OPEN ENROLLMENT Effective 1/1/2015 Highlights Please review ALL documents in this packet. All open enrollment forms (white – waiver or orange – enrollment) are due to the Office of Human Resources by December 1, 2014. The following list highlights items to consider as you complete the forms: 1) Monthly premium changes Effective 1/1/2015 the monthly premium rates will have increased when compared to the 2014 premium rates. Please be sure to review each plan carefully before selecting your plan for the upcoming 2015 coverage year to take these increases into account. 2) Affordable Care Act (ACA) Please note that ONU meets the minimum value standard for benefit plan coverage and the cost of coverage to you is intended to be affordable, based on employee wage. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information. 3) Flexible Spending Account (FSA) If you wish to elect flexible spending in 2015, you MUST submit a new Anthem flexible spending form each year, an FSA enrollment form is included in this packet. 4) Health Savings Account (HSA) Contributing to a HSA is for participants of Plan B only. If you wish to continue or start a contribution to a HSA, as an enrollee on Plan B, please complete the HSA form included in this packet. 5) Healthy Campus Program Please log onto the HR Moodle course, Healthy Campus Program, https://lms.onu.edu, for an updated look at your total healthy campus points. If you have not reached the 40 point goal to receive your 2015 discount, please join us at the upcoming health screenings for an opportunity to receive points. Information regarding the health screenings and possible healthy campus points to be earned are included in this packet. Coverage Waiver WAIVING COVERAGE: By providing my signature below, I hereby acknowledge that I was offered the opportunity to elect and participate in my employer’s healthcare plan and have decided not to enroll myself, or dependents, for such coverage. Employee Signature: __________________________________________ Date: _____________________ ANTHEM SDC OFFICE OF HUMAN RESOURCES ONLY: BANNER MEDICAL DENTAL PAYROLL LEHR MEMORIAL BUILDING • PHONE: (419) 772-2013 • FAX: (419) 772-3510 • www.onu.edu/hr • [email protected] OHIO NORTHERN UNIVERSITY HEALTH BENEFITS Premium Information Eligibility for Benefits Coverage, if elected, becomes effective the first day of employment and terminates contingent with University policy. Employees choosing not to enroll in this plan at the time of initial employment are requested to sign a waiver of insurance. Employees may change or enroll in the plan at a subsequent date as explained in the Medical Insurance Summary Plan Description (SPD) located on the Office of Human Resources website, benefits page. The total monthly premium to be paid by the employee is listed below and is based on plan choice and salary at January 1, 2015. This salary amount will be based on actual annual contracted hours, not including overtime or summer pay. Premium adjustments may be made in the case of a professional move within the employees current position. The 2015 Healthy Campus Program launch will be announced in the upcoming weeks. Information regarding this program will be sent from the Office of Human Resources soon. Dependent coverage shall be made available for spouse and children up to 26 years of age, pursuant to the terms of the SPD. Open enrollment for health insurance begins in October of each year for coverage effective January 1 of the following year. 2015 Anthem Blue Access Medical and Rx Plans 2015 ONU Plan Options Deductible (includes deductible) Plan B Non-network Network Non-network Network Non-network Single: $400.00 $500.00 $500.00 $750.00 $1,250.00 $1,500.00 Family: $800.00 $1,000.00 $1,000.00 $1,500.00 $2,500.00 $3,000.00 90% 60% 80% 50% 90% 60% Single: $2,000.00 $4,000.00 $2,500.00 $5,000.00 $3,250.00 $6,500.00 Family: $4,000.00 $8,000.00 $5,000.00 $10,000 $6,500.00 $13,000.00 $20.00 Ded. & Coins. $25.00 Ded. & Coins. Deductible & Coinsurance $100.00 copay (waived if admitted) Deductible & Coinsurance Office visit copays: Emergency room visit: Wellness: Core Plan Network Then paid at: Max out of pocket Plan A $100.00 copay (waived if admitted) 100%, unlimited benefit deductible & copays waived Rx Drug Card Plan Maximum Out of Pocket $1,200 Single, $2,400 family Prescriptions: Retail: 10% Generic/30% Formulary/40% Non-Formulary Mail Order: 5% Generic/%25 Formulary/35% Non-Formulary Mandatory Generic Drugs Provision Pretax savings plans: Flexible Spending Account available with a $2,500 per year maximum contribution for health care and $5,000 maximum for dependent day care per year 100%, unlimited Benefit Deductible & Copays waived Prescriptions accumulate to the medical deductible & coinsurance Member pays 100% of discounted cost of Rx at pharmacy. Submitted claims are applied to deductible and reimbursed at 75% after deductible is satisfied *100% Preventative tier included Flexible Spending Account (FSA) available with $2,500 healthcare (limited access)/$5,000 dependent care maximum per year Health Savings Account (HSA) available $3,350 single/ $6,650 family maximum annual contribution NOTE: All plans include Anthem Vision Plan and Superior Dental Preventative Plan Office of Human Resources Lehr Memorial Building • Phone: (419) 772-2013 • Fax: (419) 772-3510 • www.onu.edu/hr • [email protected] 2015 Employee Medical/Rx/Vision & Preventative Dental Monthly Contribution Rates Salary Range Employee annual salary or wage is ≤ $35,000 Employee annual salary or wage is $35,001 - $90,000 Employee annual salary or wage is $90,001+ Coverage Level Plan A Core Plan Plan B Employee Only $99.00 $80.00 $36.00 Employee + Spouse/Partner $354.00 $282.00 $128.00 Employee + 1 Child $294.00 $234.00 $106.00 Employee + Family $580.00 $461.00 $209.00 Dual Employee Family $343.00 $275.25 $124.25 *Healthy Campus monthly discount $15.00 $15.00 $15.00 Employee Only $137.00 $110.00 $46.00 Employee + Spouse/Partner $491.00 $392.00 $160.00 Employee + 1 Child $407.00 $324.00 $131.00 Employee + Family $804.00 $641.00 $261.00 Dual Employee Family $475.00 $380.25 $157.25 *Healthy Campus monthly discount $20.00 $20.00 $20.00 Employee Only $200.00 $160.00 $83.00 Employee + Spouse/Partner $712.00 $568.00 $291.00 Employee + 1 Child $590.00 $469.00 $239.00 Employee + Family $1,166.00 $930.00 $448.00 Dual Employee Family $691.50 $552.50 $278.00 *Healthy Campus monthly discount $25.00 $25.00 $25.00 Anthem Blue View Vision Plan Type of Service In-Network Out-of-Network Routine eye exam Eyeglass frames (once every 12 months) Eyeglass lenses (standard, one pair every 12 months) • Standard plastic single vision lenses • Standard plastic bifocal lenses • Standard plastic trifocal lenses • Standard plastic lenticular lenses Contact lenses (once every 12 months) • Elective conventional lenses • Elective disposable lenses • Non-elective contact lenses $10.00 copay, then covered in full $130.00 allowance, then 20% off remaining $35.00 allowance $45.00 allowance $25.00 copay, then covered in full $25.00 copay, then covered in full $25.00 copay, then covered in full $25.00 copay, then covered in full $25.00 allowance $40.00 allowance $55.00 allowance $80.00 allowance $130.00 allowance, then 15% off remaining $130.00 allowance, no additional discount Covered in full $105.00 allowance $105.00 allowance $210.00 allowance Superior Dental Plan Coverage Options and Monthly Rates Coverage Level & Benefit Preventative care inclusions: 2 oral exams & 2 cleanings per year, fluoride, bitewing x-rays, intraoral periapical x-rays, & minor emergency treatment Basic care inclusions: Some oral surgery, endodontics, restoratives, space maintainers, & repair of crowns, bridges, & partials Major care inclusions: Periodontics/surgical periodontics, oral surgeries, sealants, prosthodontics, crowns & onlays Maximum payment per member per year (including preventative care) RATES: Employee Only Employee + 1 Dependent Employee + multiple dependents (Family) Basic Plan (Preventative) Buy-up Plan (Enhanced) 100% 100% 50% 90% 0% 50% $750.00 With Med Dental Only Included $15.60 Included $32.67 Included $46.98 $1000.00 With Med Dental Only $22.25 $37.85 $46.83 $79.50 $66.60 $113.58 [Empl full name], [DOB], [A #], [class] OPEN ENROLLMENT - EFFECTIVE 1/1/2015 Each employee MUST complete the form below and return it to the Office of Human Resources by December 1, 2014, unless waiving coverage. The annual open enrollment period for Ohio Northern University allows eligible employees to enroll, add, or remove eligible family members to, and/or change your current healthcare selections. BUY-UP DENTAL BASIC DENTAL PLAN B (High Deduct.) HEALTHCARE CORE PLAN PLAN A Please check mark the coverage in which you would like to enroll. EMPLOYEE ONLY EMPLOYEE + SPOUSE/PARTNER EMPLOYEE + CHILD EMPLOYEE + FAMILY VOLUNTARY (employee pays 100% of cost) *The Office of Human Resources will contact you directly if a voluntary benefit is selected. AFLAC LONG TERM CARE (LTC) LIFE INSURANCE FLEXIBLE SPENDING ACCOUNT (FSA) DEPENDENT INFORMATION: Child Partner Dependent’s Full Name Spouse Please list all dependents who will be covered under your ONU healthcare plans Date of Birth Social Security # Check mark coverage desired for dependents Medical Dental ADDITIONAL INFORMATION HEALTH SAVINGS ACCOUNT (HSA): Contributing to a HSA is for participants of Plan B only. If you wish to continue or start a contribution to a HSA, please complete the attached HSA form. FLEXIBLE SPENDING ACCOUNT (FSA): If you wish to elect flexible spending in 2015, you MUST submit a new Anthem flexible spending form each year (enclosed). COVERAGE ELECTED: I hereby apply for group coverage for which I am or may become eligible under the above group programs, except those waived as indicated above. I authorize deductions, if any, from my compensation for my share of the cost of coverages to which I am entitled and have elected. I understand that I must meet the eligibility requirements of the Plan and that completion of this form does not guarantee coverage under the Plan. I affirm that the information contained herein is correct and true. Employee Signature: __________________________________________ Date: _____________________ ANTHEM SDC OFFICE OF HUMAN RESOURCES ONLY: BANNER MEDICAL DENTAL PAYROLL FSA Reimbursement Account Enrollment Form Complete this form and return it to your human resources representative Employee Information Employer Name Employee Name Account Number / Street Address SSN Daytime Phone City State Date of Birth Number Zip Date of Hire Code Gender (M or F) Do you want to know if Anthem Blue Cross and Blue Shield received and processed your claim? Please provide your e-mail address: E-mail Address Section 125 Elections Health Care Flexible Spending Account (contact your administrator for the maximum allowed contribution) I elect to participate $ I elect to waive coverage per pay period x remaining pay periods = $ Plan Year Total remaining pay periods = $ Plan Year Total Dependent Care Flexible Spending Account Annual maximum allowable is: • $5,000 for married filing jointly or single • $2,500 if married filing separately I elect to participate $ I elect to waive coverage per pay period x Employee Certification • • • • • • • I understand I may elect coverage under any or all of the above components; I understand completion of this form does not guarantee insurance coverage will be initiated and, in most cases, an application for insurance must also be completed; I understand the terms of eligibility of this plan do not override the terms of eligibility of each of the available benefit plan options; I understand my election is irrevocable for the plan year unless I have a change in status or other qualified even as a defined in the IRS Regulations, and the requested change is on account of and consistent with the event; I understand any unused contributions will be forfeited to my employer at the end of the plan year; I understand participation in this plan reduces my Social Security withholdings and could reduce my Social Security benefits; I certify I have read and agree to the terms of participation. Employee Signature Date For Employer Use Only Company Name Division Effective Date Pay Cycle Entered in Payroll Initial Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer nonHMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (serving Virginia excluding the city of Fairfax, the town of Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. TO BE COMPLETED BY PLAN B PARTICIPANTS ONLY BANK NAME MM/DD/YY If this is a new account or any banking information has been changed, please attach a voided check or letter from your banking institution. Return this form to the Office of Human Resources. PreventiveRx Drug List: Expanded Plan SM PreventiveRx covers drugs that help keep you healthy because they prevent illness and other health conditions. You can get the products on this list at low or no cost to you. This list includes only prescription products. Brand-name drugs are listed with a first capital letter. Non-brand drugs (generics) are in lowercase letters. Brand-name drugs that have a generic equivalent available are not covered under this Preventive Rx benefit. Not all drugs on this list may be covered by your plan. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your Certificate or Evidence of Coverage for coverage limitations and exclusions. Birth control All generic versions are included: Beyaz Generess-FE Lomedia 24 FE medroxyprogesterone 150mg/ml Minastrin 24 Fe Natazia Nuvaring Quartette Skyla Blood clots Brilinta Coumadin Eliquis enoxaparin fondaparinux Fragmin heparin Innohep Pradaxa warfarin Xarelto Bowel prep (laxatives) Colyte Golytely Halflytely Moviprep OCL Osmoprep peg 3350/electrolytes Prepopik Suclear Suprep Trilyte Visicol Breast cancer anastrozole 13017ANMENABS Rev. 8/14 exemestane Fareston letrozole tamoxifen citrate Diabetes Diabetic supplies, including blood sugar meters, test strips and lancets require a prescription to be covered by this plan. acarbose ActoPlusMet XR Apidra Avandamet Avandaryl Avandia Bydureon Byetta chlorpropamide Cycloset Farxiga glimepiride glipizide glipizide er/xl glipizide with metformin hcl Glumetza glyburide glyburide with metformin hcl glyburide, micronized Glyset Humalog Humulin Invokana Janumet Janumet XR Januvia Jardiance Jentadueto Juvisync Kazano Kombiglyze XR Korlym Lantus Levemir metformin hcl metformin hcl er nateglinide Nesina Novolin Novolog Onglyza Oseni pioglitazone pioglitazone-glimepiride pioglitazone-metformin Prandimet repaglinide Riomet Symlin Tanzeum tolazamide tolbutamide Tradjenta Victoza Flu Relenza Tamiflu Gout allopurinol Colcrys probenecid probenecid/colchicine Uloric Heart health and high blood pressure acebutolol hcl acetazolamide afeditab cr Aldactazide 50-50mg amiloride hcl amiloride/hctz amlodipine besylate amlodipine/benazepril Amturnide atenolol atenolol/chlorthalidone Avalide 300/25mg Azor benazepril hcl benazepril hcl/hctz Benicar Benicar HCT betaxolol hcl Bidil bisoprolol fumarate bisoprolol fumarate/ hctz bumetanide Bystolic candesartan candesartan/hctz captopril captopril/hctz Cardene SR Cardizem LA 120mg cartia xt carvedilol chlorothiazide chlorthalidone clonidine hcl Clorpres Coreg CR Covera-HS digoxin Dilatrate SR dilt-cd diltiazem hcl diltiazem hcl er Diuril doxazosin mesylate Dutoprol Dynacirc CR Dyrenium Edarbi Edarbyclor Edecrin enalapril maleate enalapril/hctz Epaned eplerenone eprosartan Exforge Exforge HCT felodipine er fosinopril sodium fosinopril/hctz furosemide guanabenz acetate guanfacine hcl Hemangeol hydralazine hcl hydralazine/hctz hydrochlorothiazide indapamide Inderal XL Innopran XL irbesartan irbesartan/hctz Isordil 40mg isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isradipine labetalol hcl Lanoxin levatol lisinopril lisinopril/hctz losartan losartan/hctz Matzim LA PreventiveRx Drug List: Expanded Plan SM methazolamide methyclothiazide methyldopa methyldopa/hctz metolazone metoprolol succinate er metoprolol tartrate metoprolol/hctz minoxidil moexipril hcl moexipril/hctz nadolol nadolol/ bendroflumethiazide Nexiclon XR nicardipine hcl nifedipine nifedipine er nimodipine nisoldipine Nitro-Bid Nitro-Dur 0.3, 0.8mg/hr nitroglycerin Nitroglycerin 400mcg Spray nitroglycerin er Nitroglycerin Lingual nitroglycerin spray Nitrostat Nymalize perindopril pindolol prazosin hcl propranolol hcl propranolol hcl er propranolol/hctz quinapril hcl quinapril/hctz ramipril Ranexa sotalol hcl sotalol hcl af spironolactone spironolactone/hctz Tarka Taztia XT Tekamlo Tekturna Tekturna HCT telmisartan telmisartan/amlodipine telmisartan/hctz 13017ANMENABS Rev. 8/14 terazosin hcl Teveten 400mg Teveten HCT thalitone timolol maleate torsemide trandolapril triamterene/hctz Tribenzor valsartan valsartan/hctz Vecamyl verapamil hcl verapamil hcl er High cholesterol Advicor Altoprev Antara 30, 90mg atorvastatin atorvastatin/amlodipine cholestyramine cholestyramine light colestipol hcl Crestor fenofibrate fenofibric acid, dr Fenoglide fluvastatin gemfibrozil Lescol XL Lipofen Liptruzet Livalo lovastatin niacin ER Niacor omega-3 ethyl ester 1 gram capsule pravastatin Prevalite Simcor simvastatin Triglide Vascepa Vytorin Welchol Zetia Malaria atovaquone/proguanil chloroquine Daraprim hydroxychloroquine mefloquine hcl primaquine quinine sulfate capsule Nausea, vomiting Aloxi Antivert 50mg Anzemet Cesamet chlorpromazine hcl Diclegis dimenhydrinate dronabinol Emend granisetron hcl ondansetron hcl ondansetron odt prochlorperazine promethazine hcl Scopace Transderm-Scop trimethobenzamide hcl Zuplenz Osteoporosis alendronate sodium Alora Angeliq Atelvia Binosto Cenestin Climara Pro Combipatch Duavee Enjuvia est. estrogens with methyltestosterone Estraderm estradiol estradiol/norethindrone acetate estropipate FemHRT 0.5mg/2.5mcg Femtrace Forteo fortical Fosamax Plus D ibandronate medroxyprogesterone acetate Menest Menostar Miacalcin Minivelle Ogen Prefest Premarin tablets Premphase Prempro Prolia raloxifene risedronate Vivelle-Dot zoledronic acid (generic Reclast) RSV (respiratory syncytial virus) Synagis Stopping smoking bupropion hcl sr (generic Zyban only) Chantix Nicotrol inhaler Nicotrol NS Stroke Aggrenox cilostazol clopidogrel bisulfate dipyridamole Effient ticlopidine hcl Zontivity Vaccines All brand and generic versions are included. Vitamins All generic versions are included: Prenatal vitamins (taken during pregnancy) Prescription multivitamins with fluoride Prescription multivitamins with fluoride and iron Weight loss benzphetamine hcl diethylpropion hcl diethylpropion hcl er phendimetrazine phentermine hcl Qsymia Regimex Suprenza ODT Xenical FALL 2014 HEALTH SCREENING INFORMATION What is the ONU Annual Health Screening Program? The Health Screening program is being held in collaboration with Ohio Northern University and Lima Memorial Health System Laboratories. This program is designed to provide important laboratory data to you and your physician at no cost. Are these tests important to me? Early detection and treatment/control of chronic diseases is one of the best ways to prolong your life and to increase your quality of life. Who may participate? The University is offering voluntary health screenings for ALL campus employees, retirees and their spouses (including Sodexo, Barnes and Noble, and The Inn) regardless of whether the employee is enrolled in our health insurance plan at no cost. *Children are not eligible to participate. IMPORTANT All medical information and blood test results are confidential and will be provided to you and your personal physician (it is no longer necessary to provide an envelope). The screenings require a 12-hour period of fasting. Please do not eat for 12 hours prior to testing with the exception of water and black coffee. ONU Annual Health Screenings: Saturday, October 25th 6:30-9:30am Activities Room, McIntosh Center Wednesday, October 29th 6:30-9:30am Activities Room, McIntosh Center To ensure good health, participation is not enough. To fully understand your results, please contact your physician or a HealthWise clinician for review. HealthWise will be available the day of the screening to schedule appointments. The review will be held on campus and will be free of charge. Getting Healthy and Giving Back: Once again, screenings will be performed by Lima Memorial Health System Laboratories through a non-profit program. Lima Memorial will be donating $1 for every screening to the West Central Ohio Medical Laboratory Science Program which is an ONU degreed program within the Department of Biology. Preregistration information: Please follow the link below and enter your name, gender, and the date you plan to attend the screening. You will then “submit” your basic information and print the downloadable form. www.onuhealthfair.squarespace.com What test will be performed? General health screening panel, including CMP, CBC, lipid panel, hepatic panel, renal panel, thyroid screening, diabetes screening and prostate screening (for men age 40 and over) If you wish to participate in IFBOT (Immunofecal Occult Blood Test), specimen sample containers will be given upon request only. Please contact the Office of Human Resources to participant in the IFBOT testing by phone at 419-772-2013 or at [email protected]. Your request for the testing kit will be processed and available for pick-up at the Office of Human Resources. The office is open on Monday through Friday from 8:00 a.m. – 5:00 p.m. No urine tests will be performed this year. Flu Shots Flu shots will be available, free of charge, to all participants of the health screening. Remember your Healthy Campus Points The annual health screening is an excellent opportunity to earn healthy campus points to reach the annual goal of 40 points during 2014. ** EARN POINTS AT THE ANNUAL HEALTH SCREENING ** Please reference the table below to see potential healthy campus points you can still earn at the annual health screening this year to receive your 2015 discount! 2014 ONU Healthy Campus Incentive Activities and Goals 2014 -- 40 Points Point Opportunity Healthy Blood Result Points (available once per calendar year) Full blood draw with follow-up wellness visit (either through ONU screenings in the Fall or with your Points to be earned Note: Blood draw must occur during the 2014 calendar year 5 points physician) Healthy cholesterol level (as determined by physician/clinician based on current practice guidelines) 5 points Blood sugar levels via A1C in acceptable range (as determined by physician/clinician based on current 5 points practice guidelines and course of treatment) Healthy blood pressure (as determined by physician/clinician based on current practice guidelines and course of 5 points treatment) Healthy Weight Points Opportunities Initial weigh-in through HealthWise screening session 3 points Healthy weight (as determined by final HealthWise weigh-in or your physician) 7 points Healthy Status and Preventative Points Non-smoker status affidavit signed 2 points Receive a flu shot 2 points Total Potential Points to be Earned at the 2014 Health Screening 34 points 2015 ONU Healthy Campus Program The 2015 Healthy Campus Program launch will be announced in the upcoming weeks. Information regarding this program will be sent from the Office of Human Resources soon.
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