Health Benefits Simplifiedpurebeautybenefits.com/wp-content/uploads/sites/77/2016/... · 2017. 3. 25. · Pay your medical bills the easy and accurate way. HealthEZpay consolidates

Pure Beauty Farms Medical Benefits OverviewEffective 1/1/2017 | 844-288-5704 | www.purebeautybenefits.com

Health Benefits Simplified

Effective 1/1/2017 | 844-288-5704 | www.purebeautybenefits.com

Welcome!HealthEZ is proud to continue to serve Pure Beauty Farms in 2017. We are a national benefit administrator that specializes in helping companies like Pure Beauty Farms provide affordable, custom benefit plans. We are here to simplify your healthcare experience.

What you need to do:• Review this benefit overview • Manage your benefits by visiting www.purebeautybenefits.com or calling customer service at 844-288-5704.

What’s inside:• Benefit Update • Online Tools • Network of Doctors • Medical Management • Pharmacy • HealthEZpay • HealthEZ Smart ID Cards • Summary of Medical Benefits • Enrollment form

Online Tools www.purebeautybenefits.com

Visit your one-stop benefit website for benefit information, forms, account balances, processed claims, previous statements and much more. An online account allows you to fully manage your benefits. To sign up for online access, follow these steps:

1. Go to www.purebeautybenefits.com and click LOGIN.

2. Click “Need to set up your online access?”

3. Enter your Member ID - found on your ID card - your Social Security number, and your date of birth. Pick a Username and Password. Be sure to make your Password at least 8 characters long; any combination of letters or numbers is acceptable. Click Proceed to my Account and you’re registered!


Network of Doctors “Is my doctor in the network?”

Your primary network is Cigna. To find an in-network physician or facility go to www.purebeautybenefits.com and click on “Find a Doctor” or call customer service at 844-288-5704.

Medical Management and NurselineYou have 24/7 access to HealthEZ’s medical management staff. They have extensive experience helping employees navigate the medical maze. These services are available to everyone — whether you have a chronic condition like asthma or diabetes, or a more complex condition such as cancer or heart disease.

If you have questions about what kind of care to seek or where to seek it (do I really need to go to the ER for this?), if you’ve just found out you’re pregnant, or if you have any nagging questions, nurses are there to help you. Just call 844-288-5704, 24/7.

Precertification The medical system is increasingly pushing patients into expensive and unnecessary procedures. To make sure you receive the best treatment possible, we are requiring your doctor to notify us before MRI and CT scans as well as inpatient treatment and surgeries.

Pharmacy MagellanRx

Your pharmacy benefit manager is MagellanRx. MagellanRx is one of the nation’s largest pharmacy benefits managers and can offer additional discounts - especially on higher cost drugs. Your pharmacy claims will also appear on your HealthEZ statement. Please see the back of your medical card for information on MagellanRx. You can also find more information by going to www.PureBeautyBenefits.com, and clicking on “Prescriptions.”

Saving on Pharmacy Costs Here are a few ways to save on pharmacy costs:

• Ask your doctor to start you on the lowest cost alternative

• Check out the “$4 prescriptions” at places like Wal-Mart

• Price shop your prescriptions at Sam’s Club and Costco; you don’t have to be a member to access their pharmacy


The HealthEZ SmartID Card With the SmartID card, you and your family will always have your HealthEZ ID card in reach – on your smartphone! Simply login to: www.purebeautybenefits.com to access your SmartID card.

You can also print a temporary ID card from the website.

Show your new ID card at the pharmacy and your doctor’s office so claims will be submitted to the proper claims processing address - as shown on the back of your ID card.

Pay your medical bills the easy and accurate way. HealthEZpay consolidates your medical bills and allows you

to review online, then simply approve or decline payment for each. You save money and time by securely paying online

using your credit/debit card that you have registered.

The EZ Way to Pay Your Medical Bills

Call 844-288-5704 for more information or go to www.

purebeautybenefits.com and click on “My Benefits” then

“HealthEZ Payment Service”

Jane DoeGroup ID: PNA11714321Member ID: 0000012345623

Medical: Employee + dependent(s)OV Copay: $25 PCP & UC/$45 SP


Summary of Medical Benefits

Calendar Year DeductibleEmployee OnlyFamily

Medical PPO Plan

In-Network Out-of-Network

$0 $0

$500 $1,000

Member CoinsuranceIndividual Out-of-Pocket MaxFamily Out-of-Pocket Max

$3,500 $7,000

$5,500 $11,000

Preventive Care (Routine physical, cancer screenings, eye exams, & prenatal care)

No Charge 30% Coinsurance after Deductible

Physician ServicesPCP Office VisitSpecialty Office VisitUrgent Care

$30 Copay$50 Copay$35 Copay

30% Coinsurance after Deductible30% Coinsurance after Deductible30% Coinsurance after Deductible

Radiology & LabsInpatient/Outpatient Lab & X-Ray ServicesMRI, CT, PET Scans at a freestanding facility

No Charge after Deductible$300 Copay

30% Coinsurance after Deductible30% Coinsurance after Deductible

Hospital CareInpatient Hospital CareOutpatient Surgery/ Hospital & Dr. Fees

$500 Copay, up to 5 daysNo Charge after Deductible


Emergency ServicesEmergency RoomAmbulance

$100 CopayNo Charge after Deductible


Mental Health/ Chemical DependencyInpatientOutpatient

No Charge after Deductible$50 Copay


Physical, Occupational, and Speech therapy $50 Copay 30% Coinsurance after Deductible

Chiropractic Services - Therapy & Manipulation $50 Copay 30% Coinsurance after Deductible

Home Health Care(100 visit limit)

No Charge after Deductible 30% Coinsurance after Deductible

Hospice No Charge after Deductible 30% Coinsurance after Deductible

Skilled Nursing Care(60 visit limit)

No Charge after Deductible 30% Coinsurance after Deductible

Durable Medical Equipment No Charge after Deductible 30% Coinsurance after Deductible

Maternity Care (physician & hospital charges) No Charge after Deductible 30% Coinsurance after Deductible

Prescription Drug CoverageGenericFormularyNon-FormularySpecialty (Mail order available for a 30 day supply)

Retail 30 Day Supply Mail Order 90 Day Supply

$15 Copay$40 Copay$70 Copay$150 Copay


Not Available

PLEASE NOTE: This only serves as a high level summary of your benefit plan. Please refer to your Summary Plan Description (SPD) for more information on coverage, limitation and exclusion provisions, how benefits are paid, how claims are filed, etc… Members can access their SPD, SBCs and ERISA notices on their custom benefit site, www.purebeautybenefits.com.

• Deductibles, copays, and coinsurance apply toward out-of-pocket maximums. • Precertification requirements will be outlined in your Summary Plan Document. • Out-of-Network services deemed to be true emergencies by the Plan Administrator will be paid at In-Network Benefit Rate


Summary of Medical Benefits

Calendar Year DeductibleEmployee OnlyFamily

$6,600 PPO Plan

In-Network Out-of-Network

$6,600 $13,200

N/AN/A

Member CoinsuranceIndividual Out-of-Pocket MaxFamily Out-of-Pocket Max

$6,600 $13,200

N/AN/A

Preventive Care (Routine physical, cancer screenings, eye exams, & prenatal care)

No Charge Not Covered

Physician ServicesPCP Office VisitSpecialty Office VisitUrgent Care


Not CoveredNot CoveredNot Covered

Radiology & LabsInpatient/Outpatient Lab & X-Ray ServicesMRI, CT, PET Scans at a freestanding facility

No Charge after deductible$300 Copay

Not CoveredNot Covered

Hospital CareInpatient Hospital CareOutpatient Surgery/ Hospital & Dr. Fees

No Charge after deductible$1,500 Copay


Emergency ServicesEmergency RoomAmbulance

$500 CopayNo Charge after deductible


Mental Health/ Chemical DependencyInpatientOutpatient

No Charge after deductible$60 Copay


Physical, Occupational, and Speech therapy $60 Copay Not Covered

Chiropractic Services - Therapy & Manipulation $60 Copay Not Covered

Home Health Care No Charge after deductible Not Covered

Hospice No Charge after deductible Not Covered

Skilled Nursing Care No Charge after deductible Not Covered

Durable Medical Equipment No Charge after deductible Not Covered

Maternity Care (physician & hospital charges) No Charge after deductible Not Covered

Prescription Drug CoverageGenericFormularyNon-FormularySpecialty (Mail order available for a 30 day supply)

Retail 30 Day Supply Mail Order 90 Day Supply

$15 Copay$45 Copay$85 Copay$250 Copay


Not Available

PLEASE NOTE: This only serves as a high level summary of your benefit plan. Please refer to your Summary Plan Description (SPD) for more information on coverage, limitation and exclusion provisions, how benefits are paid, how claims are filed, etc… Members can access their SPD, SBCs and ERISA notices on their custom benefit site, www.purebeautybenefits.com.

• Deductibles, copays, and coinsurance apply toward out-of-pocket maximums. • Precertification requirements will be outlined in your Summary Plan Document. • Out-of-Network services deemed to be true emergencies by the Plan Administrator will be paid at In-Network Benefit Rate


DeductibleEmployee OnlyFamily

Dental Plan

In-Network Out-Of-Network

$50$150

Annual MaximumLifetime Maximum - Orthodontia

$2,500$1,500

Preventive & Diagnostic CareOral Exams - Limit 2 per Calendar YearRoutine Cleanings (Prophylaxis) - Limit 2 per Calendar YearFull Mouth X-rays - Limit 1 per 36 monthsBitewing X-rays - Limit 2 per Calendar YearPanoramic X-rays - Limit 1 per 36 monthsPeriapical X-rays - Limit 1 per 36 monthsFluoride Application - Up to age 19, one per Calendar YearSealants - Limited to posterior tooth. One treatment per tooth every three years up to age 14.Space Maintainers - Limited to non-Orthodontic treatmentEmergency Care to Relieve PainHistopathologic Exams

No Member ResponsibilityNo Member ResponsibilityNo Member ResponsibilityNo Member ResponsibilityNo Member ResponsibilityNo Member ResponsibilityNo Member Responsibility

No Member ResponsibilityNo Member ResponsibilityNo Member ResponsibilityNo Member Responsibility

20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met

20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met

Basic Restorative CareFillingsRoot Canal Therapy/EndodonticsOsseous SurgeryPeriodontal Scaling and Root PlanningDenture Adjustments and Repairs - Reviewed if more than once Oral Surgery - Simple ExtractionsOral Surgery - all except simple extractionsAnestheticsSurgical Extractions of Impacted TeethRepairs to Bridges, Crowns, and Inlays - Reviewed if more than once

20% After Deductible Met 20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met20% After Deductible Met

40% After Deductible Met 40% After Deductible Met40% After Deductible Met40% After Deductible Met40% After Deductible Met40% After Deductible Met40% After Deductible Met40% After Deductible Met40% After Deductible Met40% After Deductible Met

Major Restorative CareCrowns - Replacement every 5 yearsDentures - Replacement every 5 yearsBridges - Replacement every 5 yearsInlays/Onlays - Replacement every 5 yearsProsthesis Over Implant - Limit 1 per 60 consecutive months if unserviceable and cannot be repaired.

50% After Deductible Met50% After Deductible Met50% After Deductible Met50% After Deductible Met50% After Deductible Met

50% After Deductible Met50% After Deductible Met50% After Deductible Met50% After Deductible Met50% After Deductible Met

Orthodontic ServicesDiagnose or correct misalignment of the teeth or bite

Lifetime Maximum - Coverage if for adults and children

50% After Deductible Met

$1,500

50% After Deductible Met

$1,500

NOTES: All out-of-network charges are subject to usual and customary pricing. Claims are paid at 90th percentile of usual and customary.

Missing Tooth Limitation - The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter; considered a Major Restorative service.

Benefit Enrollment/Change Form A. Employee Information (all information is required)

First Name: MI: Last Name:

SSN#: Date of Hire:

Date of Birth: Gender: o M or o F Marital Status:

Address: City: State: Zip:

Daytime Phone: ( ) Home phone: ( ) Email:

B. Medical Plan Options (if electing coverage please make a selection in both 1 & 2) 1. Plan applying for o Medical PPO Plan o $6,600 PPO Plan o Decline Coverage (please complete sections D. & E.) 2. Coverage applying for o Employee only o Employee + Spouse o Employee + Children o Family

C. Dependent/Spouse Information (must be completed for coverage of dependents) Name (Last, First, MI) Relationship Birth date SSN M/F Disabled

(Y/N) Please check below to include on medical plan

o Medical o Medical o Medical o Medical o Medical

D. Other Insurance Coverage Information Please check one: o I have other insurance coverage (please provide information below)

o I do not have other insurance coverage o I have other insurance coverage, but intend to cancel that coverage o I have enrolled thru the state or federal

Marketplace (please provide information below) Policyholder’s Name: Policyholder’s Date of Birth: Insurance Co. Name: Policy Number: Group Number: Insurance Co. Address: Names of covered individuals:

E. Enrollment Waiver (check box only if declining coverage) o I understand the benefits provided by the Group Insurance Contract under ERISA regulations include Health and/or Dental coverages. I have reviewed and understand the benefit options and requirements presented herein. I understand that I may not be eligible to enroll myself and dependents if I desire to apply for coverage at a later date, unless I qualify to enroll at a later date in accordance with the special enrollment conditions. o I understand by not enrolling in this plan or a Marketplace health plan as mandated by PPACA, that I may be subject to a tax penalty.

F. Employee Authorization. Employee Authorization I understand I have the option to pay the premiums for my employer-sponsored health plan through a before-tax reduction of my salary. I understand that if this amount increases or decreases during the plan year, my salary reduction will be adjusted to reflect that increase or decrease. I hereby apply for the coverage for which I am now or may be eligible under this group policy. I hereby authorize the deduction from my earnings of the required contribution, if any, toward the cost of such coverage. I authorize payment of medical benefits to all providers, where applicable, for those charges covered by my group insurance benefits. I authorize release to or by HealthEZ of any medical information including copies of medical records or insurance information as necessary for claims adjudication, utilization review, or coordination of benefits. To the best of my knowledge and belief, the information I have provided on this form is complete and correct. I acknowledge that the terms of the Summary Plan Description govern all payments made by the Plans. ____________________________________________________________________________________________ _______________ Employee Signature Date

H. Employer Information (to be completed by the employer or HealthEZ only) Employer: HEZ Group # HEZ Division Code: Effective Date:

To be completed by HealthEZ HEZ Received: HEZ Entered: ID Cards:

Documents

Health Benefits Simplifiedpurebeautybenefits.com/wp-content/uploads/sites/77/2016/... · 2017. 3. 25. · Pay your medical bills the easy and accurate way. HealthEZpay consolidates