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Blackfoot Fire & Police Employee Benefits Book Effective: October 1, 2021 ---PAGE BREAK--- Contact Information III-A Benefits Line: (208) 938-8199 iii-a.org PO Box 190477 Boise, ID 83719 Fax: (208) 575-6423 III-A Staff III-A staff is available 24/7, including all holidays, to assist our members, answer benefit questions and help with any issues that arise. If you have a question that is not an immediate benefit issue, please contact the appropriate staff member below: Executive Director Amy Manning (208) 317-2814 [EMAIL REDACTED] • Annual reports • New agency rate proposal Benefits Manager Lisa Fritz (208) 850-0545 [EMAIL REDACTED] • Member benefits • Prior authorizations • Prescription drug issues Benefits Specialist Nicole Tuttle (208) 371-9377 [EMAIL REDACTED] • Member benefits • Enrollment and change forms • EAP program Operations Manager Susan Lasuen (208) 869-3572 [EMAIL REDACTED] • COBRA administration • III-A internal claims payments Wellness Manager & Data Analyst Megan Smith (208) 860-1979 [EMAIL REDACTED] • Health coaching • Onsite wellness clinics & programs III-A Medical Telehealth Dustin Reno, NP: [PHONE REDACTED] or Velma Seabolt, NP: [PHONE REDACTED] Like us on Facebook! @IIIATrust ---PAGE BREAK--- Board of Trustees Rick Watkins, Chairman City of Fruitland Dan Hammond, Vice-Chairman City of American Falls Ruth Bailes, Secretary Minidoka Irrigation District Lori Yarbrough City of Athol Suzanne McNeel City of Blackfoot Tyler Lewis Eagle Fire Lisa Enourato City of Ketchum Traci Malvich City of McCall Kyla Gardner City of New Meadows Danielle Painter City of New Plymouth Pat Riley Northern Lakes Fire Gilbert Hofmeister Power County Highway Patty Parkinson City of St. Anthony Dear Member, We are excited to have you as part of the III-A family! The III-A team is dedicated to helping you with your benefits and wellness. Please do not hesitate to reach out to us at any time. Members of the III-A enjoy several enhanced benefits. Each year, the Trustees review new benefit options and, after careful consideration, choose which enhancements are added to the plans. List of the new 2021-22 benefits that will be effective October 1, 2021: • Orthotic Devices • Therapeutic Shoes for Diabetics • Orthognathic (Jaw) Surgery • Cranial Molding Helmets • Nutritional Formula • Wondr Health Program Additionally, III-A has added several new programs, contact III-A Staff for more information: • Employee Assistance Program (EAP) • Behavioral Health Management Program • Medication Infusion Benefit Program • St. Alphonsus Maternity Benefit Program Acupuncture Benefit Change: • 52 Acupuncture visits per year, up to $80 per visit. If you need additional visits, contact III-A staff. Sincerely, Amy, Lisa, Susan, Megan, and Nicole ---PAGE BREAK--- III-A Administered Benefits Contact III-A staff with questions: (208) 938-8199 EMPLOYEE ASSISTANCE PROGRAM (EAP): Members receive up to 10 free visits per incident/per year for counseling services with a III-A contracted provider. This benefit is available to all household members. EAP Provider list located on the iii-a.com website. Choose from this list of EAP providers, schedule your appointment and GO. No prior authorization is required prior to scheduling your appointment! MEDICAL TELEHEALTH: This is a no-cost Telehealth program for all III-A members. Dustin Reno, NP – Pocatello Wellness Clinic Phone: (208) 203-0783 OR Velma Seabolt, NP – Wellness Associates, Boise Phone: (208) 271-4460 Hours of Operation: 24 hours a day, 7 days a week HEARING-AIDS: 100% coverage for all members covered under the III-A medical plan up to $3,000 every other calendar year. Members do not need to meet their deductible and/or coinsurance prior to using this benefit. Reimbursement to the member upon submission of a detailed paid receipt and an internal claim form. Payment to the Hearing-Aid provider upon submission of an invoice and an internal claim form. Visit iii-a.org and complete the “Internal Claim Form”. Submit the form, along with an invoice or EOB, via fax: (208) 575-6423, scan and email to: [EMAIL REDACTED] or mail to PO Box 190477 Boise, ID 83719. HEARING PROTECTION DEVICES: Protective hearing devices are covered for all members up to $150 once every five calendar years. Only devices which are designed to protect hearing will be considered for coverage. Reimbursement to the member upon submission of a detailed paid receipt and an internal claim form. Visit iii-a.org and complete the “Internal Claim Form”. Submit the form, along with an invoice or EOB, via fax: (208) 575-6423, scan and email to: [EMAIL REDACTED] or mail to PO Box 190477 Boise, ID 83719. ---PAGE BREAK--- III-A Administered Benefits Contact III-A staff with questions: (208) 938-8199 ACUPUNCTURE: 52 Acupuncture visits (up to $80 per visit), per calendar year for each member covered under a III-A medical plan. Acupuncturist must be state licensed, and not “certified”. Please refer to our current Direct-Pay Acupuncture list on our website: iii-a.org > Member Benefits > Acupuncture Direct-Pay Acupuncturists *If you are currently seeing a licensed Acupuncturist or wish to see one who is not listed on our website, please notify the III-A staff. III-A Direct-Pay Acupuncturist (Best Option) III-A Direct-Pay Acupuncturists invoice III-A directly. There is no upfront payment required, member pays any amount over $80. BCI In-Network Acupuncturist Acupuncturist submits claim and bills member for any amount over $80 per visit. (Use the “Provider Search” tool at bcidaho.com to locate an in- Network Acupuncturist) BCI Out-of-Network Acupuncturist Acupuncturist collects payment at the time of service. Members will need to submit a claim form to Blue Cross for reimbursement. (Use the “Provider Search” tool at bcidaho.com to locate an in- Network Acupuncturist) AIR AMBULANCE: If you or your family member have a medically necessary air ambulance transport, the claim will be submitted and processed through Blue Cross of Idaho. III-A will reimburse the member’s deductible and/or out of pocket for this claim upon receipt of the member’s Explanation of Benefits (EOB) for any remaining balance. Dependents NOT enrolled in the III-A Plan: Claim will process through dependent’s medical insurance, then submit EOB to III-A for reimbursement. Visit iii-a.org and complete the “Internal Claim Form”. Submit the form, along with an invoice or EOB, via fax: (208) 575-6423, scan and email to: [EMAIL REDACTED] or mail to PO Box 190477 Boise, ID 83719. Eligible dependents without any insurance coverage: III-A will reimburse a maximum of $2,000 of the medically necessary air ambulance claim. Visit iii-a.org and complete the “Internal Claim Form”. Submit the form, along with an invoice or EOB, via fax: (208) 575-6423, scan and email to: [EMAIL REDACTED] or mail to PO Box 190477 Boise, ID 83719. HEALTH COACHING: Personalized health coaching is available to all members covered on a III-A medical plan. 1-on-1 coaching is available over the phone, or via email. Areas of focus include: Nutrition, Physical activity & exercise, Stress management, Sleep, Weight loss/maintenance, Diabetes prevention, Blood pressure and/or cholesterol management, and Tobacco cessation. This is a free benefit for all III-A Members. Contact III-A Wellness Manager, Megan Smith at [EMAIL REDACTED] or [PHONE REDACTED] to get enrolled or learn more information on this program. ---PAGE BREAK--- III-A Administered Benefits Contact III-A staff with questions: (208) 938-8199 MEDICATION INFUSION BENEFIT PROGRAM: Members who receive infusion treatments for the following medical conditions may receive reimbursement for each infusion and other allowed travel expenses if infusion treatment is at a III-A Preferred Infusion Facility. • Multiple Sclerosis (MS) • Crohn's • Lupus • Psoriasis • Rheumatoid Arthritis (RA) • Inflammatory Bowel Disease • Colitis Contact III-A staff for a Preferred Infusion Facility list. ST. ALPHONSUS MATERNITY BENEFIT PROGRAM: Members who choose to deliver their baby at a St. Alphonsus facility will receive reimbursement for their deductible and coinsurance in the amount of $1,500. If III-A is secondary medical insurance, the member may still participate and receive reimbursement. Visit iii-a.org and complete the “Internal Claim Form”. Submit the form, along with an invoice or EOB, via fax: (208) 575-6423, scan and email to: [EMAIL REDACTED] or mail to PO Box 190477 Boise, ID 83719 BEHAVORAL HEALTH MANAGEMENT PROGRAM: This program will reimburse eligible members for their deductible and coinsurance and other allowed travel expenses when inpatient treatment is at a III-A Preferred Behavioral Health Facility. Contact III-A staff to locate a III-A Preferred Behavioral Health Facility; enter treatment and successfully complete the recommended length of stay. WIGS: 100% coverage for all members covered under the III-A medical plan up to $300 per calendar year, based on medical necessity. Reimbursement to the member upon submission of a detailed receipt showing payment and an internal claim form. Payment to the wig provider upon submission of an invoice and an internal claim form. Visit iii-a.org and complete the “Internal Claim Form”. Submit the form, along with an invoice or EOB, via fax: (208) 575-6423, scan and email to: [EMAIL REDACTED] or mail to PO Box 190477 Boise, ID 83719. ---PAGE BREAK--- Preferred BluePPO This information is for comparison purposes only and not a complete description of benefits. All descriptions of coverage are subject to the provisions of the corresponding Plan, which contains all the terms and conditions of coverage. Certain services not specifically noted may be excluded. Please refer to the Plan issued for a complete description of benefits, exclusions limitations and conditions of coverage. If there is a difference between this comparison and its corresponding Plan, the Plan will control. This comparison is subject to annual update and may not reflect the information contained in the corresponding Plan. III-A City of Blackfoot Fire District 2021 PPO Plan HLS Revised 6.2021 Summary of Benefits III-A City of Blackfoot Fire District Effective Date: October 1, 2021 Preferred Blue Large In-Network Out-of-Network Benefit Period* Deductible (Individual/Family) $3,000 / $6,000 Cost Sharing You pay 20% of the allowed amount You pay 40% of the allowed amount Individual Out-of-Pocket Limit (See Plan for services that do not apply to the limit.) (Includes applicable Deductible, Cost Sharing and Copayments) $3,500 $5,000 Family Out-of-Pocket Limit (See Plan for services that do not apply to the limit.) (Includes applicable Deductible, Cost Sharing and Copayments) $7,000 $10,000 Copayment (Applies to In-Network only. Other services rendered during an Office Visit will be subject to Deductible and Cost Sharing.) You pay $20 Copayment Not applicable COVERED SERVICES By choosing a Noncontracting Provider you may be responsible for the difference between what Blue Cross allows and what the Noncontracting Provider charges. This is called balance-billing. Some services may require Prior Authorization. In-Network Out-of-Network What you pay Acupuncture (Only for a licensed acupuncturist) (Limited to 52 visits combined In- and Out-of-Network per member, per Benefit Period) No charge up to $80 of the allowed amount per day No charge up to $80 of the billed charge per day Advanced Imaging Services (Outpatient services only) (Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computed Tomography Scan (CT Scan), Positron Emission Tomography (PET), Nuclear Cardiology) Deductible and Cost Sharing Deductible and Cost Sharing Allergy Injections • Administration Only • Allergy Serum $5 Copayment (if this is the only service provided during the visit) Copayment Ambulance Transportation Services Deductible and Cost Sharing Breastfeeding Support and Supply Services (Limited to one breast pump purchase per Benefit Period, per Participant) No charge Cardiac Rehabilitation Therapy Services – Outpatient (Limited to 36 visits combined per Participant, per Benefit Period) Deductible and Cost Sharing Chiropractic Care Additional services, such as laboratory, x-ray, and other Diagnostic Services are not included in the Office Visit. (Limited to 24 visits combined per Participant, per Benefit Period) Copayment Deductible and Cost Sharing 50% Cost Sharing after Deductible Colonoscopies and Sigmoidoscopies (Preventive and Diagnostic) No charge Deductible and Cost Sharing Dental Services Related to Accidental Injury Deductible and Cost Sharing Diabetes Self-Management Education Services (Only for accredited Providers approved by BCI.) Copayment Medical ---PAGE BREAK--- Preferred BluePPO This information is for comparison purposes only and not a complete description of benefits. All descriptions of coverage are subject to the provisions of the corresponding Plan, which contains all the terms and conditions of coverage. Certain services not specifically noted may be excluded. Please refer to the Plan issued for a complete description of benefits, exclusions limitations and conditions of coverage. If there is a difference between this comparison and its corresponding Plan, the Plan will control. This comparison is subject to annual update and may not reflect the information contained in the corresponding Plan. III-A City of Blackfoot Fire District 2021 PPO Plan HLS Revised 6.2021 COVERED SERVICES By choosing a Noncontracting Provider you may be responsible for the difference between what Blue Cross allows and what the Noncontracting Provider charges. This is called balance-billing. Some services may require Prior Authorization In-Network Out-of-Network What you pay Diagnostic Services Deductible and Cost Sharing Deductible and Cost Sharing Durable Medical Equipment, Orthotic Devices and Prosthetic Appliances Emergency Services – Facility Services (Copayment waived if admitted) (Additional services, such as laboratory, x-ray, and other Diagnostic Services are subject to applicable Deductible, Cost Sharing and/or Copayment.) (BCI will provide In-Network benefits for treatment of Emergency Medical Conditions. Participant may be balance- billed for these services.) $100 Copayment for hospital Outpatient emergency room visit, then Deductible and Cost Sharing $100 Copayment for hospital Outpatient emergency room visit, then Deductible and Cost Sharing Emergency Services – Professional Services (BCI will provide In-Network benefits for treatment of Emergency Medical Conditions. Participant may be balance-billed for these services.) Deductible and Cost sharing Deductible and Cost Sharing Hearing and Hearing Aid Exams Copayment Home Health Skilled Nursing Deductible and Cost Sharing Home Intravenous Therapy 80% Cost Sharing after Deductible Hospice Services No charge Deductible and Cost Sharing Hospital Services (Inpatient and Outpatient services at a licensed general hospital or ambulatory surgical facility.) Deductible and Cost Sharing Mammograms (Preventive and Diagnostic) No charge Maternity Services and/or Involuntary Complications of Pregnancy Deductible and Cost Sharing Morbid Obesity (Includes the surgical treatment of morbid obesity, complications resulting from the surgical treatment of morbid obesity or for reversals or revisions of surgery for morbid obesity when required to correct an immediately life-threatening condition. Lifetime maximum benefit of $20,000 combined per Participant.) Outpatient Habilitation Physical Therapy Services (Limited to 40 visits combined per Participant, per Benefit Period.) Copayment Outpatient Habilitation Therapy Services (Includes speech and occupational therapies. Limited to 40 visits combined per Participant, per Benefit Period.) Deductible and Cost Sharing Outpatient Rehabilitation Physical Therapy Services (Limited to 40 visits combined per Participant, per Benefit Period.) Copayment Outpatient Rehabilitation Therapy Services (Includes speech and occupational therapies. Limited to 40 visits combined per Participant, per Benefit Period.) Deductible and Cost Sharing Physician Office Visit (Other services rendered during a Physician Office Visit will be subject to Deductible and Cost Sharing.) Copayment Post-Mastectomy/Lumpectomy Reconstructive Surgery Deductible and Cost Sharing Palliative Care Services No charge Pediatric Physician Office Visit (For Participants under the age of eighteen Prescribed Contraceptive Services (Includes diaphragms, intrauterine devices (IUDs), implantables, injections, tubal ligation and vasectomy.) PSA Tests and Pap Smears ---PAGE BREAK--- Preferred BluePPO This information is for comparison purposes only and not a complete description of benefits. All descriptions of coverage are subject to the provisions of the corresponding Plan, which contains all the terms and conditions of coverage. Certain services not specifically noted may be excluded. Please refer to the Plan issued for a complete description of benefits, exclusions limitations and conditions of coverage. If there is a difference between this comparison and its corresponding Plan, the Plan will control. This comparison is subject to annual update and may not reflect the information contained in the corresponding Plan. III-A City of Blackfoot Fire District 2021 PPO Plan HLS Revised 6.2021 COVERED SERVICES By choosing a Noncontracting Provider you may be responsible for the difference between what Blue Cross allows and what the Noncontracting Provider charges. This is called balance-billing. Some services may require Prior Authorization In-Network Out-of-Network What you pay Services – Inpatient (Facility and Professional Services) Deductible and Cost Sharing Deductible and Cost Sharing Services – Outpatient Services Copayment Pediatric Outpatient Services (For Participants under the age of eighteen No charge Facility and other Professional Services Deductible and Cost Sharing Outpatient Applied Behavioral Analysis (as part of an approved treatment plan) • Pediatric Outpatient Applied Behavioral Analysis (ABA) (For Participants under the age of eighteen Copayment No Charge Rehabilitation or Habilitation Services Deductible and Cost Sharing Skilled Nursing Facility (Limited to 30 days combined per Participant, per Benefit Period.) Sleep Study Services Surgical/Medical (Professional Services) Telehealth Virtual Care Services Telehealth Virtual Care Services are available for any category of covered outpatient services. The amount of payment and other conditions for in-person services will apply to Telehealth Virtual Care Services. Please see the appropriate section of the Benefits Outline for those terms. Therapy Services (Including chemotherapy, growth hormone therapy, radiation and renal dialysis.) Deductible and Cost Sharing Deductible and Cost Sharing Transplant Services Preventive Care Benefits (See Plan for specifically listed preventive care services.) No charge for services specifically listed For services not specifically listed Deductible and Cost Sharing Immunizations (See Plan for specifically listed immunizations.) No charge for listed immunizations Treatment for Autism Spectrum Disorder (Services identified as part of the approved treatment plan) Covered the same as any other illness, depending on the services rendered, see appropriate Covered Services section. Visit limits do not apply to Treatments for Autism Spectrum Disorder, and related diagnoses. *The specified period of time during which charges for Covered Services must be incurred in order to accumulate toward annual benefit limits, Deductible amounts and Out-of-Pocket Limits. ---PAGE BREAK--- Highlights of Your Preventive Care Benefits Preventive care is when you see a doctor or have a screening when you do not have any signs of a medical problem. • You pay nothing; no coinsurance, copayment, or deductible, for covered preventive care services when you visit in-network providers. • Preventive care benefits for services from out-of-network providers are subject to your out- of-network benefit. Services for adults (18 years and older) Services for adults (continued) Services for children (17 years and younger) • Alcohol – unhealthy use screening • Annual adult physical examinations • Abdominal aortic aneurysm screening • Behavioral counseling for participants who are overweight or obese • Bone density • Breast cancer (BRCA) risk assessment and genetic counseling and testing for high- risk family history of breast or ovarian cancer • Chemistry panels • Cholesterol screening • Colorectal cancer screening • Complete blood count (CBC) • Diabetes screening • Dietary counseling (limited to three visits per participant, per benefit period) • Health risk assessment for depression • Hepatitis B virus screening • Hepatitis C virus infection screening • HIV assessment • Lung cancer screening for participants age 55 and older • Pap test • PSA test • Screening and assessment for interpersonal and domestic violence • Screening mammogram • Skin cancer prevention counseling • Smoking cessation counseling visit • Sexually transmitted infections assessment • Transmittable disease screening and counseling (chlamydia, gonorrhea, human immunodeficiency virus [HIV], human papillomavirus [HPV], syphilis, tuberculosis [TB]) • Thyroid-stimulating hormone (TSH) • Urinalysis (UA) • Urinary incontinence screening • Well-woman visits for recommended age- appropriate preventive services • Anemia screening • Dental fluoride application for participants age 5 and younger • Lipid disorder screening • Preventive lead screening • Rubella screening • Skin cancer prevention counseling • Routine or scheduled well- baby and well-child examinations, including vision, hearing and developmental screenings • Newborn screenings: • Hearing test • Metabolic screening (PKU, thyroxine, sickle cell) • Screening EKG • Acellular pertussis • Diphtheria • Hemophilus influenzae B • Hepatitis B • Influenza • Measles • Mumps • Pneumococcal/pneumonia • Poliomyelitis/polio • Rotavirus • Rubella • Tetanus • Varicella (chicken pox) • Hepatitis A • Meningococcal • Human Papillomavirus (HPV) • Zoster Immunizations Services for pregnant women or women who may become pregnant • Breastfeeding support, supplies and counseling • Gestational diabetes screening • Iron deficiency screening • Perinatal depression counseling and intervention • Preeclampsia screening • Prescribed contraceptive coverage • RhD incompatibility screening • Urine culture Please Note: Your provider must bill these services as preventive/wellness services. For complete descriptions of your policy, please contact III-A staff. ---PAGE BREAK--- III-A PROACT PRESCRIPTION DRUG BENEFIT • Any medication Prior-Authorizations must be submitted to ProAct, NOT Blue Cross. Please provide your ProAct ID card to your doctor office. • ProAct 24/7 Customer Service: ProActRx.com ([PHONE REDACTED]) • ProAct Mail-Order Pharmacy: ProActPharmacyServices.com ([PHONE REDACTED]) Your III-A Pharmacy Benefit Copays: Retail Pharmacy: Per 30-day Supply Generic Drugs (Tier Copay up to $10 Brand Name Drugs (Tier Copay up to $25 Non-Preferred Drugs (Tier Copay up to $40 Mail Order Pharmacy: Per 90-day Supply Generic Drugs (Tier Copay up to $20 Brand Name Drugs (Tier Copay up to $50 Non-Preferred Drugs (Tier Copay up to $80 (Mail-order requires you to set up a payment profile. Your provider will need to submit a new/separate prescription on your behalf. Please let Proact know if you want your medications to be auto shipped, or by request as needed.) NEVER LEAVE THE PHARMACY WITHOUT YOUR PRESCRIBED MEDICATIONS If you encounter any issues, please contact the III-A staff at [PHONE REDACTED] DIABETIC MEMBERS DexCom G6 Continuous Glucose Monitor Program - Members may purchase this CGM at their local retail pharmacy counter, or by Mail order with a prescription from their provider. No prior authorization is required. Retail: Present your prescription & ProAct Card to the PHARMACY COUNTER. Copays: Transmitter - $25 / Reader - $25 / Sensors - $25 for a 30-day supply (3 sensors per month) Mail-Order: Members receive 90-day supply for price of 60-day supply NEW: The Omnipod Dash product is now available through ProAct at a Tier 3 Copay ($40) $0 COPAY: For diabetic supplies (including needles, syringes, and Contour Test-strips) if purchased within 90-days of an insulin fill. ---PAGE BREAK--- This information is for comparison purposes only and not a complete description of benefits. All descriptions of coverage are subject to the provisions of the corresponding plan, which contains all the terms and conditions of coverage. Certain services not specifically noted may be excluded. Please refer to the plan issued for a complete description of benefits, exclusions limitations and conditions of coverage. If there is a difference between this comparison and its corresponding plan, the plan will control. This comparison is subject to annual update and may not reflect the information contained in the corresponding plan. 10.2021 III-A Master Standard PPO Dental Plans Revised 5.2021 Dental_PPO3_Ortho_Ch_1000_HLS Summary of Benefits– III-A Trust Standard Plan Dental PPO3 Effective: October 1, 2021 Preferred Blue Dental PPO In-Network Out-of-Network Individual/Family Deductible (Deductible applies to In-Network basic, major services, and all Out-of-network services. The Family Deductible is satisfied after three Participants of the same family have met their Individual Deductible.) $50 / 3 Family Maximum Individual Benefit Period Maximum $2,000 Dental Maximum Carryover (You may carry over a portion of your unused dental benefits from one year to the next)* No Orthodontia Lifetime Maximum for Enrolled Eligible Dependent Children $1,000 Orthodontia Waiting Period None Preventive Services What you pay Oral Examinations Limited to two per Benefit Period. No charge By choosing an Out-of-Network provider 20% of the allowed amount** Fluoride Limited to one application per benefit period and limited to Participants who are under age twenty-six (26). Sealants Limited to permanent posterior unrestored dentition of Participants under age sixteen (16). Also limited to one time per tooth in any three consecutive Benefit Periods. X-rays, Bitewings Once per benefit period. X-rays, Complete Mouth Series or Panoramic x-ray One time in any five consecutive benefit periods. Prophylaxis (Cleaning) Limited to two per Benefit Period. (Regardless of type) Basic Services What you pay Fillings Restorations involving multiple surfaces will be combined and paid according to the number of surfaces treated; same tooth surface restoration is covered once in a two year period. 20% of the allowed amount By choosing an Out-of-Network provider 30% of the allowed amount** Extractions Root Canal Therapy Periodontal Maintenance Limited to two per Benefit Period. (Regardless of type) Scaling and Root planing Once per quadrant of the mouth every three benefit periods. Occlusal Guard One appliance every two benefit periods. Osseous Surgery Once per quadrant of the mouth every three years. Space Maintainers Limited to Participants who are under age sixteen (16). Benefits limited to deciduous teeth. Includes all adjustments made within six months of installation. Major Services Predetermination required on all major services What you pay Bridges, Inlays, Onlays, Crowns, Veneers, and Full or Partial Dentures Five year replacement. 50% of the allowed amount By choosing an Out-of-Network provider 60% of the allowed amount** Dental Implants Including the implant body, implant abutment and implant crown. Implant body and abutment-limited to once per tooth per lifetime. Implant crown –five year replacement. Orthodontia Services Covered What you pay Orthodontia for enrolled eligible dependent children. No charge up to Lifetime Maximum** The Preferred Provider Organization (PPO) dental program offers access to a large network of dental providers who have agreed to offer covered services at or below established maximum allowances, and, by choosing an in-network PPO provider, you maximize your dental benefit dollars. *See Group Master Plan for requirements of the Dental Maximum Carryover, if this is a selected benefit. **By choosing an Out-of-Network provider you pay your cost sharing, deductible, and any difference between what Blue Cross of Idaho allows and what the Out- of-Network provider charges. Dental ---PAGE BREAK--- Mental Health Resource Directory If this is an Emergency, please call 911. III-A Employee Assistance Program (EAP) EAP is a voluntary program that offers free counseling and confidential sessions for III-A members and their families. • Members, spouse, and dependents are eligible to receive 10 counseling sessions*, per incident, per calendar year at no cost! *After 10 sessions a copay applies under your medical plan. • Talk one-on-one with an experienced, licensed counselor face-to-face, online, by video, or by phone. • First Responders: We have a separate Network of certified First Responder Providers. Simple, CONFIDENTIAL Process: • Choose a provider from the III-A EAP Provider Directory: iii-a.org > III-A Member Benefits > Mental Health > EAP Provider Directory* • Schedule your first appointment • No prior authorization is required • It’s OK to ask for help! Questions? Contact III-A staff: [PHONE REDACTED] *If you are currently seeing a Provider or wish to see a Provider who is not listed on the III-A EAP Provider Directory, contact III-A staff. IF YOU, OR SOMEONE YOU KNOW ARE IN A CRISIS • Call or text Idaho Suicide Prevention Hotline at [PHONE REDACTED] • Call National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text HELLO to 741741 ---PAGE BREAK--- Additional Resources, Support & Information Free Online Will Preparation: Create a will online including property, funeral and burial instructions, and guardianship for children. Legal Guidance: Get a free 30-minute consultation and a 25% reduction in fees to talk with an attorney regarding: divorce, adoption, family law, wills, trusts and more. Financial Resources: Financial experts can assist with a wide range of issues: retirement planning, taxes, relocation, mortgages, insurance, budgeting, debt, bankruptcy and more. Work-Life Solutions: Referrals and resources for just about anything on your to-do list, such as: Finding child and elder care, hiring movers or home repair contractors, planning events, locating pet care, and more. Travel Assistance Program Contact Your GuidanceResources® Program: Call: (855) 387-9727 TDD: (800) 697-0353 Online: guidanceresources.com App: GuidanceResources® Now Web ID: ONEAMERICA3 Life Insurance Life, Accidental Death & Dismemberment (AD&D) Insurance: IMPORTANT: Fill out and submit your OneAmerica Beneficiary Designation form to your Employer. This form is available at iii-a.org ***Keep this form updated*** Eligibility: Active fulltime Employees and Elected Officials Benefit Amount: $20,000 Accelerated Death Benefit: 25%, 50%, or 75% of face value with remainder paid at time of death Portability: If you retire, reduce your hours to less than fulltime, or leave your Employer, you can take this coverage with you. Life Benefit Reduction: 50% at age 75 Please visit the OneAmerica website for more details: oneamerica.com ---PAGE BREAK--- Preventive Schedule Make a Plan for Your Health *Your primary care provider (PCP) will help determine frequency. Depending on your health and personal risk factors, your preventive care schedule may differ from the standard recommendations. Talk with your Primary Care Provider (PCP) about a schedule that is best for you. If you have particular risk factors like a chronic disease, obesity, or a family history of a disease, your PCP may recommend additional screenings. ✔ CHECK WHEN COMPLETED FREQUENCY DATE SCHEDULED ❒ Annual Wellness Exam Every 12 months ❒Blood Pressure At least annually* ❒Cholesterol Every 5 years* ❒Body Mass Index Annually ❒Bone Mass Measurement Every 1-2 years ❒Breast Cancer Annually ❒Colon Cancer Ask my doctor ❒Diabetes Screening (A1C) At least annually* ❒Flu Vaccine Annually ❒Immunizations As needed* ❒Pneumonia Vaccine Once after age 65 ❒ Well Baby/Well Child Exam As recommended in Well Child Schedule ❒Well Woman Exam Annually ---PAGE BREAK--- Well Child Immunization and Visit Schedule Giving Your Kids a Healthy Start Getting your child vaccinated is one of the best steps you can take for a healthy start in life. Not too long ago, diseases like measles, whooping cough and polio affected thousands of children, sometimes leading to lifelong disability or even death. Now, vaccines can help prevent children from ever suffering from these diseases. Vaccines are administered during Well Child visits with your child’s healthcare provider. These visits include a complete physical exam, developmental milestones, immunization schedules and more. The American Academy of Pediatrics Bright Futures suggest the following schedule for Well Child visits unless otherwise suggested by your pediatrician. Age Activity Immunization/ Test 2 weeks Exam, Health Education None 2 months Exam, Health Education DTaP-Polio-Hib, Hepatitis B, Pneumococcal, Rotavirus 4 months Exam, Health Education DTaP-Polio-Hib, Hepatitis B (if birth dose not given), Pneumococcal, Rotavirus 6 months Exam, Health Education DTaP-Polio-Hib, Pneumococcal, Hepatitis B, Rotavirus 9 months Exam, Health Education None 12 months Exam, Health Education MMR, VZV, Hepatitis A, Anemia test, Lead test, TB test as needed 15 months Exam, Health Education DTaP-Polio-Hib, Pneumococcal 18 months Exam, Health Education Hepatitis A 24 months Exam, Health Education Lead test, TB test as needed 30 months Exam, Health Education None 3 years Exam, Health Education Blood Pressure (at each exam 3 years & older) 4 years Exam, Health Education MMR, VZV, DTaP, Polio 5 years Exam, School Readiness Vision and Hearing Screens (MMR, VZV, DTaP, Polio if not given at 4-year WCC) 6-10 years Exam, Health Education Physical Exam Yearly Catch-up Immunizations 11-18 years Annual Sports/Adolescent Exam Yearly Tdap, Meningococcal, HPV Catch-up Immunizations Anemia Test (menstruating females) Your pediatrician will review immunizations on each visit for the needs of your child. www.completechildrenshealth.com/education-resources/immunization-schedule.php ---PAGE BREAK--- Beneficiary Designation Under Group Life Insurance Policy Submit our com leted form to our Employer *Reminder to kee this form updated Products and financial services provided by American United Life Insurance Company® a ONEAMERICA® company One American Square, P.O. Box 6123 Indianapolis, IN 46206-6123 1-[PHONE REDACTED] Fax: 1-[PHONE REDACTED] www.employeebenefits.aul.com IMPORTANT: PLEASE READ INSTRUCTIONS AND SAMPLE DESIGNATIONS ON REVERSE SIDE BEFORE COMPLETING FORM. CHECK IF BENEFICIARY FOR: □ All Policies or □ Basic Life □ Supplemental □ Voluntary Term Life □ AD&D D List Other Group Policv/Particioatinq Unit Number Name of Group Policvholder/Participatinq Unit Name of Insured Person Insured Person's SSN I I insured Person's Date of Birth I 0NEAMERICA° ,fli Shared Strength• Trusted Care Subject to the provisions of the policy, applicable laws, and the rights of any valid assignee of record with American United Life Insurance Company® (AUL), it is requested the beneficiary of any policy proceeds payable at the death of the Insured Person be as follows: PRIMARY BENEFICIARY(S) Name Relationship Address DOB SSN Percentage Total1 0 CONTINGENT BENEFICIARY(S) IF THE PRIMARY BENEFICIARY(S) PREDECEASES YOU Name Relationship Address DOB SSN Percentage Tota12 0 It is understood and agreed upon receipt of this beneficiary designation by AUL at its principal office, such beneficiary designation will become effective and shall relate back to the date this beneficiary designation is signed, but without prejudice to AUL on account of any payment made prior to the receipt of and acknowledgement of the validity of the beneficiary designation by AUL. AUL shall not be obligated to honor this beneficiary designation unless and until it has been received by AUL, acknowledged by the appropriate officer of AUL, and determined by AUL to comply with applicable law at the time a claim is made. This beneficiary designation supersedes and cancels all prior beneficiary designations by the Insured Person for the policy(s) indicated. If no beneficiary designation is named on any additional AUL coverage, the undersigned understands that this beneficiary designation will be used by AUL for any additional coverage. The undersigned hereby declares that he/she has not been declared incompetent and no court order or laws prevent naming the above designee(s). It is agreed that AUL assumes no responsibility for the validity or effect of any purported beneficiary designation or transfer of rights under the policy. The undersigned represents and warrants any information or documents provided to AUL by the undersigned prior to and after the date of the application for insurance and the facts and other matters contained in the foregoing are true and accurate to the best of the undersigned's knowledge and belief. The undersigned understands and agrees: 1) any insurance coverage or benefits is contingent upon any statements made to AUL as being complete and correct and 2) benefits under any policy will be paid only if AUL decides the applicant is entitled to them under the policy. Signature of Witness Sionature of Insured (The Witness must have no interest in the po/icy/contract or be a named beneficiary) Printed Name Printed Name Date Date Lack of Notice of Community Property Interest: If AUL has not previously received written notice of a community property interest and if the space for consent below is not signed by a person having such an interest, then AUL shall be entitled to rely upon its good faith that no such interest exists. AUL assumes no responsibility of inquiry regarding such interest and, in consideration of acknowledgement of this designation, the insured person listed above, for himself/herself and his/her estate, heirs, successors and assigns, agrees to indemnify AUL and hold it harmless from the consequences of acknowledging this beneficiary designation. Spouse's signature and consent (if applicable}:3 _ Date 1 Total percentage must equal 100%. If percentages do not equal 100%, then oonefits will be paid on a pro-rata basis, according to the percentages shown. If no percentages are shown, benefits will be distributed equally. 2 Total percentage must equal 100%. If percentages do not equal 100%, then benefits will be paid on a pro-rata basis, according to the percentages shown. If no percentages are shown, benefits will be distributed equally. 3 Spouse's signature is needed only if Insured/Beneficiary lives in a community property state which currently include AZ, CA, ID, LA NM, NV, TX, WA and WI. G-13117 8/19/14 G-620377 III-A ---PAGE BREAK---