The PMH medical plan is a PPO plan designed to provide you and your covered dependents with quality healthcare. Here are some highlights:
- Three tiered plan which provides members with a lot of choice in deciding where to receive care.
- By choosing to receive care at PMH and NHRMC facilities (Tier 1), members can obtain high quality and cost effective care.
- $25 co-pays for Tier 1 and Tier 2 PCP visits.
For detailed information about the PMH PPO plan, please review the Summary Plan Description and Summary of Benefit Coverage.
You will automatically be provided with prescription drug coverage when you elect the medical plan. The rates shown in the chart below will apply to all prescription drug purchases. Please remember that Walgreen sand Rite Aid pharmacies are not in our network. To obtain a listing of the participating pharmacies, generic equivalents and drug tier levels, go to www.MedImpact.com/.
Mandatory Generic Drug Policy
Many prescription drugs are available as both a brand name drug and a generic name drug. By law, generic drugs must meet the same standards for safety and effectiveness as brand name drugs. Obtaining generic drugs whenever possible can provide you with direct savings because you pay a lower co-pay. It also provides you with indirect savings because you save the plan money, which ultimately benefits you.
When you have a prescription filled, you will receive a generic substitute whenever possible. If there is not a generic equivalent available, tier pricing will apply. If you choose to receive the brand name drug and a generic equivalent is available, you will pay the difference between the full cost of the generic and the brand-name drug, plus the tier co-pay.
Prescription Drug Benefits
Effective January 1, 2020, employees and their covered dependents may use the Employee & Specialty Pharmacy or any Medimpact in-network retail pharmacy to fill their incidental prescriptions. Prior to January 1, 2020, incidental prescriptions can be filled at any Medimpact in-network retail pharmacy.
Co-pays for 30-day prescriptions are:
Any MedImpact In-Network Pharmacy
- Tier 1 30‐Day Supply $4
- Tier 2 30‐Day Supply $25
- Tier 3 30‐Day Supply $40
- Tier 4: 20% up to maximum of $100
Effective January 1, 2020**, all maintenance medications must be filled by the Employee & Specialty Pharmacy. Maintenance medications are drugs you take regularly to manage a chronic condition. The Plan allows you to fill a maintenance drug prescription two times for a 30-day supply at a retail pharmacy. If the drug needs to be filled for a third time, it is considered a maintenance drug and must be filled for a 90-supply. The Plan will not cover a maintenance drug prescription filled or refilled anywhere other than the Employee & Specialty Pharmacy. The employee or covered dependent will be responsible for the full cost of the medication.
|
Maintenance Medications **
effective Jan. 1, 2020 |
Prescription Drug 90-Day Supply |
| Tier 1 90-Day Supply |
Employee Pharmacy |
co-pay at 2 1/2 times |
| Tier 2 90-Day Supply |
Employee Pharmacy |
co-pay at 2 1/2 times |
| Tier 3 90-Day Supply |
Employee Pharmacy |
co-pay at 2 1/2 times |
Specialty Prescriptions
Through December 31, 2019, Medimpact Direct Specialty will continue to fill existing specialty medication prescriptions. Any new specialty medication prescriptions that need to be filled after November 1, 2019 may be submitted to the Employee & Specialty Pharmacy or Medimpact Direct Specialty. Effective January 1, 2020, specialty medications will only be filled by the Employee & Specialty Pharmacy.
Regular, professional dental care is essential to good health, and can also prevent serious and costly medical problems. To help ensure you have a clean, healthy mouth, your dental plan includes preventative, basic, and major dental care through Ameritas.
Your coverage has three levels of procedures: preventative, basic, and major. The level of coverage varies from 50% to 100%.
Preferred Provider Organization
You are free to seek care from any dentist you choose, but there are real benefits to utilizing a network provider. When visiting a provider associated with the Ameritas network, you have no claims to file, you will never be balance billed and you can generally save money in coinsurance because a provider in the Ameritas network has agreed to contracted fees which are typically lower than the average area charges. To find participating providers in our area, visit ameritasgroup.com.
Dental Rewards Program
Dental Rewards is a value-added program that encourages good dental habits through regular dental care. It allows you to earn additional money toward each year’s annual maximum.
For detailed information about the dental plan, including the Dental Rewards Program, please review the plan highlight sheet.
What to do if your dentist does not file claims with Ameritas?
You will pay for the service claim at the time of your visit. Then use the Ameritas Group Dental Claim Form for reimbursement. Mail the claim form and a receipt directly to Ameritas and the company will mail you a check, typically within two weeks
PMH offers a vision plan through Community Eye Care which provides each covered participant with:
* One routine eye exam per calendar year - $10 co-pay
* One standard contact lens fitting per calendar year - $10 co-pay
* $150 eyewear allowance per calendar year (note: unused money does not roll over)
Your eyewear allowance can be used for frames, sunglasses, spectacle lenses, contact lenses, special lens feature or any of these in combination.
How to Use the Benefit
You can access your vision benefit either in-network or out-of-network.
Find a Community Eye Care in-network provider at www.communityeyecare.net or by calling 888.254.4290. When you schedule your appointment, let your provider know you are a CEC member so they may verify eligibility and obtain an authorization code from CEC prior to your visit.
Members who opt to see an out-of-network provider must pay the provider’s full charges at the time of the visit, obtain a receipt, and file a claim with Community Eye Care.
Getting a Personalized Card
Community Eye Care issues ID cards for new enrollees. Employees may also download a temporary card or request a new card on the CEC website at www.communityeyecare.net.
You have the opportunity to participate in two pre-tax flexible spending accounts: Health Care Flexible Spending Account (HCFSA) and the Dependent Care Flexible Spending Account (DCFSA). These accounts offer you a tax-free way to pay for qualified expenses not covered by insurance. Because the dollars you place in these accounts are taken out of your pay before taxes, you lower your taxable income, saving you money. Please review IRS Publication 502 or visit www.flores247.com for a complete set of eligible expenses.
Each year you may elect to place a designated amount of pre-tax dollars in your flexible spending account(s). The dollars you place in these accounts will be deducted from each of your 26 paychecks during the calendar year.
When you submit proof of an eligible expense, you will be reimbursed from your account. Changes to your deduction amounts can only be made when there is a qualifying status change, and you must re-enroll each year during the open enrollment period to participate in the next plan year.
It is important that you carefully choose how much to elect for each flexible account. If the amount you elect for a flexible spending account exceeds your properly submitted eligible expenses for the plan year, the excess amount will be forfeited. It cannot be rolled over or distributed. This is known as the "use it or lose it rule."
Grace and Run Out Periods
For active employees: You have until June 15 following the plan year in which you contributed to an FSA to submit reimbursement claims for services and eligible expenses incurred during that plan year and the 2 ½ month grace period that ends on March 15 following that plan year.
If you participate in an FSA two years in a row, any claims that you incur during the grace period (January 1 to March 15) and submit by June 15 will first be applied to your FSA balance for prior plan year, if available. For terminated employees: You have 30 days following your plan termination date to submit claims for expenses incurred prior to your plan termination date.
Health Care FSA eligible expenses
Dependent Care FSA eligible expenses
All employees scheduled to work a minimum of 32 hours or more per week are given life insurance in the amount of $10,000 or one times their base salary (whichever is greater). Your life insurance reduces to 65% of your amount at age 65, to 40% at age 70, and to 25% at age 75.
Your basic life insurance includes Accidental Death and Dismemberment (AD&D) insurance which is equal to the amount of your life insurance coverage.
Your basic term life insurance is completely paid for by PMH.
You designate your beneficiaries through Lawson Employee Self Service (ESS) after your benefit effective start date. You may change your beneficiaries any time through ESS.
PMH provides you with long-term disability insurance at no charge to you. Disability insurance ensures you a regular income if you are injured or become ill and you are unable to work for an extended period of time. The insurance provides 60% replacement of base salary up to a monthly maximum of $5,000 following 180 days (six months) of an approved continuous disability. Claims are first subject to approval by our LTD insurance carrier. Contact NHRMC HR-Benefits if you need an LTD application. Replacement salary continues as long as you are certified disabled by the carrier up to age 65.