2015 Plan Year
The School Board of Okaloosa County
Open Enrollment
Benefits Guide
ACTIVE EMPLOYEES
HEALTH
DENTAL
VISION & LIFE
LONG TERM DISABILITY
IMPORTANT!
READ CAREFULLY BEFORE
MAKING ENROLLMENT ELECTION.
Keep this booklet for your records.
0
TABLE OF CONTENTS
PAGE
DO YOU NEED TO ENROLL? .................................................................................................................................. 1
BENEFITS GUIDE HIGHLIGHTS ............................................................................................................................... 2
MEDICAL INSURANCE ........................................................................................................................................... 5
DENTAL INSURANCE ............................................................................................................................................. 9
LIFE INSURANCE .................................................................................................................................................... 10
VISION INSURANCE ............................................................................................................................................... 11
LONG-TERM DISABILITY INSURANCE .................................................................................................................... 12
FLEXIBLE SPENDING ACCOUNT ............................................................................................................................. 13
NOTIFICATION – FLORIDA BLUE CREDITABLE COVERAGE NOTICE....................................................................... 14
INSURANCE MEETING SCHEDULE & CONTACT INFORMATION ........................................................................... 16
1
Do you need to Enroll?
Use the checklist below to help you determine if there is coverage
you may be interested in enrolling in for the 2015 Plan Year.
Remember, everyone’s needs are different. Carefully consider
the needs of you and your family before making any benefit
elections.
What you should think about:
Do you want to make a change to a
plan option?
Do you want to make a change to your
life insurance amount?
Does someone in your family need
glasses?
Do you want to add or delete
dependents?
Do you want to have a Health Care
Flexible Spending Account (FSA) for the
2015 Plan Year?
Do you want to have a Dependent Care
Flexible Spending Account (FSA) for the
2015 Plan Year?
Do you want your insurance premiums
to be deducted from your check before
taxes?
YES
NO
If you answered yes you should consider:
Changes must be marked on your
enrollment form.
You can choose to increase or decrease your
amount of optional life insurance. Any
increase is subject to medical underwriting.
You might want to consider electing vision
coverage.
This is your only opportunity during the year
to do so without experiencing an IRS
qualifying event.
Even if you currently have an FSA you will
need to complete an election form in order
for it to continue.
Even if you currently have an FSA you will
need to complete an election form in order
for it to continue.
If your insurance premiums were deducted
before taxes in calendar year 2014, they will
automatically be deducted in calendar year
2015. Otherwise, you will need to complete
an enrollment form.
.
1
School Board of Okaloosa County
Benefits Guide Highlights
Calendar Year 2015
Open Enrollment Forms must be
returned to Risk Management no
later than November 7, 2014.
Open Enrollment is your one-time opportunity to review your current benefit elections and make any changes that
may be needed for you and your family. Please take the time to familiarize yourself with the guide’s contents. We
hope that after you review this guide you will have a clear understanding of the changes that will be effective
January 1, 2015, and how they may impact you and your covered dependents.
We also recommend that you attend an enrollment meeting. A schedule of meetings may be found on page 19.
Please be sure to bring this enrollment guide and any questions you may have when attending your meeting.
When is the deadline and what happens if you don’t enroll by the deadline?
The deadline for all elections, including Flexible Spending Accounts, is November 7, 2014. If you are using the
courier, please allow at least three (3) days for delivery. The benefit elections you currently have in place will
rollover automatically, except Flexible Spending Accounts (Health & Dependent Care) your deductions will reflect
the 2015 premium amounts.
If you have a current Health or Dependent Care FSA, it will NOT rollover. You will not have a Health or Dependent
Care FSA in 2015 unless you complete and return the proper forms.
Effective January 1, 2013, the annual amount you can contribute to your FSA was reduced from $5,000 to $2,500
per employee, per plan year.
Once the deadline passes, you will not be able to add or delete dependents from any coverage and/or change
your plan options without an IRS qualifying life event – e.g., marriage, birth of a child or a spouse terminates or
commences employment.
What do I do if I want to enroll or make changes?
If you wish to enroll or make a plan change, you must complete, sign, and date the attached enrollment/benefit
authorization form (part 1 or 2) and return it to the Risk Management Department. Forms will also be available at
the meetings, Risk Management Department, and on the Risk Management page of the OCSD website.
Use your legal name (name on paycheck) and the last four numbers of your social security number on all
correspondence sent to the Risk Management Department.
Is your dependent a valid dependent?
If any of the dependents you currently cover are not your legal dependents or do not meet the eligibility
2
requirements, Open Enrollment is an opportunity to remove them from your coverage without question. The
School Board of Okaloosa County reserves the right to audit employee benefits enrollment at any time.
MEDICAL INSURANCE
Florida Blue will offer 4 health plans for 2015: Blue Options Base Plans, 3160 (Single) and 3161 (Family), and Blue
Options Buy Up Plans, 3166 (Single) and 3167 (Family). If you elected medical coverage for calendar year 2014,
you will be automatically enrolled in the same coverage for calendar year 2015. If you would like to enroll or make
changes for calendar year 2015, you must complete an enrollment/benefit authorization form. To find a physician
or to check on your deductible or claims, visit www.bcbsfl.com.

The Blue Options Buy Up Plan 3166 (Single)
o Calendar Year Deductible – $1,500 In-Network; $3,000 Out-of-Network
o Coinsurance (After Deductible Met) – Employee Pays 0% In-Network; 20% Out-of-Network
o Prescription (After Deductible Met) – Employee Pays 0% In-Network; 50% Out-of-Network
o Max Out-of-Pocket – $1,500 In-Network; $6,000 Out-of-Network

The Blue Options Buy Up Plan 3167 (Family)
o Calendar Year Deductible – $3,000 In-Network; $6,000 Out-of-Network
o Coinsurance (After Deductible Met) – Employee Pays 0% In-Network; 20% Out-of-Network
o Prescription (After Deductible Met) – Employee Pays 0% In-Network; 50% Out-of-Network
o Max Out-of-Pocket – $3,000 In-Network; $12,000 Out-of-Network
The Blue Options Base Plan 3160 (Single)
o Calendar Year Deductible – $1,250 In-Network; $2,500 Out-of-Network
o Coinsurance (After Deductible Met) – Employee Pays 20% In-Network; 40% Out-of-Network
o Prescription (After Deductible Met) – Employee Pays 20%/30%/50% In-Network;
50%/50%/50% Out-of-Network
o Max Out-of-Pocket – $5,000 In-Network; $10,000 Out-of-Network


The Blue Options Base Plan 3161 (Family)
o Calendar Year Deductible – $2,500 In-Network; $5,000 Out-of-Network
o Coinsurance (After Deductible Met) – Employee Pays 20% In-Network; 40% Out-of-Network
o Prescription (After Deductible Met) – Employee Pays 20%/30%/50% In-Network;
50%/50%/50% Out-of-Network
o Max Out-of-Pocket – $5,000 In-Network; $10,000 Out-of-Network
The Healthcare Reimbursement Account (HRA) will fund $750.00 for single coverage and $1,500.00 for family
coverage for all medical plans. You may continue to file for reimbursement for dental and vision expenditures
with the HRA for 2015. Do not discard your current HRA/Take Care card until you have verified its expiration date.
These cards are good for three years. If your card is set to expire on 12/2014 then you will automatically receive a
replacement card by mail at your home address during Winter Break. Make sure your address is up-to-date. To
check your account balance, visit www.myflexonline.com.
3
If you cancel your health insurance with the Okaloosa County School District, you will have 90 days from the date
of termination to file claims under the HRA plan. Expenses must have been incurred prior to the policy
termination date. After 90 days, any remaining account balance will be forfeited.
4
DENTAL INSURANCE
Delta Dental will continue as our dental insurance provider for 2015. If you elected dental coverage for calendar
year 2014, you will automatically be enrolled in the same coverage for calendar year 2015. If you would like to
enroll or make changes for 2015, you must complete an enrollment/benefit authorization form. For a list of
providers, visit www.deltadentalins.com.
LIFE INSURANCE
Sun Life will continue as our life insurance provider for 2015. You will be automatically enrolled in the same
coverage for calendar year 2015. The Board pays for basic life insurance for all full-time employees and offers
optional insurance for employees and their dependents.
VISION INSURANCE
Eye Med will continue as our vision insurance provider for 2015. Eye Med offers two (2) plans for our employees
to choose from. If you elected vision coverage for calendar year 2014, you will be automatically enrolled in the
same coverage for calendar year 2015. If you would like to enroll or make changes for 2015, you must complete
an enrollment/benefit authorization form.
LONG TERM DISABILITY INSURANCE
Symetra will continue as our Long Term Disability insurance provider for 2015. Long Term Disability is available to
our employees who do not wish to enroll in the Florida Blue Health Plan. This plan will pay 66 2/3% of your
monthly salary up to $3,000.00 after 90 days of disability. All other employees may elect to participate in the
Voluntary (employee paid) Long Term Disability Insurance program but will be subject to medical underwriting.
The medical underwriting form is available in the Risk Management Department.
FLEXIBLE SPENDING ACCOUNT (FSA)
You must enroll in order to use a flexible spending account (FSA) for Health Care Reimbursement and/or
Dependent Care Reimbursement. Your FSA may also be used to fund your insurance premiums with pre-tax
dollars. Effective January 1, 2013, the maximum annual FSA contribution was reduced from $5,000 to $2,500 per
employee, per plan year.
DEPENDENT CARE REIMBURSEMENT
You must enroll in order to use a flexible spending account (FSA) for Dependent Care Reimbursement. The annual
amount you can contribute is $5,000 per employee, per plan year.
5
OKALOOSA COUNTY SCHOOL DISTRICT
January 1, 2015 Renewal Plans
COST SHARING
Maximums shown are Per Benefit Period (BPM) unless
noted
Deductible (DED) (Per Person/Family Agg)
In-Network
Out-of-Network
Coinsurance (Member Responsibility)
In-Network
Out-of-Network
Out of Pocket Maximum (Per Person/Family Agg)
In-Network
Out-of-Network
Lifetime Maximum
PROFESSIONAL PROVIDER SERVICES
Allergy Injections
In-Network Family Physician
In-Network Specialist
Out-of-Network
E-Office Visit Services
In-Network Family Physician
In-Network Specialist
Out-of-Network
Office Services
In-Network Family Physician
In-Network Specialist
Out-of-Network
Provider Services at Hospital and ER
In-Network Family Physician
In-Network Specialist
Out-of-Network
Provider Services at Other Locations
In-Network Family Physician
In-Network Specialist
Out-of-Network
Radiology, Pathology and Anesthesiology Provider
Services at Hospital or Ambulatory Surgical Center
In-Network Specialist
Out-of-Network
PREVENTIVE CARE
Adult Wellness Office Services
In-Network Family Physician
In-Network Specialist
Out-of-Network
Colonoscopies (Routine)
Covered at 100% of Allowed Amt
In-Network
BlueOptions
HSA-Compatible 3166
BlueOptions
HSA-Compatible 3167
BlueOptions
HSA Compatible 3160
BlueOptions
HSA Compatible 3161
(Single Coverage)
(Family Coverage)
(Single Coverage)
(Family Coverage)
$1,500 / Not Applicable
$3,000 / Not Applicable
$3,000 / $3,000
$6,000 / $6,000
$1,250 / Not Applicable
$2,500 / Not Applicable
$2,500 / $2,500
$5,000 / $5,000
0%
20%
Includes DED & Coins
$1,500 / Not Applicable
$6,000 / Not Applicable
No Maximum
0%
20%
Includes DED & Coins
$3,000 / $3,000
$12,000 / $12,000
No Maximum
20%
40%
Includes DED & Coins
$5,000 / Not Applicable
$10,000 / Not Applicable
No Maximum
20%
40%
Includes DED & Coins
$5,000 / $5,000
$10,000 / $10,000
No Maximum
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED
In-Ntwk DED (No Coins)
DED
DED
In-Ntwk DED (No Coins)
DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
In-Ntwk DED (No Coins)
DED
In-Ntwk DED (No Coins)
DED + 20%
In-Ntwk DED + 20%
DED + 20%
In-Ntwk DED + 20%
$0
$0
20% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
$0
$0
20% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
20% (No DED)
20% (No DED)
40% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
20% (No DED)
20% (No DED)
40% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
6
COST SHARING
Maximums shown are Per Benefit Period (BPM) unless
noted
Out-of-Network
Mammograms (Routine and Dx)
In-Network
Out-of-Network
Well Child Office Visits (No BPM)
In-Network Family Physician
In-Network Specialist
Out-of-Network
EMERGENCY/URGENT/CONVENIENT CARE
Ambulance
In-Network
Out-of-Network
Convenient Care Centers (CCC)
In-Network
Out-of-Network
Emergency Room Facility Services
(also see Professional Provider Services)
In-Network
Out-of-Network
Urgent Care Centers (UCC)
In-Network
Out-of-Network
FACILITY SERVICES - HOSP/SURG/ICL/IDTF
Unless otherwise noted, physician services are in addition to
facility services. See Professional Provider Services.
Ambulatory Surgical Center
In-Network
Out-of-Network
Independent Clinical Lab
In-Network
Out-of-Network
Independent Diagnostic Testing Facility Xrays and AIS (Includes Physician Services)
In-Network - Advanced Imaging Services (AIS)
Out-of-Network
Inpatient Hospital (per admit)
In-Network
Out-of-Network
Inpatient Rehab Maximum
Outpatient Hospital (per visit)
In-Network
Out-of-Network
Therapy at Outpatient Hospital
BlueOptions
HSA-Compatible 3166
BlueOptions
HSA-Compatible 3167
BlueOptions
HSA Compatible 3160
BlueOptions
HSA Compatible 3161
(Single Coverage)
(Family Coverage)
(Single Coverage)
(Family Coverage)
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
20% (No DED)
$0
$0
20% (No DED)
20% (No DED)
20% (No DED)
40% (No DED)
20% (No DED)
20% (No DED)
40% (No DED)
DED
In-Ntwk DED (No Coins)
DED
In-Ntwk DED (No Coins)
DED + 20%
In-Ntwk DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED
DED + 40%
DED
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
Option 1 - DED
Option 2 - DED
DED + 20%
30 Days
Option 1 - DED
Option 2 - DED
DED + 20%
30 Days
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
30 Days
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
30 Days
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
7
COST SHARING
Maximums shown are Per Benefit Period (BPM) unless
noted
In-Network
Out-of-Network
BlueOptions
HSA-Compatible 3166
BlueOptions
HSA-Compatible 3167
BlueOptions
HSA Compatible 3160
BlueOptions
HSA Compatible 3161
(Single Coverage)
(Family Coverage)
(Single Coverage)
(Family Coverage)
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED + 20%
Option 2 - DED + 20%
DED + 40%
Option 1 - DED + 20%
Option 2 - DED + 20%
DED + 40%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED + 20%
Option 2 - DED + 20%
DED + 40%
Option 1 - DED + 20%
Option 2 - DED + 20%
DED + 40%
DED
In-Ntwk DED (No Coins)
DED
In-Ntwk DED (No Coins)
DED + 20%
In-Ntwk DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
In-Ntwk DED (No Coins)
DED
In-Ntwk DED (No Coins)
DED + 20%
In-Ntwk DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
Enteral Formulas:$2,500 All
Other: No Maximum
DED
DED + 20%
20 Visits
DED
DED + 20%
No Maximum
DED
DED + 20%
Enteral Formulas:$2,500 All
Other: No Maximum
DED
DED + 20%
20 Visits
DED
DED + 20%
No Maximum
DED + 20%
DED + 40%
Enteral Formulas:$2,500 All
Other: No Maximum
DED + 20%
DED + 40%
20 Visits
DED + 20%
DED + 40%
No Maximum
DED + 20%
DED + 40%
Enteral Formulas:$2,500 All
Other: No Maximum
DED + 20%
DED + 40%
20 Visits
DED + 20%
DED + 40%
No Maximum
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient Hospitalization
In-Network
Out-of-Network
Outpatient Hospitalization (per visit)
In-Network
Out-of-Network
Provider Services at Hospital and ER
In-Network Family Physician or Specialist
Out-of-Network Provider
Physician Office Visit
In-Network Family Physician or Specialist
Out-of-Network Provider
Emergency Room Facility Services (per visit)
In-Network
Out-of-Network
Provider Services at Locations other than Hospital and ER
In-Network Family Physician
In-Network Specialist
Out-of-Network Provider
OTHER SPECIAL SERVICES AND LOCATIONS
Advanced Imaging Services in Physician's Office
In-Network Family Physician
In-Network Specialist
Out-of-Network
Birthing Center
In-Network
Out-of-Network
Diabetic Equipment and Supplies*
In-Network
Out-of-Network
Durable Medical Equipment, Prosthetics, Orthotics BPM
In-Network
Out-of-Network
Home Health Care BPM
In-Network
Out-of-Network
Hospice LTM
8
COST SHARING
Maximums shown are Per Benefit Period (BPM) unless
noted
In-Network
Out-of-Network
Outpatient Therapy and Spinal Manipulations BPM
Skilled Nursing Facility BPM
In-Network
Out-of-Network
BlueOptions
HSA-Compatible 3166
BlueOptions
HSA-Compatible 3167
BlueOptions
HSA Compatible 3160
BlueOptions
HSA Compatible 3161
(Single Coverage)
(Family Coverage)
(Single Coverage)
(Family Coverage)
DED
DED + 20%
35 Visits (Includes up to 26
Spinal Manipulations)
60 Days
DED
DED + 20%
DED
DED + 20%
35 Visits (Includes up to 26
Spinal Manipulations)
60 Days
DED
DED + 20%
DED + 20%
DED + 40%
35 Visits (Includes up to 26
Spinal Manipulations)
60 Days
DED + 20%
DED + 40%
DED + 20%
DED + 40%
35 Visits (Includes up to 26
Spinal Manipulations)
60 Days
DED + 20%
DED + 40%
In-Network Health Plan DED
In-Network Health Plan DED
In-Network Health Plan DED
In-Network Health Plan DED
In-Ntwk DED then $0/$0/$0
In-Ntwk DED then $0/$0/$0
In-Ntwk DED + 20%/30%/50%
In-Ntwk DED + 20%/30%/50%
In-Ntwk DED then $0 / $0 / $0
In-Ntwk DED then $0 / $0 / $0
In-Ntwk DED + 20%/30%/50%
In-Ntwk DED + 20%/30%/50%
PRESCRIPTION DRUGS
Deductible
In-Network
Retail (30 Days)
Generic/Preferred Brand/Non-Preferred
Out-of-Network
Retail (30 Days)
Generic/Preferred Brand/Non-Preferred
Board Pd
Employee Pd
Board Pd
Employee Pd
Board Pd
Employee Pd
Board Pd
12 Month Employees
$687.42
$108.98
$822.42
$1,053.61
$687.42
$0.00
$822.42
$853.18
9 Month Employees
$916.56
$145.31
$1,096.56
$1,404.81
$916.56
$0.00
$1,096.56
$1,137.57
Rates
Employee Pd
This is not an insurance contract or Benefit Booklet. The above Benefit Summary is only a partial description of the many benefits and services covered by Blue Cross and Blue Shield of Florida, Inc., an
independent licensee of the Blue Cross and Blue Shield Association. For a complete description of benefits and exclusions, please see Blue Cross and Blue Shield of Florida’s Benefit Booklet and Schedule of
Benefits; their terms prevail.
Florida Blue is currently reviewing all health care reform legislation—the Patient Protection and Affordable Care Act and the Health Care and Education
Affordability Reconciliation Act—which includes numerous provisions to expand access to health insurance, improve the quality and comprehensiveness of
coverage, and make coverage more affordable for all Americans. Although some major elements of reform begin in 2010, others will be implemented over the next
several years. Therefore, the information in our enrollment materials is subject to change based on the final result of this legislation.
9
OKALOOSA COUNTY SCHOOL DISTRICT DENTAL INSURANCE PLAN – DELTA DENTAL
Eligibility
Primary enrollee, spouse and eligible dependent children to age 26
Deductibles
$125 per person / $375 per family each calendar year
Deductibles waived for Diagnostic & Preventive Services (D & S) for
Participating Providers only
Maximum Benefit
$2,000 per person each calendar year
Diagnostic & Preventive Services (D & P) count towards maximum
Waiting Period(s) – Waived at
Initial Enrollment Only
Diagnostic &
Preventive
0 Months
Benefits and
Covered Services*
Diagnostic & Preventive Services (D & P)
Exams, cleanings, x-rays, sealants
Basic Services
Fillings, simple tooth extractions
Endodontists (Root Canals)
Covered Under Basic Services
Oral Surgery
Covered Under Basic Services
Non-Surgical Periodontics (Gum Treatment)
Covered Under Basic Services
Crowns, Inlays, Onlays & Cast Restorations
Covered Under Basic Services
Surgical Periodontics (Gum Treatment)
Covered Under Major Services
Major Services
Bridges, Dentures and Implants
Basic
6 Months
Major
12 Months
Orthodontics
N/A
(No Benefits)
Delta Dental Dentists**
Delta %/Employee %
Non-Delta Dental Dentists**
Delta %/Employee %
100%/0%
100%/0%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
50%/50%
50%/50%
50%/50%
50%/50%
Orthodontic Benefits
Not Covered
Premiums
Type of Employee
12-Month Employees
9-Month Employees
Single
$0
$0
Family
$60.68
$80.91
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
** Reimbursement is based on PPO contracted fees for PPO dentists, Maximum Plan Allowance for Premier dentists and Maximum Plan
Allowance for non-Delta Dental dentists.
10
A list of dental providers can be found at www.deltadentalins.com by clicking the “Find a Dentist” option or
on the Risk Management page of the OCSD website under the Delta Dental tab.
Delta Dental Insurance Company
1130 Sanctuary Parkway, Suite 600
Alpharetta, GA 30009
Customer Service
800-521-2651
Claims Address
P.O. Box 1809
Alpharetta, GA 30023-1809
www.deltadentalins.com
Basic Restorative care includes the treatment of caries, commonly referred to as cavities and tooth decay. Your plan offers coverage for
anterior composite resin fillings and posterior amalgam fillings. But what does this mean?
Your mouth is comprised of two sections of teeth: anterior and posterior. Anterior teeth are the six upper and six lower front teeth. All
other teeth are considered posterior teeth. Your plan provides coverage for composite resin fillings (tooth colored fillings) on your anterior
teeth and amalgam coverage (silver colored fillings) on your posterior teeth.
However, this does not mean you cannot select a composite resin filling for a posterior tooth. If you choose a composite resin filling on a
posterior tooth, your plan will reimburse you at the amalgam level. You will be responsible for the difference between the dentist’s fees
for the composite filling vs. the amalgam filling.
OKALOOSA COUNTY SCHOOL DISTRICT LIFE INSURANCE PLAN – SUN LIFE
Employee Life Insurance Benefit – Paid by School Board
The School Board will continue to pay for a $25,000 Term Life policy for all full-time employees. When you reach
age 70, Risk Management will automatically reduce your Term Life policy to $10,000.
Optional Employee Life Insurance – Paid by Employee
The premium for Optional Life insurance is age banded as shown below:
Employee Age
18-29
30-44
45-54
55-69
Premium
$0.085/$1,000
$0.176/$1,000
$0.345/$1,000
$0.430/$1,000
If you wish to increase your Optional Life Insurance you must submit to medical underwriting. Please contact the
Risk Management Department to obtain the appropriate application documents. Once you have completed the
application, return it to the Risk Management Department so that it may be forwarded to Sun Life considered for
approval.
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Optional Employee Life Insurance After Age 70 – Paid by Employee
Once you reach age 70, Risk Management will reduce your Board-paid life insurance to $10,000 and notify you by
letter of your option to purchase an additional $10,000 in coverage at the age banded rates shown below. If you
elect not to enroll within the 30 days, you may not enroll at a later date.
Employee Age
70-74
75-79
80-84
85-89
90+
Premium
$ 4.20/$1,000
$ 6.54/$1,000
$ 9.69/$1,000
$17.71/$1,000
$44.72/$1,000
Optional Dependent Life Insurance – Paid by Employee
You also have the option to purchase life insurance on your dependents subject to medical underwriting and
approval. A Dependent Life Insurance policy will provide $5,000 in coverage for your spouse and $2,500 in
coverage for each dependent child. The employee will automatically be the beneficiary for this policy. Dependents
are eligible until age 18 or until age 22 if a full-time student depending on the you for 50% or more of their
support. The premium is $1.33 per month for 12-month employees and $1.77 per month for 9-month employees.
Dependent
Spouse
Dependent Child
Amount of Policy
$5,000
$2,500 each
Premium – 12-Month
$1.33/Month
Included
Premium – 9-Month
$1.77/Month
Included
OKALOOSA COUNTY SCHOOL DISTRICT VISION INSURANCE PLAN- EYE MED
If you enrolled in vision insurance in calendar year 2014, you will be automatically enrolled in calendar year 2015.
If you want to change, add or delete coverage, you must complete an enrollment form. Once you enroll in vision
insurance, you cannot cancel coverage during the year.
The Board offers the following two vision plans:
Benefits and Covered Services
Deductible – Exam
Deductible – Eye Glass Lenses
Maximum – Frame
Maximum – Elective Contacts
Maximum – Medically Necessary Contacts
Low Plan
$10
$25
$120
$105
Paid in Full
High Plan
$10
$25
$150
$150
Paid in Full
Premiums
Type of Employee
12-Month Employees
Low Plan – Single
$5.34
Low Plan – Family
$14.80
High Plan – Single
$6.55
High Plan – Family
$18.21
12
9-Month Employees
$7.12
$19.73
$8.73
$24.28
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OKALOOSA COUNTY SCHOOL DISTRICT LONG TERM DISABILITY INSURANCE PLAN
Long Term Disability is available as a Board-paid benefit to those employees who do not enroll in the Florida Blue
Health Insurance Plan. This plan will pay 66 2/3% of your monthly salary up to $3,000.00 after 90 days of disability.
Although open enrollment is not being offered for 2015, you may elect to participate in the Voluntary Long Term
Disability Insurance program by submitting to medical underwriting. The Medical Underwriting form is available in
the Risk Management Department. This plan will pay 60% of your monthly salary up to $6,000 after 90 or 180 days
of disability.
Complete the following steps to calculate the monthly employee-paid premium:
1.
2.
3.
4.
5.
6.
$ A
(your annual earnings) divided by 12 = $ B
$ B
(or a $10,000; whichever is less) divided by 100 = $ C
Find your rate from the table below based on your age and your plan choice.
$ C
times
D
= Monthly Premium (12 Mo Employee) $
$ E
X 12 = Annual Premium (All Employees) $ F
$ F
divided by 9 = Monthly Premium (9 Mo Employee) $ G
D
E
Example – A 38 year old employee with annual earnings of $37,000 per year purchasing the 90 day plan:
1.
2.
3.
4.
5.
6.
$ 37,000
(your annual earnings) divided by 12 = $3,083.33
$3,083.33
(or a $10,000; whichever is less) divided by 100 = $30.83
Find your rate from the table below based on your age and your plan choice. 0.220
$30.83
times 0.220
= Monthly Premium (12 Mo Employee) $6.78
$6.78
X 12 = Annual Premium (All Employees) $81.36
$81.36 divided by 9 = Monthly Premium (9 Mo Employee) $9.04
Age
Under 30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Rates
90 Day Plan
0.100
0.145
0.220
0.320
0.465
0.650
0.825
0.850
0.760
1.430
1.695
180 Day Plan
0.045
0.075
0.155
0.220
0.320
0.465
0.575
0.560
0.485
0.805
1.145
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OKALOOSA COUNTY SCHOOL DISTRICT FLEXIBLE SPENDING ACCOUNTS (FSA)
A representative from Lockard & Williams, the administrator of our Flexible Spending Accounts (FSA), also known
as the Cafeteria Plan, will be at the scheduled meetings to conduct group and one-on-one enrollments and to
assist with any individual questions you may have.
Some points to keep in mind:
 The FSA year is January 1, 2015 – December 31, 2015. Your elections will be for 12 months. (The amount
you submit on your enrollment form is per pay check.)
 The following expenses may be paid from the FSA account:
o Insurance Premiums
o Health Care Reimbursement
o Dependent Care Reimbursement
 If you only used your FSA in calendar year 2014 for insurance premiums, and do not want to make any
changes, you DO NOT need to complete any forms. If you did not pay your insurance premiums from your
FSA account in calendar year 2014 and wish to do so in calendar year 2015, you MUST complete an
election form.
 Effective January 1, 2013 the annual amount you can contribute to the FSA was reduced from $5,000 to
$2,500 per employee, per plan year. This change is due to provisions of the Affordable Care Act.
 Everyone participating in the FSA for health care reimbursement MUST complete a new form. The
maximum annual amount you may contribute is $2,500 per employee, per plan year.
 Everyone participating in the FSA for dependent care reimbursement MUST complete a new form. The
maximum annual amount you may contribute is $5,000 per employee, per plan year.
 During the year, if you have an IRS qualifying event that allows for a change of the premium you have tax
deferred, you MUST complete a change form and get approval from Lockard & Williams before the change
can be made.
 If you make an FSA health care reimbursement election for 2015, the total annual election amount will be
loaded on your TAKE CARE CARD and available for use on January 1st, 2015.
 Over the counter medications will no longer be eligible for purchase with funds from Flexible Spending
Accounts or Health Care Reimbursement Accounts, unless a prescription is provided.
 In order for employees to be reimbursed for the over the counter medications, you will need to submit a
paper claim, the receipt showing the purchase, and a physician’s prescription.
15
Important Notice from
Blue Cross and Blue Shield of Florida D/B/A Florida Blue
and Health Options Inc. D/B/A Florida Blue HMO.
About Your Prescription Drug Coverage and Medicare
This notice applies ONLY to individuals who are over age 65 and on Medicare or approaching
age 65 and eligible for Medicare or receiving Medicare Disability benefits. Please disregard
this notice if you are not in one of these categories of individuals.
Please read this notice carefully and keep it where you can find it. This notice has information about your current
prescription drug coverage with Florida Blue and about your options under Medicare’s prescription drug coverage. This
information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you
should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the
plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make
decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if
you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers
prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some
plans may also offer more coverage for a higher monthly premium.
2. Florida Blue has determined that the prescription drug coverage offered by your health plan is, on average for all plan
participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore
considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and
not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to
December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be
eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Florida Blue coverage will be affected. You can keep this
coverage if you elect to join a Medicare drug plan and your Florida Blue health plan will coordinate your benefits with
Medicare for drug coverage. If you would like more information about the prescription drug plan provisions and options
that Medicare eligible individuals may have when they become eligible for Medicare prescription drug coverage, see pages
7-9 of the CMS Disclosure of Creditable Coverage to Medicare Part D Eligible Individuals Guidance located at
http://www.cms.hhs.gov/CreditableCoverage/.
If you do decide to join a Medicare drug plan and drop your current Florida Blue coverage, be aware that you and your
dependents will not be able to get this coverage back.
16
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Florida Blue and don’t join a Medicare drug
plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a
Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up
by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage.
For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19%
higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you
have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug
Coverage…
Contact us for further information at 1-800-FLA-BLUE (TTY: 711). NOTE: You’ll get this notice each year. You will
also get it before the next period you can join a Medicare drug plan, and if this coverage through Florida Blue changes.
You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug
Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by
Medicare drug plans. For more information about Medicare prescription drug coverage:



Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare &
You” handbook for their telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For
information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-7721213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the
Medicare drug plans, you may be required to provide a copy of this notice when you join
to show whether or not you have maintained creditable coverage and, therefore, whether
or not you are required to pay a higher premium (a penalty).
Date: 9/23/2014
Name of Entity: Florida Blue
17
2014 Insurance Meeting Schedule
Schedule
Day
Monday
Monday
Monday
Date
Oct. 6
Oct. 6
Oct. 6
Time
7:30 a.m.
9:30 a.m.
3:15 p.m.
Contact
Steve Bolton
Maggie Hattaway
Janet Stein
Location
Beck Building
Beck Building
Media Center
Phone
689-7193
833-3554
833-4360x1
Maintenance - Central
Transportation Central
Nutrition Center
Ft. Walton Beach
High School
Tuesday
Oct. 7
7:30 a.m.
Steve Bolton
Dining Facility
689-7193
Tuesday
Oct. 7
9:30 a.m.
Pam Jenks
Dining Facility
833-4161
Tuesday
Oct. 7
11:00a.m.
Valerie Wooten
Tuesday
Oct. 7
4:30 p.m.
Charlene Couvillon
Dining Facility
Media Center
Conference Room
301-3020
833-3300
x3x1
Maintenance - North
Wednesday
Oct. 8
7:30 a.m.
Steve Bolton
Transportation - North
Wednesday
Oct. 8
9:30 a.m.
Mary Stevens
Carver Hill - DJJ
Wednesday
Oct. 8
1:30 p.m.
Sherry Anglin
Shoal River Middle
School
Wednesday
Oct. 8
4:00 p.m.
Cheree Davis
Lunch Room
689-7229
x2x2
Teacher’s Credit Union
Thursday
Oct. 9
8:30 a.m.
Jerry Maughon
Credit Union-Crestview
682-2225
Lowery - Active
Lowery - Retirees
Nutrition Center Retirees
Ruckel Middle School
Monday
Monday
Oct. 13
Oct. 13
9:00 a.m.
11:00 a.m.
Russ Frakes
Russ Frakes
Main Board Room
Main Board Room
833-3190
833-3190
Monday
Oct. 13
2:30 p.m.
Valerie Wooten
Dining Facility
301-3020
Monday
Oct. 13
4:00 p.m.
Kim Piccorossi
Media Center
833-4142
Tuesday
Oct. 14
11:00 a.m.
Tommy Harvell
Auditorium
689-7177
Tuesday
Oct. 14
3:00 p.m.
Mike Martello
Auditorium
689-7279
Wednesday
Oct. 15
2:40 p.m.
Lee Martello
Media Center
652-4111
Wednesday
Oct. 15
5:00 p.m.
Tommy Harvell
Media Center
689-7177
Maintenance - South
Transportation - South
Destin Elementary
Crestview High School Retirees
Baker School –
Employees & Retirees
Laurel Hill – Employees
& Retirees
Crestview High School Employees
Carver HillTraining Room
North TransportationBreak Room
Carver HillTraining Room
689-7193
689-7301
689-7117
18
RISK MANAGEMENT DEPARTMENT CONTACT INFORMATION
Hours of Operation: 7:30 a.m. to 4:00 p.m.
Address: 120 Lowery Place, S.E., Building C, Fort Walton Beach, FL 32548
Telephone Number: 833-3190
Fax Number: 833-3195
For Florida Blue, Tricare, Life and Long Term Disability questions, please contact one of the following:
Michael J. Locht
Kevin H. Locht
Florida Financial Services, Inc.
Corporate Benefits of the Emerald Coast, Inc
(850)-837-3883 * Fax (850) 837-9858
(850) 244-0849 * Fax (850) 244-0852
For Dental questions, please contact:
Delta Dental
1130 Sanctuary Parkway, Suite 500
Alpharetta, GA 30009
1-800-521-2651
www.deltadentalins.com
For FSA/HRA Account questions, please contact:
Kenny Anderson
Lockard & Williams
(800) 530-7222 * Fax (850) 479-2923
www.myflexonline.com
For Vision questions, please contact:
Eye Med
4000 Luxottica Place
Mason, OH, 45040
1-866-800-5457
www.eyemed.com
19