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Employee Health Benefits Manual @IIIATrust @IIIA_Trust City of Blackfoot Effective October 1, 2024 Benefits Line: [PHONE REDACTED] iii-a.org I PO Box 190477 I Boise, ID 83719 I F: (208) 575-6423 ---PAGE BREAK--- You are part of the III-A family! Nicole Tuttle Benefits Manager [EMAIL REDACTED] Tami Testa Benefits Manager [EMAIL REDACTED] Hana Waters Senior Benefits Specialist [EMAIL REDACTED] Alaysia Wallace Benefits Specialist [EMAIL REDACTED] III-A is a self-funded health trust that administers your health benefits. We care deeply about you and your health and are available 24/7/365. Contact the III-A Benefits Line for any benefits-related questions. LIST OF BENEFIT CHANGES EFFECTIVE OCTOBER 1, 2024: • New Pharmacy Benefit via SmithRx • Chiropractor Visits - all plans 24 visits • Insulin Pump Supplies - copay (pump - deductible/cost share) • Dry Needling - deductible/cost share in physical therapy setting • Orthoptic/Visual Therapy - deductible/cost-share • CPAP Program • Outpatient Speech and Occupational Therapy - copay Scan to Receive Important Benefit Communications: Meet Your Benefits Team Meet Your Medical Team 24/7/365 Medical Telehealth (call or text) Contact provider and leave a message with your name, DOB, and agency. Do not call the other provider, you will receive a call back within two hours. This is a no-cost program. Velma Seabolt, NP (208) 271-4460 Dustin Reno, NP (208) 203-0783 24/7/365 Benefits Line (call or text): (208) 938-8199 [EMAIL REDACTED] I *Translation services available ---PAGE BREAK--- III-A Internal Benefits ACUPUNCTURE 52 Acupuncture visits (up to $80 per visit). Acupuncturist must be state licensed and not “certified.” Find our Direct-Pay Acupuncture Network at iii-a.org. Password: IIIABenefits2011 *If you are currently seeing a licensed Acupuncturist who is not in III-A Network, call the Benefits Line. III-A Direct Pay Network Acupuncturist Acupuncturists invoice III-A directly. Member pays any amount over $80. Out-of-Network Acupuncturist Payment is collected at the time of service and member files for reimbursement. III-A Claims form located at iii-a.org AIR AMBULANCE For medically necessary air ambulance transport, deductible and cost share will be reimbursed after claim processes through Blue Cross of Idaho medical insurance. This is a household benefit (dependents up to age 26), whether covered by III-A medical plans, or not. Dependents NOT Enrolled in the III-A Plan Claim will process through dependent’s other medical insurance, after which member files for reimbursement. III-A Claims form located at iii-a.org Eligible Dependents Without Insurance Coverage III-A will reimburse a maximum of $2,000 of the air ambulance claim. III-A Specialty Programs Claim form located at iii-a.org HEARING AIDS One-time purchase of hearing aid devices, up to $3,000 every three calendar years. Member files for reimbursement or payment may be made directly to provider. III-A Claims form located at iii-a.org HEARING PROTECTION DEVICES Reimbursement up to $150 for one protective hearing device once every five calendar years. Eligible devices must be designed to reduce decibel levels and include an NRR rating or list decibel reduction (excludes air pods, Samsung earbuds, etc.). III-A Claims form located at iii-a.org ---PAGE BREAK--- III-A Medical Programs VIRTUAL PHYSICAL THERAPY & PERSONAL TRAINING Hinge Health provides personalized care plans to help people accomplish health goals related to musculoskeletal (back, muscle, and joint) health. This virtual Physical Therapy Program is available to members experiencing chronic pain (12 weeks or more of pain). Members and dependents 18+ enrolled in a III-A medical plan are eligible. No cost or benefit limit, referral or diagnosis needed from a doctor. Visit or call (855) 902-2777 to see if you qualify. For individuals that do not qualify for Hinge Health, a Blue Cross of Idaho Physical Therapist or Personal Trainer will contact you for a virtual training and coaching plan. **Claims data may also trigger the BCI clinicians to reach out to members who may qualify for virtual sessions.** DIABETES PREVENTION PROGRAM When enrolled in the program, you’ll get the tools you need to be successful in weight loss—all at no cost to you! Programs include access to tools like Fitbit activity trackers, health coaching, meal planning, and a wireless scale. To see if you qualify visit: http://solera4me.com/bcidaho Once enrolled, you’ll have access to a full year of leading weight loss programs like WeightWatchers®. BARIATRIC SURGERY PROGRAM Eligible members will be reimbursed up to $15,000 for outpatient Gastric Sleeve (Sleeve Gastrectomy) after a $2,000 member contribution. Surgery must be performed in United States. Reimbursement will apply to the following: • Consultation • Related Lab Work • Surgery • Facility Fees • Anesthesia • Medically Necessary IV Fluids • Post-Surgery Follow-up Meal kits are excluded. Eligibility • III-A member or dependents over the age of 18. • Nonsurgical methods have been unsuccessful in treating obesity. • Must have a Body Mass Index (BMI) of 40 or higher, or at least 100 pounds over or twice the ideal weight for frame, age, height and sex specified in the 1983 Metropolitan Life Insurance table, or approval after a consultation with a III-A Nurse Practitioner. • Three health coaching visits with III-A and/or completion of Wondr Health Program pre-op. For Reimbursement • Member must select and pay the cash price for surgery with the facility. • Member will submit documentation of medical necessity and a paid receipt to III-A for reimbursement up to $15,000 ($2,000 member contribution, $13,000 reimbursement from III-A). • Upon III-A receiving necessary documentation, III-A will issue a reimbursement to the member for eligible expenses. III-A Specialty Programs Claim form located at iii-a.org ---PAGE BREAK--- III-A Medical Programs BEHAVORIAL HEALTH MANAGEMENT PROGRAM Eligible members and dependents will be reimbursed for their deductible, cost share and allowed travel expenses when inpatient treatment is at a III-A Preferred Behavioral Health Facility. To locate a III-A Preferred Behavioral Health Facility, call: (208) 938-8199. Member MUST enter and successfully complete the recommended length of stay of the program per Mental Health consultant to be eligible for reimbursement. One reimbursement is allowed per lifetime. MATERNITY PROGRAM Members who choose to deliver their baby at a St. Alphonsus facility will receive reimbursement in the amount of $1,500. If III-A is secondary medical coverage, the member may still participate and receive reimbursement. III-A Specialty Programs Claim form located at iii-a.org MEDICATION INFUSION PROGRAM Members who receive infusion treatments for the listed medical conditions may receive reimbursement of deductible, cost share and allowed travel expenses when infusions are at a III-A Preferred Infusion Facility. Multiple Sclerosis (MS) • Crohn's • Lupus Rheumatoid Arthritis (RA) • Inflammatory Bowel Disease • Colitis • Psoriasis To check eligibility call: (208) 938-8199 All medications may not be eligible. CARE MANAGEMENT Care Management is available to any member who is experiencing chronic or complex health conditions. Members will receive assistance with prior authorizations, understanding bills/ invoices, and coverage questions. In addition, members will receive support, follow-up, and guidance from one of our Nurse Practitioners. No cost benefit! For assistance or questions regarding Care Management, call: (208) 938-8199 ---PAGE BREAK--- III-A Medical Programs ONSITE WELLNESS SCREENINGS, FLU VACCINES, AND SKIN CHECKS Annually, III-A will bring a Nurse Practitioner onsite for a no-cost annual wellness screening and skin exam for members and covered dependents age 18+, flu vaccines available for age Ask your HR/Clerk for your agency’s date and time and how to sign-up. You can also attend any other agency’s wellness screening, find them at iii-a.org. WIGS Eligible members will be reimbursed up to $300 per calendar year, based on medical necessity. III-A Specialty Programs Claim form located at iii-a.org CPAP PROGRAM The program will reimburse members 50% for the self-pay option for CPAP and supplies after submission of receipt and prescription. CPAP Machine: 50% reimbursement once every five years Supplies: 50% reimbursement, up to $500 per calendar year • Mask frame and cushion • Humidifier chamber • Replacement nasal cushion • Tubing • Other supplies (filters, straps/headgear, etc.) III-A Claims form located at iii-a.org ---PAGE BREAK--- III-A Wellness Programs WONDR HEALTH - DIGITAL WEIGHT LOSS PROGRAM Wondr Core: • Learn simple skills based on behavioral science Wondr Advanced: • Available to those with a BMI of 30+ or 27+ along with another medical condition • Personalized care from physicians and registered dietitians • May include covered oral weight loss medications Wondr Health is a personalized weight loss program, tailored to each user, backed by science and taught by renowned experts. Join here at anytime: HEALTH COACHING Work one-on-one with a certified health coach on goal setting and lifestyle changes. Health coaching can be utilized for a variety of topics such as nutrition, physical activity and exercise, stress management, sleep, weight loss/ maintenance, diabetes prevention, blood pressure, and/or cholesterol management, and tobacco cessation. To enroll email [EMAIL REDACTED] or call (208) 938-5632. WELLNESS WEDNESDAY WEBINARS webinars focus on mental or physical wellness. 12pm PT/1pm MT via zoom. Go to iii-a.org and visit the calendar to register. Receive a recording after the webinar if you’ve registered. Resource library: iii-a.org/wellness-resource-library/ to access our past webinars. Password: IIIABenefits2011 10/16/24 Mental Health and Movement 11/20/24 Surviving Holiday Stress 12/18/24 Reaching for Fitness 1/15/25 Conquering the Seasonal Blues 2/19/25 Wellness Benefits Highlights 3/19/25 Effective Communication and Relationships 4/16/25 Nutrition Dejunked 5/14/25 Social Media and Mental Health 6/25/25 Depression and Heart Disease 7/16/25 Brain and Gut Connection 8/20/25 Take a Break - Prevent Burnout 9/24/25 Fad Diets vs Lasting Fixes Dates and topics are subject to change. WELLNESS CHALLENGES Wellness challenges are held every other month. All participants are entered to win a prize. Sign up for III-A communication to be notified of upcoming challenges. 10/2024 Walktober 12/2024 12 Days of Fitness 2/2025 Fuel Your Body Challenge 4/2025 Stay Centered Challenge 6/2025 Opt-Outside Challenge 8/2025 Healthy Sleep Challenge TOBACCO CESSATION Work with a certified tobacco cessation coach. Quit Aids: available at no cost with a prescription. Email BCI coaches at [EMAIL REDACTED] or call (208) 286-3807. ---PAGE BREAK--- ---PAGE BREAK--- III-A Mental Health Benefits EMPLOYEE ASSISTANCE PROGRAM (EAP) Receive 10 free visits per issue, per year for counseling services with an III-A EAP Provider. This is a household benefit (spouse and/or dependents up to age 26), whether or not covered by III-A. • Go to to access the in-network EAP Provider list. Password: IIIABenefits2011 • Choose a provider and schedule your appointment. • Tell them you're using your III-A EAP benefit. To obtain an authorization code they may email or call: [EMAIL REDACTED] or (208) 938-8199 **No prior authorization is required.** FIRST RESPONDER AND FAMILY HELPLINE - 24/7/365 PTSI assistance, substance misuse, mental performance, etc. GENERAL MEMBERSHIP HELPLINE - 24/7/365 Non-first responder members in crisis can call the III-A Benefits Line (208) 938-8199. MENTAL HEALTH TRAININGS All trainings qualify for ID POST credits and/or CE hours (meets NFPA Standard 1500). Can be requested by an agency at any time. Cultivating Resiliency, Families on the Frontline, Peer Support, and many more trainings are available. Contact [EMAIL REDACTED] for training information. CRISIS RESPONSE AVAILABLE If you have a critical incident that occurs please call the III-A Benefits Line and we will coordinate with mental health providers to accommodate your needs (CISM/CISD). Contact Tami Testa at (208) 479-8309 for assistance. (208) 244-7000 ---PAGE BREAK--- Form No. III-A_Std_PPO_70-B_(10/24) Blue Cross of Idaho is a trade name for Blue Cross of Idaho Health Service, Inc. 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 and exclusions and limitations. 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. ASC PPO 70-C BENEFITS OUTLINE Visit our Website at www.bcidaho.com to locate a Contracting Provider Deductibles (per Benefit Period) Individual In-Network Out-of-Network The Participant is responsible to pay these amounts: $3,000 Family (No Participant may contribute more than the Individual Deductible amount toward the Family Deductible) $6,000 Out-of-Pocket Limits (per Benefit Period) (See Plan for services that do not apply to the limit) (Includes applicable Deductible, Cost Sharing and Copayments) Individual Family (No Participant may contribute more than the Individual Out-of-Pocket Limit amount toward the Family Out-of- Pocket Limit) $3,500 $9,000 $9,000 $12,000 Cost Sharing Unless specified otherwise below, the Participant pays the following Cost Sharing amount 30% of Maximum Allowance after Deductible 50% of Maximum Allowance after Deductible Frequently used Covered Services - Some services may require Prior Authorization. Physician Office Visits (Additional services, such as laboratory, x-ray, and other Diagnostic Services are not included in the Office Visit.) $40 Copayment Deductible and Cost Sharing Pediatric Physician Office Visits (For Participants under the age of eighteen (18). Includes Urgent Care visits. Includes mononucleosis testing, strep A and B testing, development screening(s), ear wax removal, removal of foreign body from ear, urine pregnancy tests, influenza A or B test, rapid RSV test, and pulse oximetry.) (All other additional services not listed above, such as laboratory, x-ray, and other Diagnostic Services are not included in the Pediatric Physician Office Visit Copayment.) No Charge (Deductible does not apply) Deductible and Cost Sharing MEDICAL ---PAGE BREAK--- Form No. III-A_Std_PPO_70-B_(10/24) Preventive Care Covered Services For specifically listed Covered Services Annual adult physical examinations; routine or scheduled well- baby and well-child examinations, including vision, hearing and developmental screenings; Dental fluoride application for Participants age 5 and under; Bone Density; Chemistry Panels; Cholesterol Screening; Colorectal Cancer Screening; Complete Blood Count (CBC); Diabetes Screening; Pap Test; PSA Test; Rubella Screening; Screening EKG; Screening Mammogram; Thyroid Stimulating Hormone (TSH); Transmittable Diseases Screening (Chlamydia, Gonorrhea, Human Immunodeficiency Virus (HIV); Human papillomavirus (HPV), Syphilis, Tuberculosis (TB); Hepatitis B Virus Screening; Sexually Transmitted Infections assessment; HIV assessment; Screening and assessment for interpersonal and domestic violence; Urinalysis (UA); Abdominal Aortic Aneurysm Screening and Ultrasound; Unhealthy Alcohol and Drug Use Assessment; Breast Cancer (BRCA) Risk Assessment and Genetic Counseling and Testing for High Risk Family History of Breast or Ovarian Cancer; Newborn Metabolic Screening (PKU, Thyroxine, Sickle Cell); Health Risk Assessment for Depression and/or self-harm; Anxiety Screening; Newborn Hearing Test; Lipid Disorder Screening; Nicotine, Smoking and Tobacco-use Cessation Counseling Visit; Dietary Counseling and Physical Activity Behavioral Counseling; Behavioral Counseling for Participants who are overweight or obese; Preventive Lead Screening; Lung Cancer Screening for Participants age 50 and over, Hepatitis C Virus Infection Screening; Urinary Incontinence Screening; Urine Culture for Pregnant Women; Iron Deficiency Screening for Pregnant Women; Rh Incompatibility Screening for Pregnant Women; Diabetes Screening for Pregnant Women; Perinatal Depression Counseling and Intervention; Behavioral Counseling for Healthy Weight and Weight Gain in Pregnancy. The specifically listed Preventive Care Services may be adjusted accordingly to coincide with federal government changes, updates, and revisions. For services not specifically listed No Charge (Deductible does not apply) Deductible and Cost Sharing Deductible and Cost Sharing Deductible and Cost Sharing Immunizations Acellular Pertussis, Diphtheria, Haemophilus Influenza B, Hepatitis B, Influenza, Measles, Mumps, Pneumococcal (pneumonia), Poliomyelitis (polio), Rotavirus, Rubella, Tetanus, Varicella (Chicken Pox), Hepatitis A, Meningococcal, Human papillomavirus (HPV), Zoster and COVID-19. All Immunizations are limited to the extent recommended by the Advisory Committee on Immunization Practices (ACIP) and may be adjusted accordingly to coincide with federal government changes, updates and revisions. Other immunizations not specifically listed may be covered at the discretion of the Contract Administrator when Medically Necessary. No Charge (Deductible does not apply) Deductible and Cost Sharing No Charge (Deductible does not apply) Deductible and Cost Sharing ---PAGE BREAK--- Form No. III-A_Std_PPO_70-B_(10/24) TELEHEALTH 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. COVERED SERVICES Some services may require Prior Authorization. In-Network Out-of-Network The Participant is responsible to pay these amounts: Allergy Injections • Administration Only • Allergy Serum $5 Copayment per visit if no other Office Visit Copayment is required for other Covered Services provided during the visit $20 Copayment Deductible and Cost Sharing Ambulance Transportation Services • Ground Ambulance Services • Air Ambulance Services (Payment for Out-of-Network Air Ambulance Services is based on the Qualifying Payment Amount. Out-of- Network Air Ambulance Services accumulate towards the In-Network Out-of-Pocket Limit.) Deductible and Cost Sharing Deductible and Cost Sharing Deductible and Cost Sharing Deductible and In-Network Cost Sharing Breastfeeding Support and Supply Services (Includes rental and/or purchase of manual or electric breast pumps. Limited to one breast pump purchase per Benefit Period, per Participant.) No Charge (Deductible does not apply) Deductible and Cost Sharing Cardiac Rehabilitation Therapy Services – Outpatient Up to a combined In-Network and Out-of-Network total of 36 visits per Participant, per Benefit Period. An additional 36 visits may be available with Prior Authorization. $10 Copayment Deductible and Cost Sharing Chiropractic Care Services Up to a combined In-Network and Out-of-Network total of 24 visits per Participant, per Benefit Period. (Additional services, such as laboratory, x-ray and other Diagnostic Services are not included in the Office Visit.) $40 Copayment Deductible and Cost Sharing Colonoscopies and Sigmoidoscopies (Preventive and Diagnostic) No Charge (Deductible does not apply) Deductible and Cost Sharing Dental Services Related to Accidental Injury Deductible and Cost Sharing Deductible and Cost Sharing Dermatological Skin Biopsies and Pathology (Preventive and Diagnostic) No Charge (Deductible does not apply) Deductible and Cost Sharing Diabetes Self-Management Education Services $40 Copayment Deductible and Cost Sharing Diagnostic Services - Laboratory and X-ray Deductible and Cost Sharing Deductible and Cost Sharing ---PAGE BREAK--- Form No. III-A_Std_PPO_70-B_(10/24) COVERED SERVICES Some services may require Prior Authorization. In-Network Out-of-Network The Participant is responsible to pay these amounts: Durable Medical Equipment, Orthotic Devices, Prosthetic Appliances and Insulin Pump Insulin Pump Supplies Deductible and Cost Sharing $40 Copayment Deductible and Cost Sharing Emergency Services – Facility Services (Copayment waived if admitted) (Payment for Out-of-Network Emergency Services is based on the Qualifying Payment Amount.) $100 Copayment per hospital Outpatient emergency room visit, then Deductible and In-Network Cost Sharing. Emergency Services accumulate towards the In-Network Out-of-Pocket Limit. Emergency Services – Professional Services (Payment for Out-of-Network Emergency Services is based on the Qualifying Payment Amount.) Deductible and In-Network Cost Sharing. Emergency Services accumulate towards the In-Network Out-of-Pocket Limit. Hearing and Hearing Aid Exams $40 Copayment (Deductible does not apply) Deductible and Cost Sharing Home Health Skilled Nursing Care Services Deductible and Cost Sharing Deductible and Cost Sharing Home Intravenous Therapy Deductible and Cost Sharing Deductible and 80% Cost Sharing Hospice Services No Charge (Deductible does not apply) Deductible and Cost Sharing Hospital Services Deductible and Cost Sharing Deductible and Cost Sharing Inpatient Rehabilitation or Habilitation Services Deductible and Cost Sharing Deductible and Cost Sharing Mammograms (Diagnostic) (See Preventive Care for Screening Mammography benefit.) Breast Ultrasounds No Charge (Deductible does not apply) Deductible and Cost Sharing Maternity Services and/or Involuntary Complications of Pregnancy Deductible and Cost Sharing Deductible and Cost Sharing Mental Health and Substance Use Disorder Inpatient Services • Inpatient Facility and Professional Services Deductible and Cost Sharing Deductible and Cost Sharing Mental Health and Substance Use Disorder Outpatient Services • Outpatient Services • Pediatric Outpatient Services (For Participants under the age of eighteen • Facility and other Professional Services $40 Copayment No Charge (Deductible does not apply) Deductible and Cost Sharing Deductible and Cost Sharing Outpatient Applied Behavioral Analysis (ABA) • Pediatric Outpatient Applied Behavioral Analysis (ABA) (For Participants under the age of eighteen $40 Copayment No Charge (Deductible does not apply) Deductible and Cost Sharing Treatment for Autism Spectrum Disorder Covered the same as any other illness, depending on the services rendered. Please see the appropriate section of the Benefits Outline. Visit limits do not apply to Treatments for Autism Spectrum Disorder, and related diagnoses. ---PAGE BREAK--- Form No. III-A_Std_PPO_70-B_(10/24) COVERED SERVICES Some services may require Prior Authorization. In-Network Out-of-Network The Participant is responsible to pay these amounts: Outpatient Habilitation Physical Therapy Services Up to a combined In-Network and Out-of-Network total of 30 visits per Participant, per Benefit Period. (Additional services, such as, x-ray and other Diagnostic Services are not included in the Therapy Services Copayment.) $40 Copayment Deductible and Cost Sharing Outpatient Habilitation Therapy Services • Outpatient Occupational Therapy • Outpatient Speech Therapy Up to a combined In-Network and Out-of-Network total of 30 visits per Participant, per Benefit Period. (Additional services, such as, x-ray and other Diagnostic Services are not included in the Therapy Services Copayment.) $40 Copayment Deductible and Cost Sharing Outpatient Pulmonary Rehabilitation Therapy Services $10 Copayment Deductible and Cost Sharing Outpatient Rehabilitation Physical Therapy Services Up to a combined In-Network and Out-of-Network total of 30 visits per Participant, per Benefit Period. (Additional services, such as, x-ray and other Diagnostic Services are not included in the Therapy Services Copayment.) $40 Copayment Deductible and Cost Sharing Outpatient Rehabilitation Therapy Services • Outpatient Occupational Therapy • Outpatient Speech Therapy Up to a combined In-Network and Out-of-Network total of 30 visits per Participant, per Benefit Period. (Additional services, such as, x-ray and other Diagnostic Services are not included in the Therapy Services Copayment.) $40 Copayment Deductible and Cost Sharing Palliative Care Services No Charge (Deductible does not apply) Deductible and Cost Sharing Post-Mastectomy/Lumpectomy Reconstructive Surgery Deductible and Cost Sharing Deductible and Cost Sharing Prescribed Contraceptive Services (Includes diaphragms, intrauterine devices (IUDs), implantables, injections, tubal ligation and vasectomy.) No Charge (Deductible does not apply) Deductible and Cost Sharing PSA Tests and Pap Smears (Diagnostic) (See Preventive Care for Screening PSA Tests and Pap Smears benefits.) No Charge (Deductible does not apply) Deductible and Cost Sharing Skilled Nursing Facility Up to a combined In-Network and Out-of-Network total of 30 days per Participant, per Benefit Period. Deductible and Cost Sharing Deductible and Cost Sharing Surgical/Medical (Professional Services) Deductible and Cost Sharing Deductible and Cost Sharing ---PAGE BREAK--- Form No. III-A_Std_PPO_70-B_(10/24) COVERED SERVICES Some services may require Prior Authorization. In-Network Out-of-Network The Participant is responsible to pay these amounts: Therapy Services (Including Radiation, Chemotherapy, Renal Dialysis and Growth Hormone) Deductible and Cost Sharing Deductible and Cost Sharing Transplant Services Deductible and Cost Sharing Deductible and Cost Sharing Be aware that your actual costs for services provided by an Out-of-Network Provider may exceed the Plan’s Out-of-Pocket Limit for Out-of-Network services. Except as provided by the No Surprises Act, Out-of-Network Providers can bill you for the difference between the amount charged by the Provider and the amount allowed by the Contract Administrator, and that amount is not counted toward the Out-of-Network Out-of-Pocket Limit. 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 and exclusions and limitations. 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. ---PAGE BREAK--- • Preventive care is when you see a doctor or have a screening when you do not have any signs of a medical problem. • Covered preventative care services with an in-network providers will have no cost to you. • Preventive care benefits for services from out-of-network providers are subject to your out-of- Preventative Care Benefits Services for Adults (18+) Services for Children (17 years and under) • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Note: Your provider must bill these services as preventive/wellness services. For complete descriptions of your policy, please contact III-A staff. ---PAGE BREAK--- ✔CHECK WHEN COMPLETED FREQUENCY DATE SCHEDULED Blood Pressure Cholesterol Every 5 years* Body Mass Index Bone Mass Measurement Breast Cancer Colon Cancer Diabetes Screening (A1C) Flu Vaccine Immunizations Pneumonia Vaccine Well Woman Exam *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. Preventative Schedule ---PAGE BREAK--- Age Activity 2 weeks Exam, Health Education 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 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 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) Getting your child vaccinated is one of the best steps you can take for a healthy start in life. 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. Your pediatrician will review immunizations on each visit for the needs of your child. Well Child Immunization & Visit Schedule ---PAGE BREAK--- Pharmacy Benefit Manager Where to begin: Create an account through the online Member Portal at smithrx.com/portal. Gain access to: • Pharmacy search tool and plan documents • Prescription formulary • Print ID card • ‘Find My Meds’ pricing tool • Mail order pharmacy information • Important forms request a new ID card) • Pharmacy transactions If a member gets a rejection at the pharmacy: 1. Make sure the pharmacy is using the correct/updated insurance information 2. Ask the pharmacy to explain the rejection 3. Call the III-A Benefits Line at [PHONE REDACTED] DO NOT LEAVE THE PHARMACY WITHOUT YOUR PRESCRIBED MEDICATIONS. Provide your prescription benefits card to the pharmacy and your Provider(s) and ask them to update your insurance. ---PAGE BREAK--- Pharmacy Benefits Pharmacy Copays: RETAIL PHARMACY: 30 DAY SUPPLY Generic (Tier Up to $10 Brand Name (Tier Up to $25 Non-Preferred Drugs (Tier Up to $40 SPECIALITY PHARMACY: 30 DAY SUPPLY LIMIT Contact the III-A Benefits Line to discuss the specialty med options and saving opportunities. PHARMACY OPTIONS: SmithRx partners with over 83,000 retail pharmacies across the nation. Members can still utilize their local pharmacy at any time. MAIL ORDER OPTIONS: Members can utilize the mail order partner pharmacies for convenience and savings. Below are the three preferred mail order pharmacies partnering with SmithRx: ---PAGE BREAK--- DELTA DENTAL OF IDAHO www.deltadentalid.com Customer Service PO BOX 2870 (208) 489-3580 Boise, ID 83701 (800) 356-7586 Oct 2024 BENEFITS PLAN Plan # 3-C1000 Network: PPO Premier I Out-of-Network Class I Preventive and Diagnostic Services Examinations, teeth cleaning, X-rays 100% 80% Class II Basic Services Fillings, root canals, extractions, oral surgery 80% 70% Class III Major Restorative Services Crowns, implants, onlays, bridges, dentures 50% 40% Deductible Per person per calendar year/aggregated per family. Deductible not applicable to preventive, diagnostic, or orthodontic services $50/$150 $50/$150 Annual Maximum The annual maximums and deductibles are determined each calendar year, from January 1st through December 31 St. Preventive and diagnostic services do not count towards the annual maximum $2,000 $2,000 Class IV Benefits Orthodontic Services Eligible for dependent children. Banding up to age 26. 100% 100% Orthodontia Lifetime Maximum $1,000 $1,000 Additional Benefits I Limitations Class I Preventive and Diagnostic Services Periodic exams are allowed 2 times every 1 year; Adult and child cleanings are allowed 2 times every 1 year (restricts against periodontal maintenance within the same time period); Fluoride treatment is allowed 2 times every 1 year through age 18; Full mouth series or panoramic x-rays are allowed 1 time every 5 years; Bitewing x-rays are allowed 1 time every 12 months. Class II Basic Services Periodontal maintenance procedure is allowed 4 times in 12 months (if patient has had previously treated periodontal disease); Periodontal scaling and root planing- per quadrant is allowed 1 time every 24 months; Root Canals, Extractions, Periodontics; Fillings restricted to same tooth/surface are allowed 1 time every 24 months. Dependents Eligible children must be under age 26 Class III Major Restorative Services Crowns, stainless steel crowns, onlays, or bridges on same tooth are allowed 1 time every 7 years; Porcelain, porcelain substrate, and cast restorations are not payable for children less than 12 years of age; Partials or dentures per arch are allowed 1 time every 7 years for ages 16 and older. Class III Implants Implants are a covered benefit per tooth with a maximum lifetime benefit of $1,200 or the plan's annual maximum, whichever is less (ages 19 and over). Class IV Orthodontic Services Eligible for banding up to age 26; Maximum orthodontic lifetime benefit is $1,000; Replacement of orthodontic appliance is not covered. Late Enrollee: Any employee and/or their dependent(s) who did not enroll on the dental plan following completion of the employee’s eligibility period will be considered a late enrollee and may only enroll during the next Open Enrollment Period or due to an eligible family status change. Participating and Non-Participating Dentists: If the dentist is a network participating dentist, Delta Dental will base payment on the lesser of the Submitted Amount or the Contract Fee. Delta Dental will send payment to the participating dentist and the subscriber will be responsible for any copayment and/or any non-covered services. If the dentist is a non-participating dentist, Delta Dental will base payment on the lesser of the Submitted Amount or Delta Dental's non-participating dentist Fee. It is the subscriber's responsibility to make full payment to the non-participating Dentist. For dental services rendered by an out-of-state dentist, Delta Dental will base payment on the lesser of the Submitted Amount or the Contract Fee in that area, if the out-of-state dentist is a participating dentist with a Delta Dental plan in the state in which the service is rendered. This is only a general summary of benefits. It provides a brief description about the important features of this policy and does not constitute a contract or guarantee of payment. Full terms and conditions are set forth in the policy provisions. DENTAL ---PAGE BREAK--- Life Insurance: $20,000 Tyson Griffeth I [PHONE REDACTED] [EMAIL REDACTED] Life, Accidental Death & Dismemberment (AD&D) Insurance: Complete the OneAmerica Beneficiary Designation Form and give it to your employer. Keep this form updated. 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. Other Resources: (855) 387-9727 I guidanceresources.com Password: OneAmerica3 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 Additional Benefits ---PAGE BREAK--- Workers Comp In the event of a work-related accident, please be sure to let III-A know via the benefits line. If a member experiences a work-related accident, injury, illness or occupational exposure, they should report the incident immediately, even if medical treatment is not required. Then: • Work with HR to contact your worker's compensation insurer The State Insurance Fund 208-332- 2100) • Write down your adjuster name, phone number, and claim number • Provide ANY treating physician or facility with the above claim information if treating something related to the workplace injury • Notify III-A by calling the III-A Benefits Line or emailing [EMAIL REDACTED] Subrogation Non-Work-Related Injuries/Accidents If a member is involved in an accident or sustained an injury that was the result of someone else’s negligence, please notify III-A about this injury by calling the III-A Benefits Line or emailing [EMAIL REDACTED]. Also, if a member receives a questionnaire from Davies Subrogation Management, please complete this form and return it at your earliest convenience. To contact Davies Subrogation Management email [EMAIL REDACTED] or call (815) 267-5000. Sample Letter Injury or Accident Notification ---PAGE BREAK--- G-620377 III-A Submit your completed form to your employer ***Reminder to keep this form updated*** ---PAGE BREAK---