.
Ifyouneedaninterpretertohelpwithyourquestion,pleasetellBlueCrosswhenyoucall,andtheywillprovideonefor the call.
WHen You Have a Complaint
AcomplaintisanexpressionofdissatisfactionwithanactionorpolicyofBlueCross,aclaimforbenefits,orwithaproviderofcareorservice.ThecomplaintprocessletsCustomerServicequicklyandinformallycorrecterrors,clarifydecisionsorbenefits,ortakestepstoimproveBlueCross’service.BlueCrossrecommends,butdoesnotrequire,thatyoutakeadvantageofthisprocesswhenyouhaveaconcernaboutabenefitorcoveragedecision.IfCustomerServicefindsthatyouneedtosubmityourcomplaintasaformalappeal,theywilltellyou.
Whenyouhaveacomplaint,callorwriteBlueCross’CustomerServiceDepartment.Ifyourcomplaintisaboutthequalityofcareyoureceive,itwillbegiventotheClinicalQualityManagementstaffforreview.Ifthecomplaintisofanon-medicalnaturerelatingtoaprovider,itwillbegiventotheProviderNetworkstaffforreview.BlueCrossmayrequestmoreinformationifneeded.Whentheyreceiveallneededinformation,theywillreviewyourcomplaintandrespondassoonaspossible,butinnocasemorethan30days.
WHen You Have an appeal
Anappealisanoralorwrittenrequesttoreconsider
• adecisiononacomplaint,or• adecisiontodeny,modify,reduce,orendpayment,coverage,orauthorizationofcoverage.
Thisincludesadmissionsto,andcontinuedstaysin,afacility.Yourappealmustbereceivedwithin180calendardaysofthedateyoureceivednoticeofthedecision,Ifyouareappealingacomplaintdecision,yourappealmustbereceivedwithin180calendardaysofthedatethatdecisionwasgiventoyou.
AlthoughanappealmadebyphonetotheCustomerServiceDepartmentwillbeaccepted,it’sabetterideatoputappealsinwriting.Pleasesendallwrittenappealstotheaddressbelow.Youwillbenotifiedwhenyourappealisreceived.YouhavetherighttosendBlueCrosswrittencomments,documents,orotherinformationtosupportyourappeal.
Mail all appeals to:
Premera Blue Cross Blue Shield of AlaskaAttn: Appeals Coordinator
POBox91102Seattle,WA98111-9202
appeals proCess
Thisplan,theUniversityofAlaskaandPremeraBlueCrossBlueShieldofAlaskawillcomplywithanynewrequirementsasnecessaryundertheAffordableCareActanditsgoverningregulations.Thefullappealprocessisavailableatwww.premera.com,orbycallingPremeraCustomerServiceat(800)364-2982.
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Theplan’sstandardappealsprocesshastwolevelsofreview,asexplainedbelow.
Level I:TheLevelIappealpanelwilldecidemostappealswithin30calendardays.Thispanelwillincludehealthcareprovidersasneeded.Personsinvolvedintheinitialdecisionwillnotbeonthepanel.Thereviewtimecanbeextendedupto15morecalendardaysifmoreinformationisneeded.You’llbenotifiedifadelayoccurs.
Ifyoudon’tagreewiththedecisionreachedintheLevelIreview,youmayaskPremeraBlueCrosstoperformaLevelIIreviewofyourappeal.Ifyou’reappealingaqualifyofcareissue,adecisionthataserviceorsupplyisnotmedicallynecessaryorappropriate,isexperimentalorinvestigational,orotherwisedenied,youhavetheoptiontorequestindependentreviewinsteadofLevelIIreview(see“Independentreview”below).Withanyoftheaboveop-tions,youmayalsosendmoreinformationtosupportyourappeal.YoumustmakeyourrequestforaLevelIIreviewnomorethan60calendardaysafterthedateyoureceivetheLevelIdecision.
Level II: YourappealwillbereviewedbyapanelthatincludeshealthcareprovidersandisdifferentfromtheLevelIpanel.Youand/oryourauthorizedrepresentativemaymeetwiththepanel.Thepanelwillgiveyouadecisionwithin45calendardaysofthedateyourLevelIIrequestisreceived.
Note:Unlessyourappealisdeemedurgent,yourwrittennoticeofthelevelIandLevelIIdecisionswillbemailedtoyouwithinfivedaysafterthereviewiscomplete.
Independent ReviewIndependentreviewsareconductedbyanindependentrevieworganization(IRO),whichisanorganizationofmedicalexpertsqualifiedtoreviewyourappeal.BlueCrosswillsubmityourfiletotheIROonyourbehalfandwillpaythechargesoftheIRO.TheIROwillmakeitsdecisionwithin21daysofreceiptoftheappeal(72hoursforurgentappeals)andgiveyouitsdecisioninwriting.BlueCrosswillimplementtheIRO’sdeter-minationpromptly.ThedecisionoftheIROisbindingunlessyouappealthedecisiontothesuperiorcourt,andthatappealmustbefiledwithinsixmonthsafterthedateofthedecisionoftheIRO.
PleasecallCustomerServiceifyouhavequestionsorneedmoreinformationaboutBlueCross’complaintorappealprocess.Thenumbersareshownin“WhenYouHaveQuestions”above.
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COORDINATION OF BENEFITS
introduCtion
Youmayalsobecoveredunderoneormoreotherhealthcareplans,suchasonesponsoredbyyourspouse’sem-ployer.Yourhealthcareplanincludesa“coordinationofbenefits”featuretohandlesuchsituations.BlueCrosswillcoordinatethebenefitsoftheUniversity’splanwiththoseofyourotherplanstomakecertainthat,ineachplanyear,thetotalpaymentsfromallplansarenotmorethanthetotalallowableexpenses.Allofthebenefitsofthisplanaresubjecttocoordinationofbenefits.
Ifyoudohaveothercoveragebesidesthisplan,BlueCrossrecommendsthatyousendyourclaimstotheemploy-ee’sprimaryplanfirst.Inthatway,thepropercoordinatedbenefitsmaybemostquicklydeterminedandpaid.
Ifyouarecoveredasanemployeeandalsoasadependentofacoveredemployee,youwillreceivebenefitsbothasanemployeeandasadependent.BenefitsyoureceivearesubjecttothisCoordinationofBenefitsprovision.
terms You sHould knoW
Tounderstandcoordinationofbenefits,itisimportanttoknowthemeaningsofthefollowingterms:
• Allowable Medical Expense—theusual,customaryandreasonablechargeforanymedicallynecessaryhealthcareserviceorsupplywhentheserviceorsupplyprovidedbyalicensedmedicalprofessionaliscoveredatleastinpartunderanyoftheplansinvolved.Whenaplanprovidesbenefitsintheformofservicesorsuppliesratherthancashpayments,thereasonablecashvalueofeachservicerenderedorsupplyprovidedshallbeconsideredanallowableexpense.
• Allowable Dental Expense—theusual,customaryandreasonablechargeforanydentallynecessaryserviceorsupplyprovidedbyalicenseddentalprofessionalwhentheserviceorsupplyiscoveredatleastinpartunderthisplan.Whenaplanprovidesbenefitsintheformofservicesorsuppliesratherthancashpayments,therea-sonablecashvalueofeachservicerenderedorsupplyprovidedshallbeconsideredanallowableexpense.
• Claim Determination Period—aplanyear(July1throughJune30)• Medical Plan—allofthefollowing,eveniftheydon’thavetheirowncoordinationprovisions:
• Group,individualorblanketdisabilityinsurancepolicies• Groupagreementswithhealthcareservicecontractorsandhealthmaintenanceorganizationsthatareissued
byinsurers,healthcareservicecontractors,andhealthmaintenanceorganizations• Labor-managementtrusteedplans,labororganizationplans,employerorganizationplans,oremployee
benefitorganizationplans• Governmentprogramsthatprovidebenefitsfortheirowncivilianemployeesortheirdependents• GroupcoveragerequiredorprovidedbyanylawincludingMedicare;thisdoesnotincludeworkers’com-
pensation• Groupstudentcoveragethatissponsoredbyaschoolorothereducationalinstitution,andincludesmedical
benefitsforillnessordisease• Dental Plan—allofthefollowing
• Group,individualorblanketdisabilityinsurancepolicies• Groupagreementswithhealthcareservicecontractorsandhealthmaintenanceorganizationsthatareissued
byinsurers,healthcareservicecontractors,andhealthmaintenanceorganizations• Labor-managementtrusteedplans,labororganizationplans,employerorganizationplans,oremployee
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benefitorganizationplans• Governmentprogramsthatprovidebenefitsfortheirowncivilianemployeesortheirdependents
Eachcontractorotherarrangementforcoveragedescribedaboveisaseparateplan.Also,ifanarrangementhastwoormorepartsandthecoordinationofbenefitsprovisionappliesonlytooneofthetwo,eachofthetwopartsisaseparate plan.
order oF Claim FilinG
Animportantpartofcoordinatingbenefitsisdeterminingtheorderinwhichtheplansprovidebenefits.Oneplanisresponsibleforprovidingbenefitsfirst.Thisiscalledthe“primary”plan.Theprimaryplanprovidesitsfullbenefitsasiftherewerenootherplansinvolved.Theotherplansthenbecome“secondary.”Thismeanstheyreducetheirpaymentamountssothatthetotalbenefitsfromallplansarenotmorethantheallowableexpenses.Coordinationofbenefitsalwaysconsidersamountsthatwouldbepayableundertheotherplan,whetherornotaclaimhasactuallybeenfiled.
Hereistheorderinwhichtheplansshouldprovidebenefits:
First: Aplanthatdoesnotprovideforcoordinationofbenefits.Next: Aplanthatcoversyouasotherthanadependent,i.e.asanemployee.Next: Aplanthatcoversyouasadependent.Fordependentchildren,thefollowingrulesapply:
• Whentheparentsare notseparatedordivorced—Theplanoftheparentwhosebirthdayfallsearlierintheyearwillbeprimary,ifthatisinaccordwiththecoordinationofbenefitsprovisionsofbothplans.Other-wise,therulesetforthintheplanwhichdoesnothavethisprovisionshalldeterminetheorderofbenefits.
• Whentheparentsareseparatedordivorced—Ifacourtdecreemakesoneparentresponsibleforpayingthechild’shealthcarecosts,thatparent’splanwillbeprimary.Otherwise,theplanoftheparentwithcustodywillbeprimary,followedbytheplanofthespouseoftheparentwithcustody,followedbytheplanoftheparentwhodoesnothavecustody.
Iftherulesabovedonotapply,theplanthathascoveredyouforthelongesttimewillbeprimary,exceptbenefitsofaplanthatcoversyouasalaid-offorretiredemployee,orasthedependentofsuchanemployee,shallbedeter-minedafterthebenefitsofanyplanthatcoversyouasotherthanalaid-offorretiredemployee,orasthedependentofsuchanemployee.Thisapplies,however,onlywhenotherplansinvolvedhavethisprovisionregardinglaid-offorretiredemployees.
eFFeCt oF mediCare
IfyouarealsocoveredunderMedicare,federallawmayrequirethisprogramtobeprimaryoverMedicare.Whenthisprogramisnotprimary,BlueCrosswillcoordinatebenefitswithMedicareasstatedinCoordinationofBenefits.
riGHt oF reCoverY/FaCilitY oF paYment
PremeraBlueCrossBlueShieldofAlaskahastherighttorecover,onbehalfoftheGroup,anypaymentsmadebytheplanthataregreaterthanthoserequiredbythecoordinationofbenefitsprovisionsfromoneormoreofthefol-lowing:thepersonstheplanpaidorforwhomithaspaid,providersofservice,insurancecompanies,serviceplans,orotherorganizations.Ifapaymentthatshouldhavebeenmadeunderthisprogramwasmadebyanotherprogram,PremeraBlueCrossBlueShieldofAlaskaalsohastherighttodirecttheplan’spaymentdirectlytoanotherprogramofanyamountthatshouldhavebeenpaidbytheplan.Thepaymentwillbeconsideredabenefitunderthisprogramandwillmeettheplan’sobligationstotheextentofthatpayment.
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tHird partY liaBilitY (suBroGation)
Iftheplanmakesclaimspaymentonyourbehalfforinjuryorillnessforwhichanotherpartyisliable,orforwhichuninsured/underinsuredmotorist(UIM)orpersonalinjuryprotection(PIP)insuranceexists,theplanisentitledtoberepaidforthosepaymentsoutofanyrecoveryfromthatliableparty.Theliablepartyisalsoknownasthe“thirdparty”becauseit’sapartyotherthanyouortheplan.ThispartyincludesaUIMcarrierbecauseitstandsintheshoesofathirdpartytortfeasorandbecausetheplanexcludescoverageforsuchbenefits.
Thefollowingtermshavespecificmeaningsinthissection:
SubrogationmeansBlueCrossmaycollect,onbehalfoftheplan,directlyfromthirdpartiestotheextenttheplan has paid on your behalf for illnesses or injury caused by the third party.
Reimbursementmeansthatyouareobligatedtorepayanymoniesadvancedbytheplanfromamountsre-ceivedonyourclaim.
Restitutionmeansallequitablerightsofrecoverythattheplanhastothemoniesadvancedunderyourplan.Becausetheplanhaspaidforyourillnessorinjuries,theplanisentitledtorecoverthoseexpenses.
Theplanisentitledtotheproceedsofanysettlementorjudgmentthatresultsinarecoveryfromathirdparty,uptotheamountofbenefitstheplanpaidforthecondition,whetherornotyouhavebeenmadewholepriortotheplan’srecovery.Theplan’srighttorecoverexistsregardlessofwhetheritisbasedonsubrogation,reimbursementorres-titution.Thisrightallowstheplantopursueanyclaimagainstanythirdpartyorinsurer,whetherornotyouchoosetopursuethatclaim.Theplan’srightsandpriorityarelimitedtotheextenttheplanhasmadeorwillmakebenefitpaymentsfortheinjuryorillness,butdoextendtoanycoststhatresultfromtheenforcementofitsrights.
Inrecoveringbenefitsprovidedonbehalfoftheplan,BlueCrossmay,attheGroup’selection,eitherhireanattorneyorhavetheplanberepresentedbyyourattorney.BlueCrosswillnotpayforanylegalcostsincurredbyyouoronyourbehalf,andyouwillnotberequiredtopayanyportionofthecostsincurredbytheplanortheGrouporontheirbehalf.
Beforeacceptinganysettlementonyourclaimagainstathirdparty,youmustnotifyPremeraBlueCrossinwritingofanytermsorconditionsofferedinasettlement,andyoumustnotifythethirdpartyoftheplan’sinterestinthesettlementestablishedbythisprovision.YoualsomustcooperatewithBlueCrossinrecoveringamountspaidbytheplanonyourbehalf.Ifyouretainanattorneyorotheragenttorepresentyouinthematter,youmustrequireyourattorneyoragenttoreimbursetheplandirectlyfromthesettlementorrecovery.
IfyoufailtocooperatefullywithPremeraBlueCrossintherecoverofbenefitstheplanhaspaidasdescribedabove,youareresponsibleforreimbursingtheplanforsuchbenefits.Totheextentthatyourecoverfromanyavailablethirdpartysource,youagreetoholdanyrecoveredfunintrustorinasegregatedaccountuntiltheplan’ssubroga-tionandreimbursementrightsarefullydetermined.
aGreement to arBitrate
AnydisputesbetweenyouandtheGroupand/orPremeraBlueCrossontheGroup’sbehalfthatariseincarryingoutthisprovisionwillberesolvedbyarbitration.YouandBlueCrossandtheUniversityofAlaskawillbeboundbythedecisionsofthearbitrationproceedings.
DisputeswillberesolvedbyasinglearbitratorinaccordancewiththecurrentrulesoftheAmericanArbitrationAs-sociation.Eitherpartymaydemandarbitrationbyservingnoticeofthisdemandontheotherparty.Eachpartywillbearitsowncostsandshareequallyinthefeesofthearbitrator.Arbitrationproceedingspursuanttothisprovisionshalltakeplaceinamutuallyagreeduponlocation.
Thisagreementtoarbitratewillbeginonthedatetheplangoesintoeffect.ItwillcontinueuntilanydisputeaboutPremeraBlueCross’effortstorecoverpaymenthavebeenresolved.
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TERMINATION OF BENEFITS
termination oF CoveraGe
Exceptasspecifiedunder“ExtendedBenefits,”coveragewillendwithoutnoticeonthelastdayofthemonthinwhichoneoftheseeventsoccurs:
• Fortheemployeeanddependents,whentheemployeeterminatesfromabenefits-eligibleposition,ortheem-ployeediesorisnolongereligibleasanemployee;terminationmeanscessationofemploymentforanyreason,includingresignation,retirement,andnon-retention
• Foraspouse,whenhisorhermarriagetotheemployeeisannulled,orheorshebecomeslegallyseparatedordivorcedfromtheemployee
• Forachild,whenheorsheisnolongereligibleasadependent
Please Note:TheemployeemustnotifytheUniversitywithin30daysofthedateoftheenrollee’slossofeligibil-itywhenanenrolledfamilymemberisnolongereligibletobeenrolledasadependentunderthisprogram.FailuretonotifytheUniversitywithin30daysmayresultinlossofeligibilityforcontinuationofcoverage.TheUniversitywillgiveBlueCrossnoticeofanenrollee’scancellation.
CertiFiCate oF Group HealtH CoveraGe
WhenyourcoveragethroughtheUniversityofAlaska’shealthplanterminates,theUniversityofAlaskawillprovideyouwitha“CertificateofGroupHealthCoverage.”Thecertificatewillprovideinformationregardingyourcover-ageundertheUniversityofAlaska’shealthplan.Whenyouprovideacopyofthecertificatetoyournewhealthplan,youmayreceivecredittowardanywaitingperiodforpre-existingconditions.Youwillneedacertificateeachtimeyouleaveahealthplanandenrollinaplanthathasawaitingperiodforpre-existingconditions.Therefore,itisimportantforyoutokeepthecertificateinasafeplace.
Ifyouhavenotreceivedacertificate,orhavemisplacedit,youhavetherighttorequestonefromtheUniversityofAlaskawithin24monthsofthedatecoverageterminated.
WhenyoureceiveyourCertificateofGroupHealthCoverage,makesuretheinformationiscorrect.ContacttheStatewideOfficeofHumanResourcesifanyoftheinformationlistedisnotaccurate.
plan termination
Norightsarevestedunderthisplan.TheGroupisnotrequiredtokeeptheplaninforceforanylengthoftime.Iftheplanweretobeterminated,youwouldonlyhavearighttobenefitsforcoveredcareyoureceivebeforetheplan’senddate.TerminationoftheGroupContractforthisprogramcompletelyendsallenrollees’coverageandallUni-versityofAlaskaandPremeraBlueCrossBlueShieldofAlaska’sobligations,exceptasprovidedunder“ExtendedBenefits.”
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COVERAGE CONTINUATION (COBRA)
Underthefollowingconditions,youand/oryourdependentsmaycontinuetoparticipateinthehealthplansafteryou,orthey,wouldnormallybecomeineligibleforcoverage.Youmaycontinuecoverageforyourselfandyourdependentsforupto18monthsafteroneofthefollowingqualifyingevents:
• Youretire• Youareterminated(forreasonsotherthangrossmisconduct)• Youremploymentstatusischangedtoapositionthatdoesnotincludebenefits• Reductionofhoursbelowthethresholdforbenefiteligibility,includingleavewithoutpay
COBRAcoveragecanbeextendedifyoulostcoverageduetooneoftheeventsabove,andaredeterminedtobedisabledunderTitleII(OASDI)orTitleXVI(SSI)oftheSocialSecurityActatanytimeduringthefirst60daysofCOBRAcoverage.Insuchcases,allfamilymemberswhoelectedCOBRAmaycontinuecoverageforuptoatotalof29consecutivemonthsfromthefirstdateofCOBRAeligibility.
Yourspouseand/ordependentchildrenmaycontinuecoverageforupto36monthsafteroneofthefollowingquali-fyingevents:
• Yourdeath(theUniversityofAlaskawillpaytheirfirsttwelvemonthsofcoverageandwillcountthistimeconcurrentwithCOBRA)
• Youaredivorcedorlegallyseparated• Yourdependentchildrenceasetoqualifyforcoveragebecauseofage
UndertheCOBRAregulations,you(theemployee)orafamilymemberhastheresponsibilitytonotifytheUni-versityofAlaskauponadivorce,legalseparation,orachild’slossofdependentstatus.TonotifytheUniversityofAlaskaofaqualifyingeventforspouseordependentchild,youmustsubmitadependentenrollment/dropformtoyourregionalhumanresourcesoffice.Youorafamilymembermustprovidethisnoticenolaterthan60daysafterthedateofdivorce,legalseparationorachildlosingdependentstatus.
IfyouorafamilymemberfailstoprovidethisnoticetotheUniversityofAlaskaduringthis60-daynoticeperiod,anyfamilymemberwholosescoveragewill not be offered the option to elect COBRA continuation coverage. Fur-thermore,ifyouorafamilymemberfailstonotifytheUniversityofAlaska,andanyclaimaremistakenlypaidforexpensesincurredafterthedateofthedivorce,legalseparationorachildlosingdependentstatus,thenyouandyourqualifyingfamilymemberswillberequiredtoreimbursethePlanforanyclaimssopaid.
Individualswillnolongerbeeligibleforthiscontinuedcoverageifoneofthefollowingoccurs:
• Youoryourdependentsfailtopaytherequiredpremiumforaparticipatingindividualonatimelybasis• Youoryourdependentsbecomecoveredunderanothergrouphealthplanwithnopre-existingconditionclause
afterthedateyouelectCOBRAcoverage• YouoryourdependentsbecomeentitledtoMedicarebenefitsafterthedateyouelectCOBRAcoverage• Aneligiblespouseremarriesandbecomescoveredbyagrouphealthplan• Youoryourdependentsarenolongersubjecttothepre-existingconditionclauseofanothergrouphealthplan• TheUniversityceasestoprovideagrouphealthplan
ThecontinuationcoverageprovidesthesamebenefitsastheUniversity’sHealthCarePlan.Nomedicalexaminationisrequiredforcontinuation;however,theelectionmustbemadewithin60daysofeitherthedatecoveragewastoendduetothequalifyingeventorthedateyouarenotifiedofyourcontinuationrights,whicheverislater.
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Shouldyouwishtocontinueplancoverage,youand/oryourdependentsarerequiredtopaythecostoftheinsurancepremiums.Contactyourregionalhumanresourcesofficeforcontinuationcoverageinformationandcurrentrates.
leave oF aBsenCe
Coverageforanemployeeandenrolleddependentsmaybecontinuedforupto18monthswhentheUniversityofAlaskagrantstheemployeealeaveofabsenceandtherequiredpremiumscontinuetobepaid.
TheleaveofabsenceperiodcountstowardthemaximumCOBRAcontinuationperiod,exceptasprohibitedbystateandfederalfamilyleavelaws.Contactyourregionalhumanresourcesofficeforinformationonleavesofabsence.
mediCare supplement CoveraGe
IfyouareeligibleforandenrolledinPartsAandBofMedicare,youmaybeeligibleforguarantee-issuedcoverageundercertainMedicaresupplementplans.Youmustapplywithin63daysoflosingcoverageunderthisplan.Formoreinformation,contactPremeraBlueCrossBlueShieldofAlaskacustomerserviceat(800)364-2982.
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EXTENDED BENEFITS
Underthefollowingcircumstances,certainbenefitsofthisprogrammaybeextendedafteryourcoverageends.
eXtended inpatient BeneFits
Theinpatientbenefitsofthisprogramwillcontinuetobeavailableaftercoverageendsif:
• yourcoveragehadbeenineffectformorethan31days;• yourcoveragedidnotendbecauseoffraudoranintentionalmisrepresentationofmaterialfactundertheterms
ofthecoveragebyyouortheGroup;• youwereadmittedtoamedicalfacilitypriortothedatecoverageended;and• youremainedcontinuouslyconfinedinamedicalfacilitybecauseofthesamemedicalconditionforwhichyou
wereadmitted.
Suchcontinuedinpatientcoveragewillendwhenthefirstofthefollowingoccurs:
• Youarecoveredunderahealthplanorcontractthatprovidesbenefitsforyourconfinementorcouldprovidebenefitsforyourconfinementifcoverageunderthisprogramdidnotexist.
• Youaredischargedfromthatfacilityorfromanyotherfacilitytowhichyouweretransferred.• Inpatientcareisnolongermedicallynecessary.• Themaximumbenefitforinpatientcareinthemedicalfacilityhasbeenprovided.Iftheplanyearendsbeforea
planyearmaximumhasbeenreached,thebalanceisstillavailableforthecoveredinpatientcareyoureceiveinthenextyear.Onceitisusedup,however,aplanyearmaximumbenefitwillnotberenewed.
Continued eliGiBilitY For a disaBled enrollee
Ifonthedateanemployee’scoverageterminates,heorsheisdisabledbyinjuryorillness(includingpregnancy)andisunabletoworkathisorherownoccupationasdeterminedbyanapprovedapplicationforLTDbenefits,theben-efitsoftheStandardPlanoptionwillbepaidfortheemployeeandenrolleddependentsforupto12monthsjustasiftheemployee’scoveragewerestillineffect.TheStandardPlanoptionisthedefaultuniversity-paidoption;DeluxePlanbenefitsmaybepurchasedonaself-paybasis.
However,thesebenefitswillbeavailableonlyifexpensesareforcoveredservicesandsuppliesthathavebeenren-deredand/orreceivedpriortotheendofthe12-monthperiod.
Suchbenefitswillbepaidforchargesincurreduntiltheearliestofthefollowing:
• oneyearfromthedatetheenrollee’scoverageterminatesforcomprehensivemedicalbenefits• thedateonwhichtheenrolleebecomescoveredunderanothergroupprogram• thedatetheenrolleeisnolongerdisabled• thedatetheenrollee’smaximumbenefitispaid
Thiscontinuedeligibilityrunsconcurrentwiththefirst12monthsofyourCOBRAeligibility.
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survivinG dependents
Intheeventofyourdeath,yoursurvivingenrolleddependentswillcontinuetoreceivethebenefitsoftheStandardPlanoptionforupto12months,atnocosttothesurvivingdependents.TheStandardPlanoptionisthedefaultuni-versity-paidoption;DeluxePlanbenefitsmaybepurchasedonaself-paybasis.
However,thesebenefitswillbeavailableonlyifexpensesareforcoveredservicesandsuppliesthathavebeenren-deredand/orreceivedpriortotheendofthe12-monthperiod.
Suchbenefitswillbepaidforchargesincurreduntiltheearlierofthefollowing:
• The12-monthperiodends• Adependentbecomescoveredunderanothergroupmedicalprogram• Dependentcoverageceasesunderthisprogram• Forthespouse,whenheorsheremarries• Forachild,whenheorsheisnolongereligibleasadependent
Thiscontinuedeligibilityrunsconcurrentwiththefirst12monthsoftheirCOBRAeligibility.Ifcoverageisbeingcontinuedforyourdependents,yourchildbornafteryourdeathwillalsobecovered.
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GENERAL LIMITATIONS AND EXCLUSIONS
Thissectionofyourhandbookoutlinescircumstancesinwhichbenefitsofthisprogramarelimitedorinwhichnobenefitsareprovided.BenefitscanalsobeaffectedbyBlueCross’CareManagementprovisionsandyoureligibility.Inaddition,somebenefitshavetheirownspecificlimitations.
WHat Your proGram does not Cover
Inadditiontothespecificlimitationsstatedelsewhereinthisprogram,benefitswillnotbeprovidedforthefollow-ing:
• Servicesandsuppliesdirectlyrelatedtoanycondition,service,orsupplythatisnotcoveredunderthisprogram• Servicesandsuppliesreceivedororderedwhenthisprogramisnotineffect,orwhenyouarenotcoveredunder
thisprogram,exceptasstatedunderspecificbenefitsandunder“ExtendedBenefits”• Servicesandsuppliesforwhichnochargeismade,forwhichnonewouldhavebeenmadeifthisprogramwere
notineffect,orforwhichyoudonotlegallyhavetopay,unlessbenefitsmustbeprovidedbylawinthecaseoffederallyqualifiedhealthcenterservices
• Servicesandsuppliesthatareoutsidethescopeoftheprovider’slicense,registration,orcertification,orthatarefurnishedbyaproviderthatisnotlicensed,registered,orcertifiedbythejurisdictioninwhichtheservicesorsupplieswerereceived
• Servicesandsuppliesthatyoufurnishtoyourselforthatarefurnishedtoyoubyaproviderwholivesinyourhomeorisrelatedtoyoubyblood,marriage,oradoption;examplesofsuchprovidersareyourspouse,parent,or child
• Servicesandsuppliesthatarenotmedicallynecessary,inthejudgmentofBlueCross,eveniftheyarecourt-or-dered;thisalsoincludesplacesofservice,suchasinpatienthospitalcare
• Servicesandsuppliesthatareforyourconvenienceorthatofyourfamily;servicesofapersonalnature,suchasmealsforguests,long-distancetelephonecharges,radioortelevisioncharges,orbarberorbeauticiancharges
• Anydirectcomplications,consequences,oraftereffects,whetherimmediateordelayed,thatarisefromanycondition,service,orsupplythatisnotcoveredunderthisprogram,exceptasspecificallystatedinthisprogram
• Amountsthatexceedtheallowablechargeormaximumbenefitforacoveredservice• Separatechargesforrecords,correspondenceorreports,exceptthoserequestedforutilizationreview• Custodialcare,exceptasspecifiedintheHospiceBenefit• AnyserviceorsupplythatBlueCrossdeterminesisexperimentalorinvestigationalonthedateitisfurnished;
thedeterminationisbasedonthecriteriastatedinthedefinitionof“Experimental/Investigational” IfBlueCrossdeterminesthataserviceisexperimentalorinvestigational,andthereforenotcovered,youmay
appealthedecision.Pleasereferto“YourQuestions,ComplaintsandAppeals”foranexplanationoftheappealsprocess.
Note:thisexclusiondoesnotapplytocertainexperimentalorinvestigationalservicesprovidedaspartofoncol-ogyclinicaltrials.Benefitdeterminationisbasedonthecriteriaspecifiedinthedefinitionof“OncologyClinicalTrials”intheGlossaryofTermssection.
• Carerenderedbyanymedicalfacilitythatisownedoroperatedbyagovernmentagencytotheextentrequiredbystateandfederallaw;however,thisexclusiondoesnotapplytocoveredservicestotreatamedicalemer-gency,ortocoveredservicesforwhichavailablebenefitsmustbeprovidedbylaworregulation.
• Counseling,education,ortrainingservices,exceptasstatedundertheHealthManagement,NutritionalTherapyandtheMentalHealthCareBenefit,servicesrelatedtocontraceptivemanagementandthesupportservicesstatedintheChemicalDependencyTreatmentBenefitorforservicesthatmeetthestandardsforpreventive
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medicalservicesinthePreventiveMedicalCare(Wellness)Benefit.Thisincludesvocationalassistanceandoutreach;andfamily,marital,social,sexual,lifestyle,nutritional,andfitnesscounseling
• Communitywellnessclassesandprogramsthatpromotepositivehealthandlifestylechoices.Examplesoftheseclassesandprogramsareadult,childandinfantCPR,safety,baby-sittingskills,backpainprevention,stressmanagement,bicyclesafetyandparentingskills.
• Habilitative,education,ortrainingservicesorsuppliesfordyslexia,forattentiondeficitdisorders,andfordisordersordelaysinthedevelopmentofachild’slanguage,cognitive,motor,orsocialskills,includingevalua-tionstherefor;however,thisexclusiondoesnotapplytotreatmentofneurodevelopmentaldisabilitiesundertheRehabilitationTherapy,ChronicPainCare,AndNeurodevelopmentalTherapyBenefit
• Therapydesignedtoprovideachangedorcontrolledenvironment• Cosmeticservicesandsupplies(includingreconstructivesurgeryanddrugs)orotherservicesandsupplies
whichimprove,alterorenhanceappearance,except that benefits will be provided for the following:• Allstagesoftherepairofadefectthatistheresultofanaccidentalinjuryifthesurgeryisperformedinthe
calendaryearoftheaccidentorinthenextcalendaryear• Allstagesoftherepairofadependentchild’scongenitalanomaly• ReconstructivebreastsurgeryinconnectionwithamastectomyasprovidedundertheMastectomyand
BreastReconstructionServicesbenefit• Allstagesoftherepairofamalformationthatisadirectresultofadisease,orsurgeryperformedtotreata
disease or injury• CorrectionoffunctionaldisordersuponBlueCross’reviewandapproval
• Hairprosthesis,suchaswigsorairweaves,transplants,andimplants,exceptasstatedintheProstheticDevicesbenefit;drugs,supplies,equipmentorprocedurestoreplacehair,slowhairloss,orstimulatehairgrowth
• Treatmentofobesityandservicesandsuppliesconnectedwithweightlossorweightcontrol,exceptasspecifiedunder Morbid Obesity
• Routineorpalliativefootcare,includinghygieniccare;impressioncastingforprostheticsorappliancesandpre-scriptionstherefor,exceptasspecifiedunderthe“HomeMedicalandRespiratoryEquipment/MedicalSupplies”benefit;fallenarches,flatfeet,careofcorns,bunions(exceptforbonesurgery),calluses,andtoenails(exceptforingrowntoenailsurgery),andothersymptomaticfootproblems.However,thisexclusiondoesn’tapplytoservicesandsuppliesthatmeettherequirementsforpreventivemedicalservicesasdescribedinthePreventiveMedicalCare(Wellness)Benefit.
• Diagnosisandtreatmentofsexualdisordersanddefects,whetherornottheyaretheconsequenceofillnessorinjury;examplesareimpotence,frigidity,andinfertility
• Assistedfertilizationtechniques,regardlessofreasonororiginofcondition,includingbutnotlimitedtoartifi-cialinsemination,in-vitrofertilization,andgameteintra-fallopiantransplant(GIFT)
• Reversalofsurgicalsterilization• Treatmentorsurgerytochangegender• Militaryandwar-relatedconditions,includingillegalacts.Thisincludes:
• Actsofwar,declaredorundeclared,includingactsofarmedinvasion• Serviceinthearmedforcesofanycountry,includingtheAirForce,Army,CoastGuard,Marines,National
Guard,Navy,orcivilianforcesorunitsauxiliarythereto• anenrollee’scommissionofanactofriotorinsurrection• anenrollee’scommissionofafelonyoractofterrorism
• Treatmentofcaffeinedependency,exceptforservicescoveredundertheHealthManagementBenefit• Treatmentofnicotinedependence,exceptforservicescoveredundertheHealthManagementBenefit,andas
specifiedinthePharmacyDrugBenefit• Anyillnessorinjuryarisingoutoforinthecourseofemploymentorself-employmentforwagesorprofit;for
whichtheenrolleeisentitledtoreceivebenefits,whetherornotaproperandtimelyclaimforsuchbenefitshasbeenmadeunder:
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• Occupationalcoveragerequiredof,orvoluntarilyobtainedby,theemployer• Stateorfederalworkers’compensationacts,or• anylegislativeactprovidingcompensationforwork-relatedillnessorinjury
• Servicesorsuppliestotheextentthatbenefitsarepayableunderthetermsofanycontractorinsuranceofferingoneofthesecoverages:• Motorvehiclemedical,motorvehicleno-fault,orpersonalinjuryprotection(PIP)coverage• Commercialpremisesorhomeowner’smedicalpremisescoverage,orothersimilartypeofcontractor
insurance• Servicesandsuppliesthatarenotdirectlyrelatedtoanillness,accidentalinjury,ordistinctphysicalsymptoms,
exceptasspecifiedundertheRoutineNewbornCareBenefit,theWellnessProvisionsBenefit,Physicians’ServicesBenefit,DiagnosticServicesBenefit,ortheDiagnosticandScreeningMammographyBenefit
• Well-babycare,exceptfortheservicesprovidedundertheRoutineNewbornCareBenefitandthePreventive(Wellness)Benefit
• Visiontherapy,eyeexercise,oranysortoftrainingtocorrectmuscularimbalanceoftheeye(orthoptics),andpleoptics;alsonotcoveredaretreatmenttochangetherefractivecharacterofthecornea;examplesareradialkeratotomy,keratomileusis,orrefractivekeratoplasty,includinganyresultsofsuchtreatment;routinevisionservicesandsupplies,includingservicesofanoptician,arenotcoveredexceptasspecifiedintheVisionBenefit
• Routinehearingcare,includinghearingexaminations,diagnosticscreenings,andtests;servicesandsuppliesfororrelatedtohearingaidsorotherdevicestoimprovehearingsharpnessexceptasspecifiedintheAudioCareBenefit
• Birthcontroldevices,exceptasstatedundertheContraceptiveManagementandSterilizationandthePharmacyDrugBenefit
• Over-the-counterdrugs,foodsupplements,andsupplies,exceptasspecifiedunderthePharmacyDrugBenefit• Vitamins,exceptforpre-natalandfluoridatedvitamins• Dentalservices,exceptasspecifiedundertheDentalCareBenefit,andexceptthoseperformedinconjunction
withtreatmentthatisthedirectresultofanaccidentalinjurytonaturalteeth,gums,orjaw,butonlywhenallofthefollowingrequirementsaremet:• theservicesarewithinthescopeoftheprovider’slicense;• theinjuryisnotcausedbybitingorchewing,evenifduetoaforeignobjectinfood;• theservicesareperformedintheplanyearoftheaccidentorinthenextplanyear;• forservicesprovidedtoanaturaltooth,thetoothmustbetheenrollee’snatural,livingtooththatwasfree
fromdecayandotherwisefunctionallysoundatthetimeoftheinjury.“Functionallysound”meansthattheaffected teeth:• donothaveextensiverestoration,veneers,crownsorsplints;and• donothaveperiodontaldiseaseorotherconditionthat,inthejudgmentofBlueCross,wouldcausethe
toothtobeinaweakenedstatepriortotheinjury.• theservicesare,inthejudgmentofBlueCross,essentialandappropriatetotherepairoftheaccidental
injury(treatmentplanreviewwillbeperformedbyadentistlicensedtopracticedentistryintheStateofAlaska);and
• themaximumbenefitsundertheDentalBenefitfortheaccidentalinjuryhavebeenprovided.• Orthodontia,includingcasts,models,X-rays,photographs,examinations,appliances,braces,andretainers,ex-
ceptinthecaseofaccidentalinjuryasdescribedabove,andasstatedundertheOrthodontiaBenefitofthe500Plan option
• Hospitalcarefordentalprocedures,unlessadequatetreatmentcannotbeprovidedwithouttheuseofhospitalfacilities,andyouhaveamedicalconditionbesidestheonerequiringtreatmentthatmakeshospitalcaremedi-cally necessary
• Treatmentofpsychiatricconditionsandeatingdisorders,suchasanorexianervosa,bulimia,oranysimilarcon-ditions,exceptasspecifiedundertheMentalHealthCareBenefit
• Electronic,on-lineorinternetmedicalconsultationsorevaluations.
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GENERAL PROVISIONS
enrollee Cooperation
Allenrolleesareduty-boundtocooperateinatimelyandappropriatemannerwiththeUniversityandPremeraBlueCrossBlueShieldofAlaskaintheadministrationofbenefitsorintheeventofalawsuit.
notiCe oF otHer CoveraGe
AsaconditionofreceivingbenefitsundertheUniversity’shealthcareprogram,youmustnotifyBlueCrossofthefollowing:
• AnylegalactionorclaimagainstanotherpartyforaconditionorinjuryforwhichBlueCrosspaidbenefits;andthenameandaddressofthatparty’sinsurancecarrier
• Thenameandaddressofanyinsurancecarrierthatprovidespersonalinjuryprotection(PIP),underinsuredmotorist,uninsuredmotorist,oranyotherinsuranceunderwhichyouareormaybeentitledtorecovercompen-sation
• Thenameofanyothergroupinsuranceplan(s)underwhichyouarecovered
evidenCe oF mediCal neCessitY
PremeraBlueCrossBlueShieldofAlaskahastherighttorequireproofofmedicalnecessityfromyouoryourproviderwhenyouarereceivingbenefitsunderthisprogram.Nobenefitswillbeavailableunderthisprogramiftheproof is not provided or not acceptable to the plan.
notiCe oF inFormation use and disClosure
PremeraBlueCrossBlueShieldofAlaskamaycollect,use,ordisclosecertaininformationaboutyou.Thispro-tectedpersonalinformation(PPI)mayincludehealthinformation,orpersonaldatasuchasyouraddress,telephonenumberorSocialSecurityNumber.BlueCrossmayreceivethisinformationfrom,orreleaseitto,healthcarepro-viders,insurancecompanies,orothersources.Thisinformationiscollected,usedordisclosedforconductingroutinebusiness operations such as:
• underwritinganddeterminingyoureligibilityforbenefitsandpayingclaims(BlueCrossdoesnotusegeneticinformationforunderwritingorenrollmentpurposes);
• coordinatingbenefitswithotherhealthcareplans;• conductingcaremanagement,casemanagementorqualityreviews;and• fulfillingotherlegalobligationsthatarespecifiedundertheplanandtheadministrativeservicescontractwith
theUniversityofAlaska.
Thisinformationmayalsobecollected,used,ordisclosedasrequiredorpermittedbylaw.
Tosafeguardyourprivacy,BlueCrosstakescaretoensurethatyourinformationremainsconfidentialbyhavingacompanyconfidentialitypolicyandbyrequiringallemployeestosignit.IfadisclosureofPPIisnotrelatedtoaroutinebusinessfunction,BlueCrossremovesanythingthatcouldbeusedtoeasilyidentifyyouortheyobtainyourpriorwrittenauthorization.Youhavetherighttorequestinspectionand/oramendmentofrecordsretainedbyBlue
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CrossthatcontainyourPPI.PleasecontactBlueCrossCustomerServiceandaskthatarequestformbemailedtoyou.
riGHt to and paYment oF BeneFits
Allrightstothebenefitsofthisprogramareavailableonlytomembers.
However,BlueCross,onbehalfoftheplan,willhonorsubscribers’requeststoassignbenefitpaymentstothepro-viderwhofurnishedthecarewhensuchrequestsdonotconflictwithBlueCross’obligationsundertheirprovideragreements.BlueCrosswillalsohonorsuchassignmentsonbehalfoftheplanwhentheyaremadebyathirdpartytowhomtherighttomakesuchassignmentshasbeenclearlydesignatedinavalidqualifieddomesticrelationsorder.Tofindouthowtomakeassignments,pleasecallCustomerServiceatthenumbersshownin“YourQuestions,ComplaintsandAppeals”sectionofthisHandbook.BlueCrosswillnothonoranyotherattemptedassignment,garnishment,attachmentortransferofanyrightofthisprogram.
AtBlueCross’optionandinaccordancewiththisprovision,BlueCrosshastherighttodirecttheplan’sbenefitstothesubscriber,provider,othercarrier,member,orotherpartylegallyentitledtosuchpaymentunderfederalorstatemedicalchildsupportlaws,orjointlytoanyofthese.Suchpaymentwilldischargetheplan’sobligationtotheextentoftheamountpaidsothattheplanwillnotbeliabletoanyoneaggrievedbytheirchoiceofpayee.
riGHt oF reCoverY
Onbehalfoftheplan,PremeraBlueCrosshastherighttorecoveramountstheplanhasoverpaidinerror.Suchamountsmayberecoveredfromtheemployee/subscriberoranyotherpayee,includingaprovider.Or,suchamountsmaybedeductedfromfuturebenefitsofthesubscriberoranyofhisorherdependents(eveniftheoriginalpay-mentwasnotmadeonthatmember’sbehalf)whenthefuturebenefitswouldotherwisehavebeenpaiddirectlytothesubscriberortoaproviderthatdoesnothaveacontractwithBlueCross.Theplanmayalsoexercisetherighttodelegateallorpartoftheresponsibilityforrecoveriestoanotherthirdparty.
venue
Allsuitsorlegalproceedings,includingarbitrationproceedings,broughtagainsttheUniversityofAlaskaand/orBlueCrossBlueShieldofAlaskabyyouoranyoneclaiminganyrightunderthisprogrammustbefiled:
• within3yearsofthedateBlueCrossdenied,inwriting,therightsorbenefitsclaimedunderthisprogram;and• inamutuallyagreeduponlocation.
Workers’ Compensation insuranCe
Thiscontractdoesnotreplace,affect,orsupplementanystateorfederalrequirementfortheUniversityofAlaskatoprovideworkers’compensationinsurance,employer’sliabilityinsuranceorothersimilarinsurance.
intentionallY False or misleadinG statements
Ifthisprogram’sbenefitsarepaidinerrorduetoanyintentionallyfalseormisleadingstatements,theplanwillbeentitledtorecovertheseamountsonbehalfoftheUniversityofAlaska.See“RightOfRecovery”above.
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Please Note: your coverage cannot be voided (in other words, cancel back to it’s effective date as if it had never existed at all) based on a misrepresentation you made unless you have performed an act or practice that constitutes fraud; or made an intentional misrepresentation of material fact that affects your (or your depen-dent’s) acceptability for coverage.
limitations oF liaBilitY
Theplan,theUniversityofAlaskaandBlueCrossarenotliableforanyofthefollowing:
• Situationssuchasepidemics,disasters,orothercausesorconditionsbeyondtheircontrol,thatpreventenrolleesfromobtainingthebenefitsofthiscontract
• Thequalityofservicesorsuppliesreceivedbyenrollees,ortheregulationoftheamountschargedbyanypro-vider,becauseallthosewhoprovidecaredosoasindependentcontractors
• Harmthatcomestoanenrolleewhileinaprovider’scare• Amountsinexcessoftheactualcostofservicesandsupplies• Amountsinexcessofthisprogram’smaximums;thisincludesrecoveryunderanyclaimofbreach• Generaldamagesincluding,withoutlimitation,allegedpain,suffering,ormentalanguish
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FLEXIBLE SPENDING ACCOUNTS
introduCtion
Thehighcostsofhealthcareanddependentcarearen’tgoingaway.Howcanyougetthecareyouneedandkeepmoremoneyinyourpocket?OpenaFlexibleSpendingAccount(FSA).TheseIRS-approvedaccountsallowyoutosetasideaportionofyourtaxableincomepriortopayingtaxes.Then,asyouincureligibleexpenses,yourequesttax-freewithdrawalsfromyouraccounttoreimburseyourself.TherearetwokindsofFSAs:aMedicalFSAandaDependentCareFSA.TheseflexiblespendingaccountsareadministeredbyFringeBenefitsManagementCompany,aDivisionofWageWorks.
BeneFits
BeginningonyoureffectivedateinthePlan,youmaychoosetoreduceyoursalarytopayforthefollowingtax-freebenefits:
• Medical FSA—Allowsyoutopayforyourmedical,dentalandvisionout-of-pocketexpensesbeforetaxes.Employeescancontributeamaximumof$5,000perPlanYear.
• Dependent Care FSA—Allowsyoutopayforemployment-relateddaycareexpensesbeforetaxes.Youmaycontributeamaximumof$5,000perPlanYear($2,500,ifmarried,filingseparately).
plan Year
ThePlanYearforboththeMedicalFSAandtheDependentCareFSArunsfromJuly1throughJune30.AllclaimsmustbesubmittedbySeptember30followingtheendoftheplanyear.
eliGiBilitY
Ifyouarearegularorterm-fundedemployeeandeligibletoparticipateintheUniversity’shealthcareplan,youareeligibletoparticipateintheFSAPlan.Currentemployeeshavetheopportunitytoelectaflexiblespendingaccounteitherduringopenenrollmentorwithin30daysafteramajorlifeevent.
enrollment
Tobecomeaparticipant,youmustfilloutandsigntheappropriateform.Ifyouareanewemployee,thisformshouldbecompletedandsignedpriortoreceivingyourfirstpaycheck,butnolaterthan30daysafteryoubecomeeligible.
IfyouwillbeaneligibleemployeeonJuly1,youreffectivedatewillbeJuly1.IfyoubecomeaneligibleemployeeafterJuly1,youreffectivedatewillbethedateyoubecomeeligibletoparticipate.IfyouelectanFSAbecauseofaneligiblemajorlifeevent,youreffectivedatewillbethedateofyourlifeevent.Yourpayrollreductionswillstartonthefirstpaydayonorafteryoureffectivedate.
You mustcompleteandsignanewelectionformduringtheopenenrollmentperiodforeachnewPlanYear.Ifyoudonotcompletetheappropriateformasindicatedabove,youwillnotbeeligibletoparticipateintheplanuntilthefollowingJuly1,unlessyouhaveamajorlifeevent.
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major liFe event
OnceyouhaveenrolledinthePlan,youcannotrevoke,discontinue,orchangeyourelectionforthedurationofthePlanYearunlessyouhaveaqualifiedchangeinfamilystatus,ormajorlifeevent.Ifyouhaveamajorlifeevent,youareallowedtochangeyourelectionprovidingthechangeisappropriateandconsistentwithyourlifeevent.
Someexamplesofmajorlifeeventsareasfollows:
• Marriageordivorceoftheemployee• Birthoradoptionofachild• Terminationorcommencementofyourspouse’semployment• Deathofaspouseorchild• Reductionorincreaseinhoursofyouroryourspouse’semployment
Contactyourregionalhumanresourcesofficeimmediatelyifyouexperienceamajorlifeeventandwouldliketochangeyourelection.Youmustnotifyyourregionalhumanresourcesofficewithin30daysofyourmajorlifeevent.Theeffectivedateofthechangewillbethedatethemajorlifeeventoccurred.
IfyouelecttoreducethecontributiontoyourMedicalFSAduetoamajorlifeevent,yourannualcontributionamountwillberecalculatedandreducedbasedonyournewelectionregardlessoftheamountofreimbursementsmadetoyou.IfyouelecttoincreasethecontributiontoyourMedicalFSAduetoamajorlifeevent,yourannualcontributionamountwillberecalculatedandincreasedbasedonyournewelectionregardlessoftheamountofreim-bursementsmadetoyou.
termination oF BeneFits
YouwillremainaparticipantintheFSAPlanuntiltheearliestofthefollowingdates:
• Thedateyouarenolongeraneligibleemployee(throughterminationortransfertoanineligibleposition)• ThedateyoustopparticipatinginthePlanbecauseofamajorlifeevent• ThedatethePlanYearends(June30)• ThedatethePlanends
use it or lose it rule
TheIRShasestablishedstrictguidelinesforflexiblespendingaccounts.Oneoftheguidelinesisknownasthe“useitorloseit”rule.ThismeansthatifyouelecttocontributemoneytoaFlexibleSpendingAccount,andthendonotincurenoughexpensesduringthePlanYeartomeettheamountyouelected,youwilllosetheunusedmoney.IfyouleavetheUniversityduringthePlanYear,youmaycontinuetosubmitclaimsandbereimbursedduringtheremain-derofthePlanYear;however,thedatesofserviceyouaresubmittingmusthavebeenpriortoyourtermination.Bylaw,anyforfeitedamountwillrevertbacktotheUniversitytocoveradministrativecostsassociatedwiththeFSAPlan.
BeconservativewhendeterminingtheamountyouwanttoputintoyourMedicaland/orDependentCareFSA.
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mediCal FleXiBle spendinG aCCount
Ifyouknowyouwillhaveout-of-pockethealthcareexpensesduringthePlanYear,youmayelecttosetupaMedi-calFSAtopayforthoseexpenseswithtax-freedollars.Afteryoudeterminetheamountyouwanttocontribute,theUniversitywilldeductasetdollaramounteachpayperiod,onapre-taxbasis,untilyouhavereachedyourannualgoalamount.ThemoneywillbeplacedinyourMedicalFSA,withthetotalannualgoalamountavailabletoyouatanytimeduringyourperiodofcoverage.It’slikeacashadvancebecauseyoudon’thavetowaitforthecashtoac-cumulateinyouraccountbeforeyoucanuseit.
AsyourhealthcareclaimsareprocessedbyBlueCross,yourout-of-pocketexpenseswillbeeligibleforreimburse-mentfromyourMedicalFSA.IfyouhaveexpensesthatarenotsubmittedtoBlueCrossbecausetheyarenoteli-gibleunderyourhealthplan,oryouhavesecondaryhealthcareinsurance,youmaysubmitacopyoftheprovider’sbillingoracopyoftheExplanationofBenefits(EOB)fromBlueCross(andanyotherinsuranceyoumayhave)withacompletedFSAReimbursementRequestFormforreimbursement.Pleasesee“HowToSubmitaReimburse-mentClaim”fordetailedinstructions.
Please note:premiumsforcontinuedcoverageunderCOBRAarenotaneligibleexpenseforyourMedicalFSA.
eliGiBle eXpenses
Healthcareexpensesthatareeligibleforreimbursement,perIRSregulations,areexpensesincurredbyyou,oryourspouseordependent(s),formedicallynecessaryservicesasdefinedinSection213oftheIRSCode.Yourdepen-dentsdonothavetobeenrolledinthehealthcareplantobeeligibleforthisplan,buttheydoneedtobedependentsasdefinedbyIRSCode.Taxable financially interdependent partners are not eligible for this plan.Expensesaretreatedashavingbeenincurredwhenthemedicalcarewasgiven,notthedateyouwerebilledorcharged,orthedateyoupaidfortheservices.Inaddition,theexpensemustnotbeeligibleforreimbursementfromanyotherhealthplan.
EffectiveJanuary1,2011,changestofederallawlimitsthereimbursementofover-the-counter(OTC)medica-tionstorequireaprescriptionororderfromyourphysician.Thischangedoesnotapplytoitemslikewristsplints,band-aids,magnifyingreaders,incontinenceproductsanddurablemedicalitemssuchascanesandcrutches.FringeBenefitsManagementCompanymaintainsacurrentlistofeligibleOTCmedicationsatwww.fbmc-benefits.com;itisyourresponsibilitytocheckthelistregularlyforupdates.AllclaimsforOTCmedicineexpensereimbursementmustincludeaprescriptionororderfromyourphysicianandadetailedreceiptshowingthepurchasedateandnameofthemedicine.
Someexamplesofeligibleexpensesare:
• Yourout-of-pocketexpenses,suchasdeductibles,coinsuranceandcopays• Hearingaids• Orthodontics• Dentures• Chargesovertheallowedamount• Acupuncture• Alcoholandsubstanceabusetreatmentchargesnotcoveredunderyourhealthplan• Naturopathy• Biofeedback• Psychiatriccarenotcoveredbyyourhealthplan• Eyeexaminationchargesnotcoveredbyyourvisionplan• Homehealthcare
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• Contactlensesandglasses• Experimentalorinvestigativetreatments• Certainover-the-counteritems(seelistofeligibleitemsatwww.fbmc-benefits.com)• Contactlenscleaningandsalinesolutions
SomeexpensesthatarenoteligibleforreimbursementfromyourMedicalFlexibleSpendingAccountinclude:
• Servicesforpurelycosmeticpurposes• VitaminormineralsupplementsnotcoveredbyBlueCross• ServiceswithdatesofserviceoccurringpriortoyoureffectivedateorafterthecloseofthePlanYear• Weightlossprogramsforgeneralhealthpurposes,evenifprescribedbyyourdoctor• Insurancepremiums(includingpremiumsforcontinuingcoverageunderCOBRA)• Exerciseequipmentforgeneralhealthpurposes,evenifprescribedbyyourdoctor• ClaimssubmittedwithoutafullycompletedReimbursementRequestForm,alongwithacopyofanexplanation
ofbenefitsfromyourinsurancecompany,oraprovider’sbillingshowingdatesofserviceandcharge
dependent Care FleXiBle spendinG aCCount
Ifyouknowyouwillhaveemployment-relateddependentdaycareexpensesforaneligibledependentduringthePlanYear,youmayelecttousetheDependentCareFSAtopayforthemwithtax-freedollars.Thismaybedoneonlyiftheexpensesareincurredtoallowyou(andyourspouse,ifapplicable)towork.Themaximumamountyoumaycontributetotheplaninaplanyearis$5,000($2,500ifmarriedandfilingseparately);orifyouoryourspouseearnslessthan$5,000ayear,yourmaximumcontributionisequaltothelowerofthetwoincomes.Ifyourspouseisafull-timestudentorincapableofself-care,yourmaximumcontributionamountis$2,400ayearforonedependentand$4,800ayearfortwoormoredependents.
Aneligibledependentfallsunderoneofthesetwocategories:
• Youoryourspouse’schild(dependingonthetaxstatusofthatdependent)whoisunder13yearsofage• Yourspouse(orotherindividualclaimedasadependentforfederaltaxpurposes)whoisphysicallyormentally
incapableofself-careandwhoregularlyspendsatleasteighthoursadayinyourhome
Dependentcarecanberenderedeitherinsideoroutsidethehome.Ifcareoutsidethehomeisprovidedbyadepen-dentcarecenterthatcaresforsevenormorechildren,itmustcomplywithallapplicablestateorlocallawsandregulations.Also,theprovidermustnotbeyourchildage18oryounger,orsomeonewhoyouclaimasadependentforfederalincometaxpurposes.
AfteryoudeterminetheamountofdependentcareexpensesyouwillincurduringthePlanYear,theUniversitywilldeductaportioneachpayperiod,onapre-taxbasis,untilyouhavereachedyourannualgoalamount.ThemoneywillbeplacedinyourDependentCareFSA,tobereimbursedtoyouasyouincurdependentcareexpenses.Pleasesee“HowToSubmitaReimbursementClaim”fordetailedinstructions.
Dependingonyourincomelevel,youmayalsousetheFederalIncomeTaxCreditfordependentcareexpenses.Itisimportanttorememberthatyoumayuseeitheroftheseuptothemaximumallowable,butyoumaynottakeataxdeductionforthoseexpensesreimbursedunderthisplan,orviceversa.SeeIRSPublication503oryourtaxadvisorformoredetails.
UnliketheMedicalFSA,anyreimbursementwillnotexceedthebalanceavailableinyouraccountwhenyourclaimisreceived.Dependentcareservicesmusthavebeenincurredtoreceivereimbursement,regardlessofwhenyoupayfor the service.
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HoW to suBmit a Claim For reimBursement
mediCal Fsa Claim suBmissions
It’seasytosubmitaclaimtoFringeBenefitsManagementCompany.JustcompleteaFlexibleSpendingAccountReimbursementRequestFormalongwiththeExplanationofBenefits(EOB)fromBlueCross(andanyotherinsur-anceyoumayhave)forservicescoveredbythehealthcareplan,oradetailedreceiptwithactualdateofservice,nameandaddressoftheprovider,descriptionoftheservicesrenderedandactualamountchargedfornon-coveredservices to FBMC.
Remember, to be reimbursed for your out-of-pocket expenses you must submit a claim form. If you have ques-tionsaboutyourclaim,callFBMCCustomerServiceat(800)342-8017,from4a.m.to6p.m.AlaskaTime.
PleasecompleteallsectionsoftheclaimformsothatFBMCcanprocessyourclaim.Ifyoufailtocompletetheforminfulland/oryoudonotprovideanExplanationofBenefitsoritemizedbillingshowingdatesofserviceandcharge,yourclaimwillbedelayedordenied.
dependent Care Fsa Claim suBmissions
CompleteaFlexibleSpendingAccountReimbursementRequestFormalongwiththereceiptsfromyourdependent/childcareprovidershowingthename,addressandtaxIDnumber(orSocialSecuritynumber)oftheprovider,andbeginningandenddatesofservice.Ifyourproviderisanindividual,theymustsignthereceipt.Inlieuofaseparatereceipt,yourdaycareprovidermaysigntheClaimForm.
Mailyourclaimstothisaddress:
Fringe Benefits Management CompanyA Division of WageWorks
POBox1800TallahasseeFL32302-1800
Oryoucanfaxyourclaimtollfreeto(866)440-7145,orsubmityourclaimonline.Seemyfbmc.comfordetails.
PleaseretainoriginalsofallclaimsanddocumentationforIRSpurposes.ItisyourresponsibilitytoprovidetheclaimsinformationifyouareauditedbytheIRS.
questions reGardinG Your plan?
IfyouneedadditionalinformationaboutyourFlexibleSpendingAccountsPlan,pleasecontacttheFBMCCustomerServiceDepartmentat(800)342-8017.
CoBra riGHts
TotheextentrequiredbytheConsolidatedBudgetReconciliationActof1985(COBRA,codifiedunderCodeSection4980B),theParticipant,Spouse,andDependents,whosecoverageterminatedunderthePlanbecauseofaCOBRAqualifyingevent,shallbegiventheopportunitytocontinuetheircoverageundertheMedicalReimburse-mentPlanonanafter-taxbasisforthetimeperiodprescribedbyCOBRA,subjecttoallconditionsandlimitationsunder COBRA.
IfyouhavequestionsaboutthePlan,youshouldcontactyourregionalhumanresourcesoffice.
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EMPLOYEE ASSISTANCE PROGRAM
TheUniversityoffersanEmployeeAssistanceProgram(EAP)toallitsregularfull-orpart-timefacultyandstaffandtheirdependents,aswellasCOBRAparticipants.TheUniversityoffersthisprogrambecausefromtimetotime,anyonecanbeburdenedbythepressuresoflife.Suchburdenscanaffectyourhealth,familylife,abilities,andworkperformance.
Maintainingahealthybalancebetweenyourworkandpersonallifeisimportanttoyou.Atworkandhome,ourlivesarebusierthanever,andattimes,weallcanusealittleextrahelpincopingwithpersonalchallenges.YourEAPprovidesyouandyourfamilywithshort-term,person-to-personcounselingservicestohelpyouhandleconcernsbeforetheybecomemajorissues.
Toprovideyouwithafull-servicebenefitthatyouandyourfamilycaneasilyaccessasyouneedit,theUniversityofAlaskaselectedComPsych,oneofthenation’sleadingindependentprovidersofEAPservices.
Professionalcounselorsareavailable24hoursaday,7daysaweektohelpyouwithissuessuchas
• Joborworkstress• Family/Parentingissues• Alcohol,drugsandothersubstanceabuse• Burnout• Maritalorrelationshipproblems• Anxietyordepression
• Angermanagement• Legalissues• Financialconcerns• Copingwithchange• Self-esteem• Grieforbereavement
Crisiscounselingisalwaysavailabletoprovideyouwithassistanceyouneedwhenyouneedit.ComPsychalsoof-fersfree,easy-to-usepersonalhelpwithchildandeldercareservices.
AllEAPcounselorsarefullyqualifiedandlicensedintheirareaofservice.Theprogram’sstaffincludeslicensedpsychologists,socialworkers,marriageandfamilycounselors,andlawyers.Theidentityofthepeoplewhoelecttousethisprogram,aswellasanyinformationrevealedtoEAPstaff,isheldinthestrictestprofessionalconfidenceallowedbylaw.
HoW to use tHe proGram
YouoryoureligiblefamilymembersmaycontactComPsych,theGuidanceResourcesCompany,directlyanytime,24hoursaday,7daysaweek,at(866)465-8934foranyreasonandtalktoatrainedcounselor.Thesecounselingprofessionalscanassistyouandguideyoutoin-personcarewithanexpertinyourarea.TheEAPisstrictly confi-dential,asmandatedbylaw.
YoucanalsoaccessyourEAPservicesviatheWebwithGuidanceResourcesOnline.Gotowwwguidanceresources.comandentertheuniversityID:GC5901Q.Informationabouthealth,work-lifebalance,buyingcars,relocating,buyinganewhome,exerciseandfitness,lifeevents(suchasmarriage,havingoradoptingchildren,sendingchildrentocollege,divorce,deathofalovedone)andavarietyofothertopicsisjustaclickaway.
Formosttypesofproblems,youandyoureligibledependentsareentitledtoreceiveupto6counselingsessionsperincident.AllEAPsessionsareprepaidbytheUniversityofAlaska.IfyouwantcounselingbeyondthebenefitsoftheEAP,yourEAPcounselorcanhelpyouselectthemostcost-effectiveandappropriatetreatmentresources.
ContactyourlocalhumanresourcesofficeforfurtherinformationabouttheEmployeeAssistanceProgram.
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DISABILITY BENEFITS
introduCtion
TheUniversity’sdisabilityplanwillhelptoreplacelostincomefromseriousdisabilitiesthatlastlongerthan90days.TheLongTermDisabilityincomeplanpremiumispaidbytheUniversityonyourbehalf.TheUniversity’sLongTermDisabilityplanbenefitsareprovidedbyTheHartford.
Inadditiontothisplan,youmaybeentitledtodisabilitybenefitsfromthefollowingsources:
• othergroupinsurancecontracts• Workers’Compensation• benefitsprovidedbyanystateorfederalgovernment• anyretirementplanbenefittowardwhichtheUniversitycontributesormakespayrolldeductions(suchasPERS
orTRS)• leaveshareprogram(s)
Becausedisabilityinsuranceisdesignedtosupplementotherdisabilitybenefits,theamountpayableundertheLongTermDisabilityplanwillbereducedwhencoordinatedwithpaymentsfromothersources.
eliGiBilitY
Ifyouareanactiveregularorterm-fundedemployeeworkingatleast20hoursaweek,youareeligibleforLongTermDisabilitycoverage.Youreligibilitybeginsonthefirstdayofthemonthfollowingthedateyouarehired.Dis-abilitiesresultingfrompregnancyarecoveredonthesamebasisasanillnessorinjury.
deFinition oF disaBilitY
Duringthefirst36months,disabilitymeansthatyouareunabletoperformwithreasonablecontinuitytheessentialfunctionsofyourownoccupation.
AfteryoureceiveLongTermDisabilitybenefitsfor36months,youareconsidereddisabledifyouareunabletoperformtheessentialfunctionsofanygainfuloccupationforwhichyouarequalifiedbyeducation,experience,ortraining.
BeneFits
LongTermDisabilitybenefitsstartafteryouhavebeendisabledforthelongerofthesequalifyingperiods:
• 90days• thedurationofyouraccumulatedsickleaveplusanyleavebenefitsfromanyapplicableleaveshareprogram(s) Ifyouareabletoreturntoworkinsomecapacity,youmaystillbeeligibleforbenefits.
Periodsofdisabilityasaresultofthesamecauseorcausesareconsideredasingleperiodofdisability,providedtheyareseparatedbyarecoveryperiodoflessthan180days.
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Ifyouhavemorethanoneperiodofdisabilityandtheperiodsarefromdifferentcauses,theyareconsideredseparateperiodsofdisability.Eachperiodofdisabilityissubjecttoanewqualifyingperiodandtothemaximumdurationofthebenefit.
montHlY BeneFit amount
TheincomeyoureceivefromtheLongTermDisabilityplandependsuponyourmonthlyearningsatthetimeyouaredisabled.Themaximummonthlybenefitisthelesserofthefollowing:
• 60%ofyourmonthlyearnings• or$3,000
Themaximumdisabilitybenefitisreducedbybenefitsyoumayreceivefromothersources(seeBenefitOffsets).
Theminimummonthlybenefitis$100,regardlessofhowmuchyoureceivefromothersources.Ifyouaredisabledforlessthanafullmonth,yourbenefitswillbeproratedforthatmonth.
montHlY earninGs
Ifyouarecompensatedona12-monthbasis,monthlyearningsmeansyourcurrentrateofwagesorsalary,computedonamonthlybasis.Thisdoesnotincludeovertimepay,out-of-classearnings,overloadpay,additionalassignmentpay,bonuses,shiftdifferential,premiumpay,orotherspecialcompensation.Thefollowingrulesapplytothecom-putationofyourannualrateofearnings:
• Ifyouarepaidonanannualcontractbasis,yourannualrateofearningsisyourannualsalaryforyourprimaryassignment.
• Ifyouarepaidonanhourlybasis,yourannualrateofearningsisyourhourlyratetimesthenumberofhoursyouareregularlyscheduledtoworkeachyear.Ifyoudonothaveregularhours,yourannualrateofearn-ingswillbebasedonthenumberofmonthsyouworked,notcountinganyhoursover173inanyonecalendarmonth.
• Ifyouarepaidonanyotherbasis,yourannualrateofearningswillbethepayyoureceivedfortheperiodyouareregularlyscheduledtoworkeachyear.
Monthsinwhichyouwouldnototherwisereceiveasalaryarenotusedincomputingmonthlyearnings.Monthlyearningsarebasedonyoursalaryorwagesthelastdayyouareatworkbeforeyouweredisabled.
BeneFit oFFsets (inCome From otHer sourCes)
Ifyouarealsoeligibletoreceivedisabilitybenefitsfromanyofthefollowingsources,theamountyoureceivemaybesubtractedfromyourmonthlyLongTermDisabilitybenefit:
• Benefitsforlossoftimeprovidedbythefollowing:• Anyothergroup-sponsoreddisabilityinsurancecontract• Worker’scompensation,non-job-relateddisabilitybenefitlaws,orsimilarlegislation
• BenefitspayableundertheU.S.SocialSecurityAct(asaprimarybenefit),oranyotherbenefitsprovidedbyU.S.orCanadianlaw,orbyanystateorfederalregulation
• RetirementbenefitsthatareprovidedbythePublicEmployees’RetirementSystem,theTeachers’RetirementSystemortheUniversityofAlaskaOptionalRetirementPlan
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• Periodicbenefitsforlossoftimeinconnectionwithaccidentalbodilyinjuryorillness
Foracompletedescriptionofallbenefitoffsets,pleaseseetheLongTermDisabilitybenefitbooklet,onlineatwww.alaska.edu/benefits/long-term-disability.
reHaBilitation/return to Work inCentive
TheLongTermDisabilityplanincludesarehabilitation/returntoworkincentiveforupto12consecutivemonths.Yourmonthlybenefitwillcontinueaslongasthesumofyourcurrentmonthlyearningsandnetdisabilitybenefitdonotexceed100%ofyourpre-disabilityearnings.Ifthesumofyourmonthlybenefitandearningsexceeds100%ofyourpre-disabilityearnings,themonthlybenefitwillbereducedbytheamountoftheexcess.However,yourmonthlybenefitwillnotbelessthantheminimummonthlybenefit.
Youmaybeeligibleforaworkplacemodificationbenefit.IftheuniversityandtheHartfordagreetoworkplacemodificationstoreasonablyaccommodateyourreturntoworkandtheperformanceofyouressentialjobfunctions,benefitsuptothemonthlymaximumbenefitmaybepayabletoreimbursetheuniversityforsuchworkplacemodifi-cations.
lenGtH oF BeneFit paYments
Thelongestperiodforwhichdisabilitybenefitsarepayableforoneperiodofcontinuousdisabilityisdeterminedasfollows:
Your Age When Disability Begins YourMaximumBenefitPeriod
63yearsofageoryounger Tonormalretirementageor48months,ifgreaterAge63 Tonormalretirementageor42months,ifgreaterAge64 36monthsAge65 30monthsAge66 27monthsAge67 24monthsAge68 21monthsAge69orolder 18months
NormalRetirementAgemeanstheSocialSecurityNormalRetirementAge,determinedbyyourdateofbirth.Formoredetails,seethelong-termdisabilitybenefitbookletatwww.alaska.edu/benefits/long-term-disability.
limitation oF BeneFits
Benefitswillnotbepaidforanyperiodwhenyouarenotunderthecareofaphysician.
Ifadisabilityiscausedbyamentaldisorder,alcoholism,drugaddiction,orchemicaldependency,paymentofben-efitsislimitedto24monthsduringyourentirelifetime.
However,ifyouarearesidentpatientinahospitalattheendofthe24months,oryoubecomearesidentpatientinahospitalwithin6monthsofdischargefromapreviousconfinementforwhichLTDbenefitswerepayable,thislimitationwillnotapplywhileyouremaincontinuouslyconfined.
Paymentofbenefitsislimitedto12monthswhileyouarecontinuouslyresidingoutsideoftheUnitedStatesandCanada.
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lonG term disaBilitY eXClusions
YourLongTermDisabilityinsurancedoesnotcoveranydisabilitycausedorcontributedtobyself-inflictedinjury,waroranactofwar,yourcommittingorattemptingtocommitanassaultorfelony,oryouractiveparticipationinaviolent disorder or riot.
lonG term disaBilitY Claims
Notifyyourregionalhumanresourcesofficeimmediatelyofyourdisabilityandobtainaclaimform.Completedformsaretobereturnedtothatofficefortransmittaltotheinsurancecarrier.Youmustfilewrittenproofofyourdis-abilitywithin90daysafterthebeginningofthedisability.Theinsurancecarrierhastherighttohaveyouexaminedbythedoctor(s)oftheirchoice.
termination oF insuranCe
YourinsuranceendswhenyouremploymentwiththeUniversityends,yourpositionnolongermeetstheeligibilityrequirements,ortheUniversitydiscontinuesofferingaLongTermDisabilityprogram.Ifyourenewyouremploy-mentcontractwiththeUniversityforthefollowingyearandthenceaseactive,full-timeworkduringthesummermonths,yourcoveragecontinuesduringthesummermonths.
Conversion privileGe
IfthisprotectionceasesbecauseyouremploymentwiththeUniversityterminates,youmayarrangewiththeinsur-ancecarriertoprovideLongTermDisabilitycoverageunderanindividualpolicy.Thiscoveragemaybeconvertedwithoutmedicalexaminationifyouapplywithin30daysfromthedateyourgroupcoverageceases.TheindividualLongTermDisabilitybenefitsarenotthesameastheUniversity’sGroupLongTermDisabilityPlan.
Torequestconversioncoverage,contactyourregionalhumanresourcesofficeforforms.Youmaynotconverttoanindividualplanifyouaredisabledatthetimeemploymentterminates.
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LIFE INSURANCE BENEFITS
introduCtion
Financialprotectionforyoursurvivorsintheeventofyourdeathisimportantforyourfamily’swelfare.TheUniver-sityofAlaskaprovidestheopportunityforincomeprotectionthroughthefollowingbenefitplans:
• Basiclifeinsurance• Supplementallifeinsurance(alsocalledOptionallifeinsurance)• Accidentaldeathanddismembermentinsurance
Benefitspaidtoyourbeneficiaryand/orbenefitstowhichtheymaybeentitledatthetimeofyourdeathmayincludethefollowing:
• LifeInsurance• PERS/TRSRetirementBenefits• UniversityofAlaskaPensionPlanBenefits• SickLeavePayoff• AnnualLeavePayoff• SpecialContinuationofHealthCareBenefits• DistributionsfromTDAAccounts• OptionalRetirementPlanAccounts
TheUniversityofAlaska’slifeinsuranceandaccidentaldeathanddismembermentbenefitsareprovidedbyTheStandard.
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BASIC LIFE INSURANCE
introduCtion
TheUniversityprovidesabasic$50,000LifeInsurancebenefitatnocosttoemployees.
Employeesmaypurchaseadditionallifeinsurancethroughpayrolldeductions(seesupplementallifeinsurancesec-tions).
eliGiBilitY
Allregularfull-time,andregularpart-timeemployeesareeligibleforinsurancecoverage.Eligibilitybeginsonthedate of hire.
BeneFits
Theamountthatwillbepaidtoyourbeneficiaryintheeventofyourdeathis$50,000(unlessyouhaveelectedtopurchaseadditionalinsurance).Benefitswillbepaidbycheckandsentdirectlytoyourbeneficiary.
BeneFiCiaries
Thebenefitswillbepaidtothebeneficiaryyoudesignateonthebeneficiaryform.Youmaychangeyourbeneficiaryatanytimebycompletinganewbeneficiaryformandreturningittoyourregionalhumanresourcesoffice.
Claims
Lifeinsuranceandtravelaccidentclaimsshouldbefiledthroughyourregionalhumanresourcesoffice.Claimsshouldbereturnedtothatofficeforfinalcompletionandtransmittaltotheinsurancecarrier.
termination
YourBasicGroupLifeInsuranceceasesonthedatethatyouterminateeligibleemploymentwiththeUniversity.ConversionorPortabilitytoanindividualpolicyisavailable;seethePortabilityorConversionPrivilegeinformationat the end of this section.
travel aCCident BeneFits
Thereisanadditional$250,000travelaccidentpolicyineffectanytimeyouaretravelingonUniversitybusiness.(Commutingtoandfromworkisnotcovered.)ThisbenefitisprovidedbyUARiskManagementandisnotpartofyour Group Basic Life Insurance.
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disaBilitY Waiver oF premium
Ifanemployeebecomestotallydisabledwhileinsuredandbeforereachingage60,basiclifeinsurancecoveragewillremainineffectwithoutfurtherpremiumpaymentaslongasthedisabilitycontinuesoruntilage65,whicheverissooner.
Proofofyourinabilitytoworkbecauseoftotaldisabilitymustbefurnishedannually.Ifdisabledpriortoage60,insurancewillcontinueaslongasyouaredisabled,butnotpastage65.Theamountofcontinuedprotectionissubjecttoanyplanchangesandtoreductionsshownintheinsuranceschedule.Withinoneyearofthestartofyourdisability,youmustsubmitproofthatyouarecurrentlydisabledandhavebeencontinuouslydisabledforatleastsixmonths.
Applicationforthewaiverofpremiumshouldbemadewithinthe90-daywaitingperiodpriortothecommencementofLong-TermDisabilitybenefits,butnolaterthansixmonthsafteryoubecomedisabled.
portaBilitY or Conversion privileGe
YoumayarrangewithTheStandardtocontinueyourbasiclifeinsuranceprotectionunderanindividualpolicy,withoutmedicalexamination,ifyouapplyforitwithin31daysafterthedateyourgroupinsuranceceases.
BecausetheGroupLifeInsurancewillbepayablefordeathoccurringduringthe31daysafterthedateyourinsur-anceceases,theindividualpolicywillnotbecomeeffectiveuntilafterthe31-dayperiodhasexpired.Withcon-version,theindividuallifeinsurancebenefitswillbeconvertedtoaWholeLifepolicy.Portabilityallowsyoutocontinuethesamegrouptermsupplementallifeinsuranceyouhadasanactiveemployee.
FormoreinformationandtorequestanapplicationforPortabilityorConversion,contacttheStandardat(800)378-4668,ext.6785within31daysofemploymentterminationorlossofeligibility.Applicationsshouldbesentto:
The Standard Insurance CompanyAttn:ContinuedBenefits
920SW6thAvePortland,OR97204
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SUPPLEMENTAL LIFE INSURANCE
introduCtion
Thisplanprovidesforincomebenefitstothesurvivorsofadeceasedemployee.Coverageamountsunderthisplanareinmultiplesof$25,000toamaximumof$400,000.Anewemployeemaypurchasethemaximumamountofcoveragewithin30daysofhire.IfyoudonotenrollinSupplementalLifewithinthistime,youmaynotenrolluntilthenextopenenrollmentperiod,orafteraqualifyingmajorlifeevent.
eliGiBilitY
OnlyUniversityofAlaskaemployeesareeligibleforenrollmentintheplan;dependentsarenotcovered.Ifyouarearegularfull-timeorregularpart-timeemployee,youareeligibleforthisoptionalplan;howeverbenefitreductionsapplytoemployeesage65orolder.
enrollment
Youmayenrollwithin30daysofthedateofyouremployment,duringopenenrollment,orafteraqualifyingmajorlifeevent.Themaximumamountofsupplementallifeinsurancethatauniversityemployeecanpurchaseunderthisplanis$400,000.Youwillneedtosubmitevidenceofinsurabilityifyouareelectingover$200,000ofcoverage.
SubmittheSupplementalBenefitsElectionformtoyourregionalhumanresourcesoffice.Ifelectingmorethan$200,000ofcoverage,youmustcompletetheMedicalHistoryStatementasevidenceofinsurability,andsenditdi-rectlytoTheStandardattheaddressontheform,orfaxitto(971)321-5060.Youwillbeissued$200,000untilthehigherbenefitlevelisapprovedbyTheStandard.Initialenrollmentinthesupplementallifeinsurancebenefitalsorequiresacompletedbeneficiaryform.Allformsareavailableonthebenefitswebsiteatwww.alaska.edu/hr/forms.
Employeeswithcurrentcoveragelevelsover$200,000whoareelectingahigherlevelofcoverageatopenenroll-mentorbecauseofaqualifyinglifeeventwillmaintaintheircurrentleveluntiltheincreaseisapproved.Iftheincreaseisnotapproved,theywillretaintheircurrentlevelofcoverage.
Youmaycancelthiscoverageatanytimebycompletingasupplementalbenefitselectionformoruponwrittenno-ticetoyourregionalhumanresourcesoffice.
Costs
Thisplanisage-bandedsothateachemployeepaysonlyforhisorherowncoverage.TheratethatwillbechargedanemployeeisbasedupontheirageasofJuly1ofeachyear.
Paymentsforthecoveragearemadethroughbi-weeklypayrolldeductionsonanafter-taxbasis.Forthemostcur-rentrates,pleaseseethebackpageofthecurrentyear’ssupplementalbenefitselectionform,orconsultwithyourregionalhumanresourcesoffice.
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paYment oF BeneFits
Theamountthatwillbepaidtoyourbeneficiaryintheeventofyourdeathisthemostrecenteffectivelevelofsupplementalinsurance.Employeesage65orolderarelimitedto$25,000ofsupplementalcoverage.
Ifyoudiewhilecoveredbytheplan,benefitswillbepaidbychecktothebeneficiaryyounameandsentdirectlytothatbeneficiary.
Torequestpaymentofbenefits,thebeneficiaryshouldcontactyourregionalhumanresourcesofficeforaclaimformandinformationaboutotherrequireddocuments.Claimsshouldbereturnedtothatofficeforfinalcompletionandprocessing.
termination
YourSupplementalLifeInsuranceceasesonthedatethatyouterminateeligibleemploymentwiththeUniversity.ConversionorPortabilitytoanindividualpolicyisavailable;seethePortabilityorConversionPrivilegeinformationbelow.
disaBilitY Waiver oF premium
Ifanemployeebecomestotallydisabledwhileinsuredandbeforereachingage60,coveragewillremainineffectwithoutfurtherpremiumpaymentaslongasthedisabilitycontinuesoruntilage65,whicheverissooner.
Proofofyourinabilitytoworkbecauseoftotaldisabilitymustbefurnishedannually.Ifdisabledpriortoage60,in-surancewillcontinueaslongasyouaredisabled,butnotpastage65.Theamountofcontinuedprotectionissubjecttoanyplanchangesandtoreductionsshownintheinsuranceschedule.Waiverofpremiumbeginswhenyoucom-pletethewaitingperiod.Waitingperiodmeansthe180consecutivedayperiodbeginningonthedateyoubecometotallydisabled.Premiumpaymentmustcontinueuntilthelaterofthedateyoucompleteyourwaitingperiod,orthedateweapproveyourclaimforwaiverofpremium.
Applicationforthewaiverofpremiumshouldbemadewithinthe90-daywaitingperiodpriortothecommencementofLong-TermDisabilitybenefits,butnolaterthansixmonthsafteryoubecomedisabled.
portaBilitY or Conversion privileGe
YoumayarrangewithTheStandardtocontinueyoursupplementallifeinsuranceprotectionunderanindividualpolicy,withoutmedicalexamination,ifyouapplyforitwithin31daysafterthedateyourgroupinsuranceceases.
BecausetheGroupLifeInsurancewillbepayablefordeathoccurringduringthe31daysafterthedateyourinsur-anceceases,theindividualpolicywillnotbecomeeffectiveuntilafterthe31-dayperiodhasexpired.Withcon-version,theindividuallifeinsurancebenefitswillbeconvertedtoaWholeLifepolicy.Portabilityallowsyoutocontinuethesamegrouptermsupplementallifeinsuranceyouhadasanactiveemployee.
FormoreinformationandtorequestanapplicationforPortabilityorConversion,contacttheStandardat(800)378-4668,ext.6785within31daysofemploymentterminationorlossofeligibility.Applicationsshouldbesentto:
The Standard Insurance CompanyAttn:ContinuedBenefits
920SW6thAvePortland,OR97204
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ACCIDENTAL DEATH AND DISMEMBERMENT
introduCtion
Thissupplementalplanprovidesfinancialbenefitsforlossoflife,limbs,oreyesasaresultofbodilyinjuryinanaccident.
eliGiBilitY
Allregularfull-timeandregularpart-timeemployeesandtheirdependentsareeligibleforthisplan.Employeesbe-comeeligibleforenrollmentintheplanontheirdateofhireintoaneligibleposition.Employeedependentsbecomeeligibleforcoverageifandwhentheemployeeenrollsforfamilycoverageintheplan.
enrollment
Toenroll,completetheoptionalbenefitselectionformandreturnittoyourregionalhumanresourcesoffice.Yourcoveragewillbeginthefirstdayofthepayperiodfollowingyourpayrolldeductionforthiscoverage.Youmayenrollwithin30daysofthedateyouarehired,duringopenenrollment,orfollowingamajorlifeevent.
Costs
Currentratesmaybeobtainedatyourregionalhumanresourcesoffice.
BeneFits
Thefullbenefitamountforyou,theemployee,is$100,000.
If,whileyouarecoveredunderthisplan,youshoulddiewithinoneyearoftheaccident,thefullbenefitwillbepaidtothebeneficiaryyouhavedesignated.
Ifyoushouldhaveanyofthefollowinglosseswithinoneyearoftheaccident,benefitswillbepaidasfollows:
• Lossofbotheyes,feet,orhandsoranycombinationthereof:fullbenefitamount• Lossofoneeye,foot,orhand:one-halfofbenefitamount• Lossofthumbandindexfingerofsamehand:one-fourthofbenefitamount
Ifyouenrollforfamilycoverage,thebenefitamountfordependentsisbasedonthecompositionofthefamilyatthetimeoftheloss.Theactualamountthatwillbepaidisapercentageoftheamountthatyouwouldbepaidifyousustainedthesameloss:
• Ifyouhaveaspousebutnodependentchildren,yourspousewillbecoveredfor50%ofthefullbenefit.• Ifyouhavedependentchildrenbutnospouse,eachchildwillbecoveredfor15%ofthefullbenefit.• Ifyouhavebothaspouseanddependentchildren,yourspousewillbecoveredfor40%andeachchildfor10%
ofthefullbenefit.
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BeneFiCiaries
EmployeeAccidentalDeathbenefitswillbepaidtothebeneficiarytheyhaveselected.Ifyouwishtochangeyourbeneficiary,completeanewbeneficiaryformandreturnittoyourregionalhumanresourcesoffice.EmployeeAc-cidentalDismembermentbenefitsanddependentAD&Dbenefitswillbepaidtotheemployee.
ad&d eXClusions
Benefitswillnotbepaidifthelossresultsdirectlyorindirectlyfromanyofthefollowing:
• Waroractofwar;warmeansdeclaredorundeclaredwar,whethercivilorinternational,andanysubstantialarmedconflictbetweenorganizedforcesofamilitarynature
• Suicide,attemptedsuicideorotherintentionallyself-inflictedinjury,whilesaneorinsane• Committingorattemptingtocommitanassaultorfelony,oractivelyparticipatinginaviolentdisorderorriot;
activelyparticipatingdoesnotincludebeingatthesceneofaviolentdisorderorriotwhileperformingofficialduties.
• Thevoluntaryuseorconsumptionofanypoison,chemicalcompound,alcoholordrug,unlessusedorcon-sumedaccordingtothedirectionsofaphysician
• Sicknessorpregnancyexistingatthetimeoftheaccidentorexposure• Heartattackorstroke• Medicalorsurgicaltreatmentordiagnosticprocedureforanyoftheabove.
Claims
Torequestpaymentofbenefits,youoryourrepresentativeshouldcontactyourregionalhumanresourcesofficeforclaimformsandinformationaboutotherrequireddocuments.Claimsshouldbereturnedtothatofficeforprocessing.
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RETIREMENT PLANS AND OPTIONS
introduCtion
ThereareseveralretirementprogramsavailabletoUniversityofAlaskaemployees.Theyarethe:
• UniversityofAlaskaOptionalRetirementPlan(ORP)• UniversityofAlaskaPensionPlan• StateofAlaskaPublicEmployees’RetirementSystem(PERS)• StateofAlaskaTeachers’RetirementSystem(TRS)• Tax-DeferredAnnuityProgram(TDA)• SocialSecurity
Eachoftheaboveplanshaslimitationsastowhichemployeesareeligibletoparticipate.Theplansaredescribedinsummaryonthefollowingpages.Formoredetailedinformation,pleaseconsultthespecificplan’shandbookorplandocument.
soCial seCuritY
TheUniversityofAlaskawithdrewfromthefederalSocialSecuritysystemonJanuary1,1982,afteruniversityem-ployeesvotedtodiscontinueparticipationintheprogram.Consequently,universityemployeesdonotearnquarterstowardaSocialSecuritybenefitduringtheiremploymentwiththeuniversity.
PensionincomebasedonearningsfromajobnotcoveredbySocialSecuritycanreducefutureSocialSecuritybenefitswhenyouretireorbecomedisabled.UndertheSocialSecuritylaw,therearetwowaysyourSocialSecuritybenefitamountmaybeaffected.
• UndertheWindfall Elimination Provision,yourSocialSecurityretirementordisabilitybenefitisfiguredusingamodifiedformulawhenyouarealsoentitledtoapensionfromajobwhereyoudidnotpaySocialSecuritytax.Thisprovisionreduces,butdoesnottotallyeliminate,yourSocialSecuritybenefit.
• TheGovernment Pension Offset ProvisionoffsetsanySocialSecurityspouseorwidow(er)benefittowhichyoubecomeentitledbytwo-thirdsoftheamountofyourpension.Evenifyourpensionishighenoughtototallyoffsetyourspouseorwidow(er)benefit,youarestilleligibleforMedicareatage65.
SocialSecuritypublicationsandadditionalinformation,includinginformationaboutexceptionstoeachprovision,areavailableatwww.socialsecurity.gov.Youmayalsocalltollfree(800)772-1213,orforthedeaforhardofhear-ing,calltheTTYnumber(800)325-0778,orcontactyourlocalSocialSecurityoffice.
EffectiveApril1,1986,federallawrequiresthatallemployeeshiredafterMarch31,1986,participateintheMedi-careportionoftheSocialSecurityprogram.TheMedicareportionoftheSocialSecuritycontributionis1.45%ofgrosswagesinacalendaryear.
EffectiveJuly1,1991,alltemporarystaffemployeesarerequiredbyfederallawtoparticipatefullyinbothMedi-careandSocialSecurity.Thecontributionforbothportionsis7.65%ofsubjectgrosswages.Ifyouhaveanyques-tionsregardingyourparticipationineitherplan,contactyourregionalhumanresourcesoffice.
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UNIVERSITY OF ALASKA OPTIONAL RETIREMENT PLAN
EligibleUniversityofAlaskaemployeesmustmakeanirrevocableelectiontoparticipateineithertheOptionalRetirementPlan(ORP)ortheappropriatestateretirementsystem(TRSorPERS)within30daysfromnotificationofeligibility.YourchoicetoparticipateornottoparticipateisirrevocableforthedurationofyourcurrentemploymentorfutureemploymentwiththeUniversityofAlaskaoraslongasyouremaininaparticipatingposition.PleaseseetheUniversityofAlaskaRetirementPlanDecisionGuideformoredetailedinformationaboutthisprogramandadescriptionofthetiers.
eliGiBilitY
EffectiveJuly1,2006,allnewlyhiredbenefit-eligibleemployeesareeligibletoparticipateintheORPTier3.EmployeesfirsthiredbeforeJuly1,2006hadtobeafacultymember,officerorsenioradministratortoparticipateineitherTier1orTier2oftheORP.
ContriButions
ContributionsmadebyyouandbytheUniversityonyourbehalfwillbeinvestedinanaccountinyournameandwiththefundsponsor(s)youselectfromthelistbelow.TheamountofthecontributiondependsonwhichTieroftheplanyouareparticipatingin,basedonyourinitialdateofhireinaneligibleposition.
vestinG
TheOptionalRetirementPlanTier3providesforfullvestingoftheemployercontributionaccountafterthreeyearsofemployment.TheTier3employeecontributionaccountisalways100%vestedwiththeemployee.EmployeesparticipatingintheORPTier1orTier2areimmediately100%vestedinboththeemployerandemployeeaccounts.
Your investment deCision
Youmustchooseaninvestmentcompanyforallyouremployeeandemployercontributions(canbethesamefundsponsor,oradifferentoneforeachtypeofcontribution)fromthesefourinvestmentfundsponsors:
Company Phone Number
FidelityInvestments (800)343-0860LincolnNational (800)348-1212 TollFreeinAlaska (800)478-6393 inFairbanks 452-6393
Company Phone Number
TIAA-CREF (800)842-2776VALIC (866)350-8302 inAnchorage 279-8302 inFairbanks 451-0511
Theplanallowsyoutochangeyourinvestmentelectionswithinorbetweenfundsponsorsatanytime.
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Forms oF paYment
Afteranofficialterminationofallemploymentanda45-daywaitingperiod,youmaychooseoneofthefollowingoptions for your ORP account:
• Transferyouraccounttoanotherqualifiedplan• RollyouraccounttoanIRA• Receivepaymentofyouraccountbalancethroughanannuitycontractpurchasedfromthefundsponsor• Receivealump-sumdistribution,subjecttoanyapplicableearlywithdrawalpenaltiesandtaxes
Please Note:Loansorhardshipdistributionsarenotpermittedunderthisplan.Alldistributionsrequireemployerauthorization.
IfthereisanyconflictbetweeninformationintheRetirementPlandocumentandthishandbook,theRetirementPlandocumentwillprevail.
Your CHoiCes oF investment options
TheORPconsistsoftwoaccounts:oneforcontributionsmadebyyou(themandatory403(b)account),andoneforcontributionsmadebytheUniversityonyourbehalf(the401(a)employer-fundedaccount).Onlyoneoftheoptionslistedbelowcanbeselectedforeachaccountatanyonetime,yetchangescouldbemadeeachpayperiod.Youcanusethesamefundsponsorforbothaccounts,ordifferentfundsponsors.Youmayalsotransferaccountbalancesbetweenthefundsponsorsasallowedbyyourfundsponsor.Pleasebeawarethatsomeoftheaccountsthatfundsponsorsofferdohaverestrictions,penaltiesforearlywithdrawalandchargesformakingtransfers.
FidelitY investments
FidelityInvestmentsappliesmorethan50yearsofinvestmentexperience,innovationandprofessionalismtohelpmeettheneedsofitsclients.Onceknownprimarilyasamutualfundcompany,Fidelityhasadaptedandevolvedovertheyearstomeetthechangingneedsofitscustomers.InvestingwithFidelityInvestmentswillgiveyouabroadrangeofover100investmentoptions.Youcanchoosefromrelativelyconservativemoneymarketfundstoaggres-siveinternationalequityfunds.FidelityalsooffersafixedannuitywhichisunderwrittenbyMetropolitanLife.Atwww.fidelity.com/atworkyouwillfindanextensivearrayofretirementplanningtools,calculators,videosandotherretirementplanningresources.
linColn national
LincolnNationalLifeInsuranceCompany,amemberoftheLincolnFinancialGroup,wasfoundedin1905.LincolnNationalhasbeenselectedbyoverhalfamillionindividuals,withapproximatelyhalfoftheseemployedbyanedu-cationalorganization.Lincoln’svariableannuitybusinessisthesixthlargestinthenation,asmeasuredbyassetsasofJune30,2005.Withanemphasisoncustomerservice,LincolnNationalclientscanaccesstheiraccountsonline,throughLincoln’sautomatedtelephonenetwork,orbycontactingaLincolnretirementrepresentativewithofficesinFairbanksandAnchorage.Lincolnoffersawidevarietyofinvestmentoptionsandbringsyouthechoicesandflex-ibilitynecessarytohelpyoumeetyourretirementgoals.
tiaa-CreF
TIAA-CREFisthenationwide,non-profitorganizationservingtheeducationandresearchcommunities.Foundedin1918,TIAA-CREFmanagesmorethan$350billioninassets,providingretirementservicestooverthreemillionparticipantsat15,000institutions.TIAA-CREFoffersyouachoiceoftenaccountsinfourdifferentassetclasses.TheTIAATraditionalAnnuityisaguaranteedaccountwiththetopratingsfromthenation’sleadinginsurancerating
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agencies.TheTIAA-CREFvariableaccounts,withbroadlydiversifiedportfolios,offerparticipantstheopportunitytodiversifytheirretirementsavingsinequities,fixed-incomeandrealestateinvestments.ExpensesfortheTIAA-CREFaccountsareamongthelowestintheinsuranceandmutualfundindustries.
valiC
VALICstrivestopositivelyanddramaticallyimpactourclients’andtheirfamilies’financialfutures.Asbothanindustrypioneerandcurrentleaderoverthepasthalf-century,wespecializeinprovidingretirementprogramsandrelatedinvestment,recordkeepingandadministrativeservicestotwomillionemployeesofmorethan28,000em-ployersintheeducation,healthcareandgovernmentsectors.Ournationalnetworkofexperienced,trustedfinancialadvisorsincludefull-timeadvisorsinAnchorageandFairbanks.Theirmissionistohelpclientsplanfortheirfuturebyofferingobjectiveandexpertadviceandachoicefromavastarrayofproductsandservices.Valicisthemarket-ingnameforthegroupofcompaniescomprisingVALICFinancialAdvisors,Inc.,VALICRetirementServicesCom-pany,andtheVariableAnnuityLifeInsuranceCompany(VALIC),eachofwhichisamembercompanyofAmericanInternationalGroup,Inc.
deFault investment
TheUniversitywilldirectcontributionsforbothORPaccountstotheFidelityInvestmentsdefaultaccountuntilyouhaveselectedaninvestmentoption.ThedefaultinvestmentisoneoftheFidelityFreedomFunds,amixofequityandincomeinvestmentsbasedonyourprojectedretirementdate.
CHoosinG a Fund sponsor
Thevarietyofinvestmentopportunitiesprovidesconsiderableflexibilityindesigningaretirementinvestmentpro-gramthatfitsyourpersonalfinancialsituation.Youmightconsiderafewthingswhenmakingyourdecision:
• Yourfamilycircumstances• Thebalanceofriskandreturnyouarecomfortablewith• Youranticipatedincomeneedsatretirement• Yourfinancialobjectives• Yourabilitytosaveoutsidethepensionplan• Thenumberofyearstoretirement
IfyouhavequestionsabouttheUniversity’splan,contactyourregionalhumanresourcesoffice.
distriButions
VestedORPaccountbalancescanbedistributedafteranofficialterminationofallemploymentfromtheUniver-sity;however,distributionsaresubjecttoa45-daywaitingperiod.TerminationofemploymentmeansthatforanextendedperiodoftimeyouhavenotreceivedanywagesorsalaryfromtheUniversity(transferringintoapositionorstatusthatisnotbenefiteligibleisnotatermination).Theexceptiontothisruleisemployeeswhohavereachednormalretirementage(60)andhavetransferredtoanon-participatingposition.
TorolloveryouraccounttoanIndividualRetirementAccountoranotherqualifiedplan,beginanannuitypaymentorrequestalump-sumdistribution,contactyourfundsponsorfortheappropriateforms.Alldistributionsrequireemployerauthorization.
IfthereisanyconflictbetweeninformationintheRetirementProgramplandocumentandthisHandbook,theRe-tirementProgramplandocumentwillprevail.
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UNIVERSITY OF ALASKA PENSION PLAN
OnJanuary1,1982,inconjunctionwiththeUniversity’swithdrawalfromthefederalSocialSecuritysystem,asupplementalretirementplanwasadoptedforUniversityemployeescalledtheUniversityofAlaskaPensionPlan.ItdoesnotattempttoduplicatebenefitsavailableunderSocialSecurity.ThePensionPlanisaUniversity-sponsored401(a)plan.TheUniversitycontributestothisprogramonbehalfofeligibleregularfull-timeandpart-timefacultyandstaff.Employeesarenoteligibletomakesupplementalcontributionsintothisplan.
eliGiBilitY
Regularfull-timeandpart-timefacultyandstaffhiredpriortoJuly1,2006areeligibleforthePensionPlan.EmployeesfirsthiredonorafterJuly1,2006mustelecttheOptionalRetirementPlantoparticipateinthePensionPlan.
ContriBution rate
TheUniversitycontributesanamountequalto7.65%ofanemployee’swages,uptoanannualwagebaseof$42,000,totheemployee’sPensionPlanaccount.
vestinG and distriButions
EmployeesfirsthiredandparticipatingintheplanbeforeJuly1,2006are100%vestedfromthedateofhire.Partici-pantsfirsthiredonorafterJuly1,2006aresubjecttoavestingperiodofthreeyearsfromdateofhireinaneligibleposition.
VestedaccountbalancesareavailablefordistributionafterterminationofallemploymentfromtheUniversity(sub-jecttoa45-daywaitingperiod).Theexceptiontothisruleisemployeeswhohavereachednormalretirementage(60)andhavetransferredtoanon-participatingposition.Pleasenotethathardshipdistributionsorloansagainstthisaccountarenotallowed.
investment options
TheUniversity’sPensionPlanprovidesemployeesinvestmentflexibilityandbroadinvestmentopportunities.Youshouldreceiveastatementonaquarterlybasisfromthecompanyyouselecttomanageyourpensionplanaccount.Itiscriticalthatyouthoroughlyreviewyourquarterlystatementandnotifythecompanyand/ortheUniversityofanyerrors.
Theplanoffersemployeesfourinvestmentcompany(orFundSponsor)options:
Company Phone Number
FidelityInvestments (800)343-0860LincolnNational (800)348-1212 TollFreeinAlaska (800)478-6393 inFairbanks 452-6393
Company Phone Number
TIAA-CREF (800)842-2776VALIC (866)350-8302 inAnchorage 279-8302 inFairbanks 451-0511
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STATE RETIREMENT PLANS
ThroughtheUniversity’saffiliationwiththeStateofAlaska,regularemployeesareeligibletoparticipateineithertheTeachers’RetirementSystem(TRS)orthePublicEmployees’RetirementSystem(PERS).
eliGiBilitY
trs
Ifyouareanactiveregularemployeeoccupyingaregularpositionthatrequiresacademicstandingand/orteaching,youareeligibletoparticipateinTRSontheeffectivedateofhireorthefirstdayofemploymentunlessanelectionismadewithin30daystoparticipateintheOptionalRetirementPlan.
pers
Allregularfull-timeandpart-timeexemptornon-exemptstaffmembersareeligibleforPERSonthefirstdayofemployment.EmployeesfirsthiredbeforeJuly1,2006identifiedasExecutiveStaff,andalleligiblestaffmembershiredonorafterJuly1,2006,maychoosebetweenPERSandORP.
ContriBution rate
CostsoftheplanaresharedbytheemployeeandtheUniversity.TheamountofthecontributiondependsonwhetheryouareaparticipantofTRSorPERS,andyourdateofhire.
trs
EmployeesparticipatingintheTRSdefinedcontributionplanhiredonorafterJuly1,2006contribute8%ofsalarythroughabi-weeklypre-taxpayrolldeduction.ThedefinedcontributionplanisreferredtoasTRSTierIII.
EmployeesinTRShiredbeforeJuly1,2006contribute8.65%oftheirsalarythroughabi-weeklypayrolldeductiontotheTRSdefinedbenefitplanknownasTRSTierIorTierII.
ForallTRStiers,theUniversitycontributesanadditionalpercentageofsalaryasdeterminedannuallybytheTRSprogram.
pers
EmployeesparticipatinginthePERSdefinedcontributionplanhiredonorafterJuly1,2006contribute8%ofsalarythroughabi-weeklypre-taxpayrolldeduction.ThedefinedcontributionplanisreferredtoasPERSTierIV.
EmployeesinPERShiredbeforeJuly1,2006contribute6.75%oftheirsalary(7.5%forPeaceOfficersandFire-fighters)throughabi-weeklypre-taxpayrolldeductiontothePERSdefinedbenefitprogramunderPERSTiersI,IIor III.
ForallPERStiers,theUniversitycontributesanadditionalpercentageofsalaryasdeterminedannuallybythePERSretirementprogram.
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vestinG
BothTRSandPERScontainvestingfeaturesthatgiveyoutherighttoyouraccountbalanceorretirementbenefitsafteraspecifiedperiodoftime.Definedbenefitplanmembersaccruemembershipservicethat,whenvested,givesyoutherighttofutureretirementbenefitsregardlessofcontinuedemploymentwiththeUniversity.PleaserefertoyourPERSorTRShandbookformoredetailedinformationonvesting.
BeneFits
deFined ContriBution plan memBers
Withadefinedcontributionplan,youandtheuniversitymakebi-weeklycontributionstoaccountssetupforyoubytheStateofAlaskaDivisionofRetirementandBenefits.Contributionsandinvestmentearnings(andlosses)accu-mulateinyouraccountandthebenefitpayableatretirementdependsonthevalueofyouraccount.
deFined BeneFits memBers
TheamountofyourmonthlyretirementincomeisdeterminedbyyourlengthofserviceattheUniversity,aswellasanyadditionalcreditedservice,andyouraveragemonthlycompensation(usuallyyourthreehighestyears’salary;PERSyearsmustbeconsecutive,highestfiveconsecutiveyearsforPERSemployeesfirsthiredbetweenJuly1,1996andJune30,2006).Benefitsmayalsobepaidintheeventofapermanentdisabilityorintheeventofyourdeath.PleaserefertoyourPERSorTRShandbookformoredetailedinformation.
termination
IntheeventofyourterminationofemploymentwiththeUniversity,youremployeecontributionstoeitherTRSorPERSmayberefundedtoyou;employercontributionsarenon-refundable.Ifyouhavequestionregardingvestingand/orbenefitsavailableuponyourtermination,pleasecontactyourregionalhumanresourcesoffice.
additional inFormation
ThissummaryhighlightsonlykeyfeaturesoftheTRSandPERSplans.Formorespecificinformation,pleaserefertotheTRSorPERShandbook.Whereanyinconsistencyexistsbetweenthisdescriptionandtheofficialdocuments,therulesandregulationsofPERSandTRSwilltakeprecedence.AlloftheprovisionsoftheplansareexplainedinmoredetailinthePERSandTRShandbooks.ThehandbooksareavailablefromtheStateofAlaskaDivisionofRe-tirementandBenefits,P.O.Box110203,Juneau,AK99811-0203,or550West7thAvenue,Suite540,Anchorage,AK99501-3555.Youcanalsoaccessthehandbooks,formsandmoreinformationon-lineatthefollowingaddress:
http://doa.alaska.gov/drb/
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TAX-DEFERRED ANNUITY (TDA) PLANS
Tax-deferredannuityplans(TDAs)aredesignedtoofferyoutheopportunitytomaketax-deferredcontributionstosupplementyourretirementincome.Theseplansareavailableonlytoemployeesofnonprofitandgovernmentalorganizations.
AllUniversityofAlaskaemployeeshavetheopportunitytoinvestinavarietyoftax-deferredannuityor403(b)plans.Eachoftheseplanshasspecificadvantagesforretirementsecurity.WhencombinedwiththeUniversity’soth-erretirementprograms,theyenhanceyourabilitytoprovideasolidfinancialfoundationforyourretirementyears.
Tax-deferredannuitiesareavailablewithavarietyofcompaniesthroughtheUniversityofAlaska.Contactyourregionalhumanresourcesofficeforanupdatedlist,orvisitthebenefitswebsiteatwww.alaska.edu/benefits.
disClaimer oF responsiBilitY
Asabenefittoitsemployees,theUniversityofAlaskaallowsparticipationinvariousTDAplans.Anumberofthetax-deferredannuities(InternalRevenueCodeSection403(b)plans)areavailablethroughvariousproviderswhoareregisteredwiththeUniversity.Registrationmerelyindicatesthattheannuityorfundproviderhasagreedtoprovidetax-deferredannuitiestouniversityemployeesandhasdemonstratedthatanumberofemployeeshaveaninterestinparticipatingintheirplan.Registrationdoesnotmeanthattheproviderhasmetanyspecificstandardofqualityorreliability.
Important:Theparticipantissolelyresponsibleforpersonalincometaxconsequencesassociatedwiththepartici-pationintax-deferredannuityarrangements.IRSrequirementsrelatedto403(b)planscanbeextremelycomplex.WhilerecenttaxlawchangeshavemadecontributingtoaTDAeasierformanyemployees,theparticipantisurgedtoseekappropriateincometaxadvicepriortocontributingtoaTDAplan.
eliGiBilitY
AllemployeesoftheUniversityofAlaskaareeligibletoparticipateinthetax-deferredannuityplans.Participationis voluntary.
enrollment
Toenrollinthisprogram,youneedtocompleteanenrollmentformorapplicationwiththeappropriatecompanyaswellasaSalaryReductionAgreementform(availablefromyourregionalhumanresourcesofficeoronthewebatwww.alaska.edu/benefits).Throughthisagreement,youauthorizetheUniversityofAlaskatoreduceyoursalarybyadesignatedamountanddirectthisportionofyoursalarytoatax-deferredannuity.
ContriButions
Youdecidetheamountofyourbi-weeklypayrollreductionandhowthefundswillbeinvested.TheamountyoumayinvestislimitedbytheInternalRevenueCode.Employeesareresponsiblefordeterminingiftheircontributionsarewithintheprovisionsofthelaw.Fordetails,refertoIRSPublication571.
Ineffect,yourtotalyearlycontributionstotheTDAaccountreduceyourgrossannualsalarybythatamount.You
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payfederalincometaxonlyonyourreducedannualsalary.Contributionsandearningswillbetaxedupontheirwithdrawal.
IftheUniversitydeterminesthatyouhaveexceededthemaximumallowablecontributionlimits,theUniversitywilltakecorrectiveaction.
paYment oF BeneFits
Tax-deferredannuitiescanbeusedforavarietyofpurposes.Theyareprimarilyusedforretirementbecauseoftheimmediatetaxreductionstoyourincome.SomeTDAprogramsallowyoutoborrowagainstthevalueofyourac-count;checkwithyourTDAprovidertoseeifloansareaprovisionoftheir403(b)program.
Manydifferentpayoutoptionsareofferedatretirement,includingsinglelifeandsurvivorannuities;fundscanbedistributedasalifetimeannuity,anannuityoverafixedperiodofyears,apartialortotallump-sumpaymentwith-drawnatonetime,orotheroptions.ContactyourTDAproviderfortheoptionsofferedundertheirprogram.
IfyourdeathshouldoccurbeforeTDAretirementbenefitsbegin,avarietyofoptionsaregenerallyavailabletoben-eficiariesforthepaymentofdeathbenefits.
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OTHER BENEFITS
introduCtion
ThissectionsummarizesUniversitypoliciessuchasleavesandeducationalbenefitsthatdirectlyaffectregularnon-unionemployees.Youareencouragedtocontactyourregionalhumanresourcesofficeforanyfurtherpolicyinformationyoumayneed.
eduCational BeneFits
Allregularfull-timeandpart-timeemployeesmaytakeuptosixcredithoursofUniversitycoursecreditspersemes-ter,withnotuitionfee,toamaximumof12credithourspercalendaryear.Youmaytakeupto3credithoursduringworkinghours,withoutbeingrequiredtomakeupthetime,ifthecoursewillenhancejob-relatedskillsorknowl-edge;approvalmustbegrantedbyyoursupervisorandtheappropriateformscompleted.
Inaddition,youmayhavecoursechargeswaivedforuptothreenon-creditcoursesfromaUA-approvedlistpersemester,withpriorapprovalfromyoursupervisor.Thesenon-creditcoursesaredesignedtoenhancejob-relatedskillsandworkperformance.
Coursechargesmaybewaivedforamaximumof12credithoursandsixnon-creditcoursesperacademicyear,be-ginningwiththefallsemesterandendingwiththesummerterm.Coursefeesotherthantuition,suchaslab,supplyortechnologyfees,studentactivityorhealthcenterfees,andbooks,etc.,arenotcoveredbythetuitionwaiverandarethestudent’sresponsibility.
Yourspouseanddependentchildrenthroughage23maytakeUniversitycoursecreditswithoutlimitationoratu-itionfee(self-supportcoursesexcluded).
Ifthecoursestakenbyeitheranemployee,spouse,ordependentareconsideredgraduatelevelcourses,thevalueoftheseclasseswillbeaddedtotheemployee’sgrossincomeandtaxedasifitwereregularearnings.However,iftheemployeeistakinggraduate-levelcoursesthatarearequirementoftheirposition,thosecoursesmaynotbesubjecttotaxation.
HolidaYs
TheUniversityobservestwelveholidayseachyear.TheseincludeNewYear’sDay,MartinLutherKing,Jr.DayinCelebrationofAlaskaCivilRights(thethirdMondayinJanuary),adayduringspringrecess,MemorialDay,Inde-pendenceDay,LaborDay,ThanksgivingDayandthefollowingFriday,andChristmasDay.Threeadditionaldays,eitherthedaybeforeorafterNewYear’s,July4,andChristmas,arealsoobservedasholidays.Eachmemberoftheclassifiedstaffmayalsoselectapersonalholiday,whichmustbeapprovedbytheimmediatesupervisor.PersonalholidaycannotbeusedduringthepayperiodinwhichJuly1falls.
AlistofholidaysandthedatesonwhichtheyareobservedisissuedbythePresident’sOffice.Generally,holidaysfallingonaSaturdayareobservedontheprecedingFriday,whilethosefallingonaSundayarecelebratedonthefollowingMonday.
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annual leave
Universityemployees(non-faculty)earnannualleaveonabi-weeklybasis.Theamountearneddependsonthenumberofyearsemployed.Regularfull-time,regularpart-time,andextendedtemporaryemployeeswhoworkatleast20hoursaweekareentitledtoearnannualleave.Regularpart-timeemployeesareeligibletoearnanamountofleavebasedonthepercentageoffull-timehourstheyworkperweek.Yourimmediatesupervisormustapproveallannualleavetaken.Annualleavemustbetakenwhileanemployeeisoncontract.Facultydonotaccrueannualleave
Annualleaveforfull-timeemployeesisaccruedasfollows:
• 5.54hoursperpayperiodduringthefirst5yearsofemployment• 6.46hoursperpayperiodduringyears6through10• 7.38hoursperpayperiodafter10yearsofemployment
Unusedannualleavemaybeaccruedtoamaximumof240hours.AnyunusedleaveinexcessofthisamountwillbecanceledattheendofthepayperiodinwhichJanuary31falls.
Ifyoutransferfromapositionthatprovidesannualleavetoonethatdoesnot,orifyouterminatefromtheUniver-sity,youwillbepaidforthebalanceofyourearnedannualleavetimeupto240hours.Ifyoudiewhileemployed,yourbeneficiarywillbepaidforyouraccruedleavetime.
Annualleavecannotbeaccruedduringleavewithoutpay,norcananemployeeaccrueleavewhenrunningoutannualleaveforterminationpurposes.Annualleavecash-outwhileemployedorpay-offatterminationdoesnotgenerateretirementplancontributionsnorcounttowardscalculatingannualsalaryforretirementverification.
siCk leave
TheUniversitygrantspaidsickleavetoallfacultymembers,regularfull-time,regularpart-time,andextendedtemporaryemployeeswhowork20ormorehoursperweekonaregularbasis.Full-timeemployeesaccrue4.62hoursperpayperiod(iftheyareinpaystatusfortheentirepayperiod),whilepart-timeemployeesearnanamountbasedonthepercentageoffulltimehourstheyworkperpayperiod.Youmayusesickleaveforthosehoursyouareregularlyscheduledtowork.Ifyoursickleavebalanceisexhausted,eligiblesickleavehourswillbedeductedfromyourannualleave.Ifallleaveisexhausted,youmaybeeligiblefortheLeaveShareProgramorleavewithoutpay.
Sickleavemaybetakenforavarietyofreasons:
• Illnessormedicalcondition• Anappointmentwithadoctorordentist• Emergencycareformembersofyourimmediatefamily• Childbirth(byyouoryourspouse)ornewbornadoptedchild• Adoptionofaminorifrequiredbytheadoptionprocess• Adeathinthefamily;funeralattendance(maximumoffivedays);additionaltimemaybegrantedbythesuper-
visor/departmentheaduponapprovalofawrittenrequestfromtheemployee
Whenyoumustbeabsent,youmustnotifyyourimmediatesupervisorwithinthefirsthourofthenormallysched-uledworkday(exceptionsmaybemadeinemergencysituations).Anabsenceduetoanillnessmayrequireaphysician’snoteorotherverificationastoyourillness(unlesswaivedbyyoursupervisor).
Formoreinformation,orforextendeduseofsickleave,pleaseseethesectiononFamilyMedicalLeave(FML).
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leave oF aBsenCe WitHout paY
Ifanemployeemustbegonefromworkforanextendedperiodoftime,theUniversitymaygrantaleaveofabsencewithoutpay.Uptoayearofapprovedleavetimemaybegranted.Ifnecessary,theleavemayberenewedforanad-ditional year.
Duringtheleave,annualorsickleavedoesnotaccrue.However,participationinhealth,life,andretirementpro-gramsmaybecontinuediftheemployeepaysthepremium.TheeffectonPERSorTRSretirementservicecreditvaries.Pleasecontactyourregionalhumanresourcesofficeformoreinformationonbenefitcontinuationwhileonaleaveofabsencewithoutpay.
TheUniversitymaygrantleavesofabsenceforavarietyofreasons,andavailablebenefitsmayvarywitheachsetofcircumstances.YourregionalhumanresourcesofficecanexplainhowanextendedleaveofabsencewouldaffectyourownpositionandUniversitybenefits.Ingeneral,applicationmustbemadetocontinuebenefits.
otHer leaves
Leavesofabsencearegrantedforavarietyofreasons,includingmedical,family,andmilitary,aswellasjuryduty.
mediCal leave
Medicalleavemaybegrantedincaseofseriousillness,accident,surgery,orothermedicalconditionascertifiedbyaphysician.Duringamedicalleaveofabsence,youwillberequiredtouseallpaidleavethatyouhaveaccruedbeforebeginningleavewithoutpay.Thispaidleaveincludessickleavebenefitsandannualleave.After90daysofmedicaldisability,youmaybecomeeligibletoreceivelong-termdisabilitybenefits.
FamilY mediCal leave (Fml)
TheUniversity’sbenefitprogramshavetwodistincttypesofsickleaveabsences:absencesforminorillness,inju-ries,andprofessionalappointments;orabsencesforhealthconditionsthatqualifyundertheUniversity’sFamilyandMedicalLeaveprovisions.FamilyandMedicalLeave(FML)willbegrantedinaccordancewithapplicablestateandfederallawwhenanemployeetakesleaveforoneofthefollowingreasons:
• theemployeeisunabletoworkbecauseofaserioushealthcondition• theemployee’sorspouse’shealthisaffectedbypregnancy• childbirth• tocareforachild(withinthefirst12monthsfollowingbirthorplacementthroughadoptionorfostercare)• tocareforaspouseorcertainimmediatefamilymemberswithaserioushealthcondition• aqualifyingexigencywhenacoveredservicememberiscalledtoactiveduty
Uponapprovaloftheemployee’srequestorneedforFML,theemployeewillbegrantedFMLforoneormoreofthefollowing:
• upto18weeks(720hours)ina“rolling”24-monthperiodforaserioushealthconditionunderstatelaw,or• upto18weeks(720hours)ina“rolling”12-monthperiodforpregnancyorchildbirthunderstatelaw,and• upto12weeks(520hours)ina“rolling”12-monthperiodforanyqualifyingreasonunderfederallaw,
The12-and24-monthperiodsarecalculatedbackwardfromthedateofanyFMLAleaveusage.AllFMLtaken,
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eitherpaidorunpaiddependingontheemployee’savailableleavebalances,willbecountedtowardsthelengthofleaveavailableundertheUniversity’sFMLRegulation(R04.06.160).Wheneverpossible,stateandfederalFMLentitlementsarecountedconcurrently.FMLwillnotcontinuebeyondtheexpirationofanemployee’sappointment.
Inadditiontotheabovereasonsforleave,underthefederalFMLA,eligibleemployeesmayalsotakeupto26weeksofunpaidleaveinasingle12-monthperiodtocareforacoveredservicememberwithaseriousinjuryorill-ness.
Anemployeemustgive30days’noticeforscheduledoranticipatedleave,suchasscheduledsurgery,childbirthoradoption.If30days’noticeisnotpossible,theemployeemustgivenoticeassoonasitispracticabletodoso.
TobeeligibleforstateFML,anemployeemusthavebeenemployedwiththeUniversityofAlaskaforatleast35hoursaweekforatleastsixconsecutivemonths,orforatleast171/2hoursaweekfortwelveconsecutivemonthsimmediatelyprecedingtheleave.TobeeligibleforfederalFML,anemployeemusthavebeenemployedwiththeUniversityofAlaskaforatleasttwelvemonthsandhaveworkedatleast1,250hoursduringthe12-monthperiodimmediatelyprecedingthecommencementoftheleave.
Theemployeewillbeaskedtoprovidecertificationoftheserioushealthconditionfromtheirhealthcareprovider.TheemployermayplaceanemployeeonFMLwhenthereiscausetobelieveaserioushealthconditionexists.
IfyouanticipatetheneedforleaveunderFML,pleasecontactyourregionalhumanresourcesofficeformoreinfor-mationandthenecessaryforms.
leave sHare proGram
Aleaveshareprogramhasbeenestablishedtoallowemployeestovoluntarilytransferhoursfromtheirunusedsickleavebalancetothesickleavebalanceofanemployeewithacatastrophicmedicalcrisis.Tobeeligibleforleaveshare,anemployeemustbeeligibleforFML.Theleaveshareprogramislimitedtoamaximumof520hoursina12-monthperiod.
Proceduresforrequestanduseoftheleaveshareprogramareavailablethroughyourregionalhumanresourcesof-fice.
parental leave
Parentalleaveisavailabletoemployeesandwillbegrantedintheorderofsickleavewithpay,accruedannualleaveandsickleavewithoutpay.AllparentalleavewillbegrantedinaccordancewiththeUniversity’sFMLRegulations.Parentalleaveisnoteligiblefortheleaveshareprogram.TheuseofintermittentFMLforparentalleaveissubjecttosupervisory approval.
jurY dutY
InorderthatUniversityemployeesmayfulfilltheircivicresponsibilityasjurorsorsubpoenaedwitnesses,regularemployeesaregrantedleaveofabsencewithpayforthesepurposes.
Itistheresponsibilityoftheemployeetokeepher/hissupervisorordepartmentheadinformedoftheanticipatedtimetobespentawayfromthejobforthispurpose.
AnypayreceivedbyregularemployeesfromacourtsystemmustbepromptlysubmittedbytheemployeetotheUniversitytooffsetpartofthecostofsuchabsences.Temporaryemployeesreceiveleavewithoutpayandmayretainthemoneysfromthecourt.
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militarY leave
AregularemployeewhoisamemberofareservecomponentoftheUnitedStatesArmedForcesisentitledtoaleaveofabsencewithpayforalldaysduringwhichtheemployeeisrequiredtoserveinordertokeepcurrenttheirstatuswiththeNationalGuardorReserveForces.Suchleavesofabsencewithpaymaynotexceed16andone-halfworkingdaysinonecalendaryear.Otherthanfortrainingperiodsdiscussedabove,regularemployeesoftheUni-versityareentitledtoamilitaryleaveofabsencewithoutpaytoserveintheArmedForcesoftheUnitedStatesandshallbeentitledtostatutoryre-employmentbenefitsprovidedforbyfederallaw.
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GLOSSARY OF TERMS
Accidental Injury—Physicalharmcausedbyasuddenandunforeseeneventataspecifictimeandplace.Itisinde-pendentofillness,exceptforinfectionofacutorwound.
Affordable Care Act—ThePatientProtectionandAffordableCareActof2010(PublicLaw111-148)asamendedbytheHealthCareandEducationReconciliationActof2010(PublicLaw111-152).
Allowable Charge—PremeraBlueCrossBlueShieldofAlaskareservestherighttodeterminetheamountallowedforanygivenserviceorsupply.Themeaningofthistermdependsontheprovider:
Providers in Alaska and Washington Who Have Agreements with Premera Blue Cross—Theallowablechargeisthefeethattheproviderhasagreedtoacceptasfullpaymentformedicallynecessarycoveredservicesandsupplies.ThisfeeisdeterminedbyagreementsthatBlueCrosshaswiththeproviders.ProvidersthathavecontractswithBlueCrosswillseekpaymentfromBlueCrosswhentheyfurnishcoveredservicestoyou.Youwillberesponsibleonlyforanyapplicabledeductibles,coinsurance,copayments,chargesinexcessofthestatedbenefitmaximums,andchargesforservicesandsuppliesnotcoveredunderthisprogram.
Yourliabilityforanyapplicabledeductibles,coinsurance,copayments,andamountsappliedtowardbenefitmaximumswillbecalculatedonthebasisoftheallowablecharge.
Providers Outside Alaska and Washington Who Have Agreements with other Blue Cross Blue Shield Licensees—ForcoveredservicesandsuppliesreceivedoutsideAlaskaandWashington,allowablechargesaredeterminedasstatedin“TheBlueCardProgram”sectionofthishandbook.
Providers Who Do Not Have Agreements with Premera Blue Cross or another Blue Cross Blue Shield Li-censee—ForservicesandsuppliesreceivedwithinAlaskaandWashington,theallowablechargeisdeterminedbyestablishingaprofileofbilledcharges,usingstatisticallycreditabledataforaperiodoftwelvemonthsbyexaminingtherangeofchargesforthesameorsimilarservicefromproviderswithineachgeographicalareaforwhichclaimsarereceived.Theallowablewillbenolessthanthe80thpercentileofbilledchargesforthatser-vice.IfBlueCrossisunabletoobtainsufficientdatafromagivengeographicalarea,awidergeographicalareaisused.Ifinclusionofthewidergeographicalareastilldoesnotprovidesufficientdata,theallowablechargewillbesettonolessthantheequivalentofthe80thpercentileornolowerthan250%ofMedicareallowablechargesforthesameservicesorsupplies,whicheverisgreater.
Theallowablechargeforservicesandsuppliesfromthefollowingproviderclasseswillbenolessthanthe80thpercentileofbilledchargesasdeterminedfromaprofilederivedfromthemethodologydescribedabove
• ProfessionalProviders• AmbulatorySurgicalCenters• SkilledNursingFacilities• ExtendedCareFacilities• BirthingCenters• KidneyDialysisCenters• RehabilitationFacilities• OtherSub-acuteFacilities
ServicesfromHospitals(AcuteFacilities):Theallowablechargeisdeterminedbyestablishingaprofileofbilledcharges,usingstatisticallycreditabledataforaperiodoftwelvemonthsbyexaminingtherangeofchargesfor
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thesameorsimilarservicefromfacilitieswithineachgeographicalareaforwhichclaimsarereceived.Theallowablewillbenolessthanthe80thpercentileofbilledchargesforthatservice.IfBlueCrossisunabletoobtainsufficientdatafromagivengeographicalarea,awidergeographicalareaisused.Ifinclusionofthewidergeographicalareastilldoesnotprovidesufficientdata,theallowablechargewillbesettonolessthantheequivalentofthe80thpercentileornolowerthan250%ofMedicareallowablechargesforthesameservicesorsupplies,whicheverisgreater.
For Services and Supplies Received Outside Alaska and Washington theallowablechargeforcoveredser-vices and supplies is the fee schedule established by the local Blue Cross Blue Shield licensee.
Remember,whenyouseekservicesfromprovidersthatdonothaveagreementswithBlueCross,yourli-abilityisforanyamountabovetheallowablecharge,andforanyapplicabledeductibles,copayments,coinsur-ance,amountsinexcessofstatedbenefitmaximums,andchargesfornoncoveredservicesandsupplies.TheseamountswillbereflectedontheExplanationofBenefitsthatBlueCrosssendstoyou.
Ambulatory Surgical Center—Afacilitythatiscertifiedorlicensedasrequiredbythestateinwhichitoperatesandmeetsallofthefollowingrequirements:
• Ithasanorganizedstaffofphysicians.• Ithaspermanentfacilitiesthatareequippedandoperatedprimarilyforthepurposeofperformingsurgicalpro-
cedures.• Itdoesnotprovideinpatientservicesoraccommodations.
Chemical Dependency—Aconditioncharacterizedbyaphysiologicaland/orpsychologicaldependenceonalcoholorastate-regulated,controlledsubstance.Itisfurthercharacterizedbyafrequentorintensepatternofpathologicaluse,tothepointthattheuser:
• Losesself-controlovertheamountandcircumstancesofuse• Developssymptomsoftolerance,orpsychologicaland/orphysiologicalwithdrawalifuseisreducedorstopped• Substantiallyimpairsorendangershisorherhealthorsubstantiallydisruptshisorhersocialoreconomicfunc-
tion
Chemicaldependencyincludesalcoholanddrugpsychoses,andalcoholanddrugdependencesyndromes.
Complication of Pregnancy—Aconditionfallingintooneofthethreecategorieslistedbelowthatrequirescovered,medicallynecessaryservicesinadditiontothoseservicesusuallyprovidedforantepartumcare,normalorcesareandelivery,andpostpartumcare,inordertotreatthecondition:
• Diseasesofthemotherthatarenotcausedbypregnancybutco-existwithandareadverselyaffectedbypreg-nancy
• Maternalconditionscausedbythepregnancythatmakeitstreatmentmoredifficult.Theseconditionsarelim-itedtothefollowing:• Ectopicpregnancy• Hydatidiformmole/molarpregnancy• Incompetentcervixrequiringtreatment• Complicationsofadministrationofanesthesiaorsedationduringlaborordelivery• Obstetricaltraumauterinerupturebeforeonsetorduringlabor• Antepartumorpostpartumhemorrhagerequiringmedical/surgicaltreatment• Placentalconditionsthatrequiresurgicalintervention• Pretermlaborandmonitoring
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• Toxemia• Gestationaldiabetes• Hyperemesisgravidarum• Spontaneousmiscarriageormissedabortion
• Fetalconditionsrequiringinuterosurgicalintervention
Congenital Anomaly—Amarkeddifference,fromthenormalstructureofabodypart,thatisphysicallyevidentatbirth.
Coordination of Benefits—Agrouphealthprogramproceduredesignedtoeliminateduplicatepaymentsforthesameserviceasaresultofaclaimbeingsubmittedtotwodifferentprograms.
Convalescent Nursing Home—Aninstitutionthatprovidesroom,board,andskillednursingcare24hoursadayorunderthesupervisionofaregisteredprofessionalnurse.
Cost Containment—Planmodificationsthatareaimedatholdingdownthecostofthehealthcareprogramorreducingitsrateofincrease.
Cost Sharing—Aplanmodificationwherebyemployeespayaportionofthecostoftheirhealthcareprogram.
Custodial Care—Anyportionofaservice,procedure,orsupplythat,inthejudgmentofBlueCross,isprovidedprimarilyforthefollowingreasons:
• Ongoingmaintenanceoftheenrollee’shealth,andnotfortherapeuticvalueinthetreatmentofanillnessorinjury.
• Toassisttheenrolleeinmeetingtheactivitiesofdailyliving.Examplesarehelpinwalking,bathing,dress-ing,eating,preparationofspecialdiets,andsupervisionoverself-administrationofmedicationnotrequiringconstantattentionoftrainedmedicalpersonnel.
Dental Care Provider—Adentistorotherdentalcareprofessionalnamedinthisplanthatislicensedorcertifiedasrequiredbythestateinwhichtheserviceswerereceivedtoprovideadentalserviceorsupply,andwhodoessowithinthelawfulscopeofthatlicenseorcertification.
Dentally Necessary—Thosecoveredservicesandsuppliesthatadentist,exercisingprudentclinicaljudgment,wouldprovidetoapatientforthepurposeofpreventing,evaluating,diagnosingortreatinganillness,injury,diseaseoritssymptoms,andthatare:
• Inaccordancewithgenerallyacceptedstandardsofdentalpractice• Clinicallyappropriate,intermsoftype,frequency,extent,siteandduration,andconsideredeffectiveforthe
patient’sillness,injuryordisease• Notprimarilyfortheconvenienceofthepatient,dentistorotherdentalcareprovider,andnotmorecostlythan
analternativeserviceorsequenceofservicesatleastaslikelytoproduceequivalenttherapeuticordiagnosticresultsastothediagnosisortreatmentofthatpatient’sillness,injuryordisease
Forthosepurposes,“generallyacceptedstandardsofdentalpractice”meansstandardsthatarebasedonauthoritativedentalorscientificliterature.
Decisionsregardingdentalnecessityarebasedonthecriteriastatedabove.Ifyoudisagreewithadecisionthathasbeenmade,youhavetherighttoadditionalreview.Seethe“WhenYouHaveAnAppeal”sectionofthisHandbook.
Disability—Disabilityoccurswhenyouarepreventedfromengaginginyourcustomaryoccupationbecauseofinju-
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ryordisease,andareperformingnoworkofanykindforpayorprofit,orwhenanyinsureddependentisprevented,becauseofinjuryordisease,fromengaginginsubstantiallyallofthenormalactivitiesofapersonoflikeageandingoodhealth.
Effective Date—Thedateonwhichyourcoverageunderthisprogrambegins.Ifyoureenrollinthisprogramafteralapseincoverage,youreffectivedatewillbethedatethatthecoveragebeginsagain.
Enrollee—Apersonwhoiscoveredunderthisprogramasanemployeeordependent,asdescribedinthe“Eligibil-ity”sectionofthishandbook;alsocalled“you”and“your”inthisbooklet.
Enrollment Date—Fortheemployeeandeligibledependentsenrollingwhenfirsteligible,theenrollmentdateistheemployee’sdateofhireorthedatetheyenteraneligibleclass,whicheverislater.Foradependentwhoenrollsonadateotherthanwhenfirsteligibleforcoverage,theenrollmentdateistheeffectivedateofcoverage.
Expense Incurred—Anexpenseisincurredonthedatethattheserviceisreceivedorthesupplyisordered.
Experimental/Investigational—Anyservice,includingatreatment,procedure,equipment,drug,drugusage,medi-caldevice,orsupplywhich,asdeterminedbyPremeraBlueCrossBlueShieldofAlaska,meetsoneormoreofthefollowingcriteria:
• AdrugordevicewhichcannotbelawfullymarketedwithouttheapprovaloftheUnitedStatesFoodandDrugAdministration,andhasnotbeengrantedsuchapprovalonthedateitisfurnished.
• TheserviceissubjecttooversightbyanInstitutionalReviewBoard.• Reliableevidencedoesnotdemonstrateefficacyoftheservice,nordoesitdefineaspecificrolefortheservice
inclinicalevaluation,managementortreatment.• Theserviceisthesubjectofongoingclinicaltrialstodetermineitsmaximumtolerateddose,toxicity,safetyor
efficacy.• Evaluationofreliableevidenceindicatesthatadditionalresearchisnecessarybeforetheservicecanbeclassi-
fiedasequallyormoreeffectivethanconventionaltherapies.
Reliableevidenceincludes,butisnotlimitedto,reportsandarticlespublishedinauthoritativemedicalandscientificliterature,andassessmentsandcoveragerecommendationspublishedbytheBlueCrossBlueShieldAssociationTechnicalEvaluationCenter(TEC).
Explanation of Benefits (EOB)—Asummarydescriptionofbenefitsreceivedandpaidunderthehealthprogram.
Group—Theentitythatsponsorstheself-fundedhealthplan,inthiscasetheUniversityofAlaska.
Home Medical and Respiratory Equipment/Medical Supplies—Mechanicalequipmentthatcanstandrepeateduseandisusedinconnectionwiththedirecttreatmentofanillnessoraccidentalinjury.Itisofnouseintheabsenceof illness or accidental injury.
Hospital—Afacilitylegallyoperatingasahospitalinthestateinwhichitoperatesandthatmeetsthefollowingrequirements:
• Ithasfacilitiesfortheinpatientdiagnosis,treatment,andacutecareofinjuredandillpersonsbyorunderthesupervision of a staff of physicians.
• Itcontinuouslyprovides24-hournursingservicesbyorunderthesupervisionofregisterednurses.
Innoeventwilla“hospital”beaninstitutionthatisrunmainlyasoneofthefollowing:
• Arest,nursing,orconvalescenthome;residentialtreatmentcenter;orhealthresort
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• Toprovidehospicecareforterminallyillpatients• Forcareoftheelderly• Fortreatmentofchemicaldependencyortuberculosis
Illness—Asickness,disease,medicalcondition,complicationofpregnancy,orpregnancy.
Inpatient—Confinedinamedicalfacilityasanovernightbedpatient.
Medical Emergency—Asuddenonsetofamedicalconditionoraccidentalinjurymanifestingitselfbyacutesymptomsofsufficientseveritythattheabsenceofimmediatemedicalattentionwouldreasonablybeexpectedbyaprudentpersonwhopossessesanaverageknowledgeofhealthandmedicinetoresultinoneofthefollowing:
• Placetheenrollee’slifeinseriousjeopardy• Seriousimpairmenttobodilyfunctions• Seriousandpermanentdysfunctionofanybodilyorganorpart
Medical Facility(alsocalledFacility)—Ahospital,skillednursingfacility,state-approvedchemicaldependencytreatmentfacility,orhospice.
Medically Necessary—Thosecoveredservicesandsuppliesthataphysician,exercisingprudentclinicaljudgment,wouldprovidetoapatientforthepurposeofpreventing,evaluating,diagnosingortreatinganillness,injury,diseaseoritssymptoms,andthatare• Inaccordancewithgenerallyacceptedstandardsofmedicalpractice;• Clinicallyappropriate,intermsoftype,frequency,extent,siteandduration,andconsideredeffectiveforthe
patient’sillness,injuryordisease;and• Notprimarilyfortheconvenienceofthepatient,physician,orotherhealthcareprovider,andnotmorecostly
thananalternativeserviceorsequenceofservicesatleastaslikelytoproduceequivalenttherapeuticordiag-nosticresultsastothediagnosisortreatmentofthatpatient’sillness,injuryordisease.
Forthesepurposes,“generallyacceptedstandardsofmedicalpractice”meansstandardsthatarebasedoncred-iblescientificevidencepublishedinpeerreviewedmedicalliteraturegenerallyrecognizedbytherelevantmedi-calcommunity,physicianspecialtysocietyrecommendationsandtheviewsofphysicianspracticinginrelevantclinical areas and any other relevant factors.
Member—Apersonwhoiscoveredunderthisprogramasanemployeeordependent,asdescribedinthe“Eligibil-ity”sectionofthishandbook;alsocalled“you”and“your”inthisbooklet(alsosee:Enrollee).
Non-Occupational Injury/Disease—A non-occupational injury is an accidental bodily injury that does not arise out of(orinthecourseof)anyworkforpayorprofit,norinanywayresultsfromaninjurythatdoes.
Anon-occupationaldiseaseisadiseasethatdoesnotariseoutof(orinthecourseof)anyworkforpayorprofit,norinanywayresultsfromadiseasewhichdoes.However,ifproofisfurnishedthattheindividualiscoveredunderaworkers’compensationlaworsimilarlaw,butisnotcoveredforthatparticulardiseaseundersuchalaw,thatdiseasewillbeconsiderednon-occupationalregardlessofcause.
Oncology Clinical Trials—Treatmentthatispartofascientificstudyoftherapyorinterventioninthetreatmentofcancerbeingconductedatthephase2orphase3levelinanationalclinicaltrialsponsoredbytheNationalCancerInstituteorinstitutionofsimilarstature,ortrialsconductedbyestablishedresearchinstitutionsfundedorsanctionedbyprivateorpublicsourcesofsimilarstature.AllapprovabletrialsmusthaveInstitutionalReviewBoard(IRB)ap-provalbyaqualifiedIRB.
Theclinicaltrialmustalsobetotreatcancerthatiseitherlife-threateningorseverelyandchronicallydisabling,hasapoorchanceofapositiveoutcomeusingcurrenttreatment,andthetreatmentsubjecttotheclinicaltrialhasshown
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promiseofbeingeffective.
An“oncologyclinicaltrial”doesnotincludeexpensesfor:
• costsfortreatmentthatarenotprimarilyforthecareofthepatient(suchaslabservicesperformedsolelytocol-lectdataforthetrial;
• anydrugordeviceprovidedaspartofaphase1oncologyclinicaltrial;• services,suppliesorpharmaceuticalsthatwouldnotbechargedtothemember,weretherenocoverage;• servicesprovidedinaclinicaltrialthatarefullyfundedbyanothersource.
Thememberforwhombenefitsarerequestedmustbeenrolledinthetrialatthetimeoftreatmentforwhichcover-ageisbeingrequested.You,yourprovider,orthemedicalfacilityshouldaskBlueCrossforabenefitadvisorytodeterminecoverage before you enroll in the clinical trial.
Orthodontia—Thebranchofdentistrythatspecializesinthecorrectionoftootharrangementproblems,includingpoorrelationshipsbetweentheupperandlowerteeth(malocclusion).
Orthotics—Asupportorbraceappliedtoanexistingportionofthebodyforweakorineffectivejointsormuscles,toaid,restore,orimprovefunction.
Outpatient—Treatmentreceivedinasettingotherthanasaninpatientinamedicalfacility.
Period of Convalescent Nursing Home Confinement—Ifyouarere-admittedintoaconvalescentnursinghomeandlessthan90dayshaspassedbetweenconfinements,itisconsideredonestay.
Periods of Hospital Confinement—Ifyouarere-admittedintoahospitalandtherehasnotbeenatleast90daysbetweenconfinements,itisconsideredonestay.
Physician—Astate-licensedDoctorofMedicineandSurgery(M.D.),DoctorofOsteopathyandSurgery(D.O.)oraPodiatrist(D.P.M.).Professionalservicesprovidedbyoneofthefollowingtypesofproviderswillalsobeconsid-eredtobephysicians’servicesforthepurposesofthisprogrambutonlywhentheproviderislicensedtopracticewherethecareisprovided,isprovidingaservicewithinthescopeofthatlicense,isprovidingaserviceorsupplyforwhichbenefitsarespecifiedinthisprogram,andwhenbenefitswouldbepayableiftheserviceswereprovidedbya“Physician”asdefinedabove:
• AdvancedRegisteredNursePractitioner(A.R.N.P.)• CertifiedDirect-EntryMidwife• Chiropractor(D.C.)• ChristianSciencePractitionerauthorizedbytheMotherChurch,theFirstChurchofChrist,Scientist,inBoston,
Massachusetts• Dentist(D.D.S.orD.M.D.)• LicensedClinicalSocialWorker(L.C.S.W.)• LicensedMaritalandFamilyTherapist(L.M.F.T)• LicensedMarriageandFamilyCounselor(L.M.F.C.)• Naturopath(N.D.)• NurseMidwife• OccupationalTherapist(O.T.)• Optometrist(O.D.)• PhysicalTherapist(P.T.)• PhysicianAssistantsupervisedbyacollaboratingM.D.orD.O.
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• PsychologicalAssociate• Psychologist
Physician Assistant—Aprofessionalwhoistrainedtoperformcertainmedicalproceduresandisemployedunderthe supervision of a physician.
Plan (also called “This Plan”)—Theself-fundedhealthplandescribedinthisHandbook.
Plan Year—Theperiodof12consecutivemonthsthatstartseachJuly1at12:01a.m.andendsonthenextJune30atmidnight.
Premera Blue Cross Blue Shield of Alaska—PremeraBlueCrossBlueShieldofAlaskaintheStateofAlaska,andPremeraBlueCrossinWashingtonState.
Prescription Drug—Anymedicalsubstance,includingbiologicalsusedinananticancerchemotherapeuticregimenforamedicallyacceptedindicationorforthetreatmentofpeoplewithHIVorAIDS,thelabelofwhich—undertheFederalFood,Drug,andCosmeticAct,asamended—isrequiredtobearthelegend:“Caution:Federallawprohib-itsdispensingwithoutaprescription.”
Benefitsavailableunderthisprogramwillbeprovidedfor“off-label”use,includingadministration,ofprescrip-tiondrugsfortreatmentofacoveredconditionwhenuseofthedrugisrecognizedaseffectivefortreatmentofsuchconditionbyoneofthefollowingstandardreferencecompendia:
• TheAmericanHospitalFormularyService-DrugInformation;• TheAmericanMedicalAssociationDrugEvaluation;• TheUnitedStatesPharmacopoeia-DrugInformation;or• OtherauthoritativecompendiaasidentifiedfromtimetotimebytheFederalSecretaryofHealthandHuman
ServicesortheInsuranceCommissioner.
Ifnotrecognizedbyoneofthestandardreferencecompendiacitedabove,thenrecognizedbythemajorityofrel-evant,peer-reviewedmedicalliterature(originalmanuscriptsofscientificstudiespublishedinmedicalorscientificjournalsaftercriticalreviewforscientificaccuracy,validity,andreliabilitybyindependentunbiasedexperts),ortheFederalSecretaryofHealthandHumanServices.
“Off-label”usemeanstheprescribeduseofadrugwhichisotherthanthatstatedinitsFDA-approvedlabeling.
BenefitsarenotavailableforanydrugwhentheU.S.FoodandDrugAdministration(FDA)hasdetermineditsusetobecontraindicated,orforexperimentalorinvestigationaldrugsnototherwiseapprovedforanyindicationbytheFDA.
Program, This—Thebenefits,terms,andlimitationssetforthinthecontractbetweenPremeraBlueCrossBlueShieldofAlaskaandtheUniversityofAlaska.
Provider—Aphysicianorotherhealthcareprofessionalorfacilitynamedinthisprogramthatislicensed,regis-tered,orcertifiedtoprovideamedicalserviceorsupplyasrequiredbythestateinwhichtheserviceswerereceived,andwhodoessowithinthelawfulscopeofthatlicense,registration,orcertification.
Psychiatric Condition—Aconditionlistedinthecurrenteditionof“DiagnosticandStatisticalManualofMentalDisorders.”
Required Contributions—Theratesforthebenefitsofferedinthisprogram.
Reasonable and Customary Charge—SeeAllowableCharge.
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Service Area—TheserviceareaforPremeraBlueCrossmeansthestateofAlaskaandthestateofWashington,exceptforClarkCountyWashington.
Skilled Care—Carewhichisorderedbyaphysicianand,inthejudgmentofBlueCross,requiresthemedicalknowledgeandtechnicaltrainingofalicensedregisterednurse.
Skilled Nursing Facility—Amedicalfacilityprovidingservicesthatrequirethedirectionofaphysicianandnursingsupervisedbyaregisterednurse,andthatisapprovedbyMedicareorwouldqualifyforMedicareapprovalifsorequested.
Subscriber—AnenrolledemployeeoftheUniversityofAlaska.Coverageunderthisplanisestablishedinthesubscriber’sname.
Temporomandibular Joint (TMJ) Disorders—TMJdisordersshallincludethosedisorderswhichhaveoneormoreofthefollowingcharacteristics:paininthemusculatureassociatedwiththetemporomandibularjoint,internalderangementsofthetemporomandibularjoint,arthriticproblemswiththetemporomandibularjoint,oranabnormalrangeofmotionorlimitationofmotionofthetemporomandibularjoint.
University—University of Alaska
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