Plan Options & Enrollment Guide - TX | Workforce

Plan Options &

Enrollment Guide

MEC Plan and Voluntary Benefits

Your employer offers you and your eligible family

members a comprehensive and valuable benefits program.

We encourage you to take the time to educate yourself about

your options and choose the best coverage for you and your

family.

This guide is a sampling of the benefits. All benefits, premiums, exclusions and limitations are covered only by the actual contract as approved by their respective carrier. Always refer to the Summary and Benefits and Coverage (SBC) for each plan for the entire list of limitations, exclusions, coverage, etc., including out-of-network benefits.

Plan, Documents and Limitations and exclusions always prevail.

Welcome!

You will find more detailed information about each of these benefits in the following pages of this booklet.

Life InsuranceHospital PlanCritical IllnessAccident ExpenseVoluntary Benefits

MEC Plan

Below are the benefits available to you for this new plan year.

The elections you make will be effective from: The open enrollment period is: Once you have made your elections, you will not be able to change them until the next open enrollment period, unless you have a qualified change in status. Qualified changes in status include: marriage, divorce, legal separation, birth or adoption of a child, change in a child’s dependent status, death of a spouse, change in residence, commencement or termination of adoption proceedings, change in employment states, or change in coverage under another employer-sponsored plan.

Welcome!

benefit elections for the upcoming plan year. You must complete and returnThe first step is to review your current benefit elections. Next decide on your How to Enroll:

up to age 26 (married or unmarried), and guardian children.The following family members are also eligible for coverage: spouse, children

Who is Eligible?

December 6, 2019 to December 20, 2019.

January 1, 2020 until December 31, 2020.

eligible to enroll in the benefits described in this document.If you are full-time employees (working 40 or more hours per week), you are

the enclosed enrollment application to your payroll department prior to the endof your organization’s open enrollment in order to be enrolled in coverage.Completed forms must be submitted by December 20th, 2019.

Covered Services for Adults (18 years old and older) 1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who

have ever smoked 2. Alcohol Misuse screening and counseling 3. Aspirin use to prevent cardiovascular disease for men and women of certain ages 4. Blood Pressure screening for all adults 5. Cholesterol screening for adults of certain ages or at higher risk 6. Colorectal Cancer screening for adults over 50 7. Depression screening for adults 8. Diabetes (Type 2) screening for adults with high blood pressure 9. Diet counseling for adults at higher risk for chronic disease 10. Hepatitis C screening for adults at increased risk, and one time for everyone born

1945 – 1965

11. HIV screening for everyone ages 15 to 65, and other ages at increased risk 12. Immunization vaccines for adults —doses, recommended ages, and

recommended populations vary: Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella

13. Lung cancer screening for adults 55 - 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years

14. Obesity screening and counseling for all adults 15. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk 16. Syphilis screening for all adults at higher risk 17. Tobacco Use screening for all adults and cessation interventions for tobacco

users

Covered Services for Women (including Pregnant Women) 1. Anemia screening on a routine basis for pregnant women 2. Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for

breast cancer 3. Breast Cancer Mammography screenings every 1 to 2 years for women over 40 4. Breast Cancer Chemoprevention counseling for women at higher risk 5. Breastfeeding comprehensive support and counseling from trained providers, and

access to breastfeeding supplies, for pregnant and nursing women 6. Cervical Cancer screening for sexually active women 7. Chlamydia Infection screening for younger women and other women at higher risk 8. Contraception: Food and Drug Administration-approved contraceptive methods,

sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

9. Domestic and interpersonal violence screening and counseling for all women 10. Folic Acid supplements for women who may become pregnant

11. Gestational diabetes screening for women 24 to 28 months pregnant and those at high risk of developing gestational diabetes

12. Gonorrhea screening for all women at higher risk 13. Hepatitis B screening for pregnant women at their first prenatal visit 14. HIV screening and counseling for sexually active women 15. Human Papillomavirus (HPV) DNA Test every 3 years for women with normal

cytology results who are 30 or older 16. Osteoporosis screening for women over age 60 depending on risk factors 17. Rh incompatibility screening for all pregnant women and follow-up testing for

women at higher risk 18. Sexually Transmitted Infections counseling for sexually active women 19. Syphilis screening for all pregnant women or other women at increased risk 20. Tobacco Use screening and interventions for all women, and expanded

counseling for pregnant tobacco users 21. Urinary tract or other infection screening for pregnant women 22. Well-woman visits to get recommended services for women under 65

Covered Services for Children 1. Alcohol and Drug Use assessments for adolescents 2. Autism screening for children at 18 and 24 months 3. Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4

years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 4. Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4

years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 5. Cervical Dysplasia screening for sexually active females 6. Depression screening for adolescents 7. Developmental screening for children under age 3 8. Dyslipidemia screening for children at higher risk of lipid disorders at the following

ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 9. Fluoride Chemoprevention supplements for children without fluoride in their water

source 10. Gonorrhea preventive medication for the eyes of all newborns 11. Hearing screening for all newborns 12. Height, Weight and Body Mass Index measurements for children at the following

ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 13. Hematocrit or Hemoglobin screening for children 14. Hemoglobinopathies or sickle cell screening for newborns

15. HIV screening for adolescents at higher risk 16. Hypothyroidism screening for newborns 17. Immunization vaccines for children from birth to age 18 - doses, recommended

ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Hemophilus influenzae type b, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Meningococcal Pneumococcal, Rotavirus, Varicella

18. Iron supplements for children ages 6 to 12 months at risk for anemia 19. Lead screening for children at risk of exposure 20. Medical History for all children throughout development at the following ages: 0 to

11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 21. Obesity screening and counseling 22. Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4

years, 5 to 10 years. 23. Phenylketonuria (PKU) screening for this genetic disorder in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for

adolescents at higher risk 25. Tuberculin testing for children at higher risk of tuberculosis at the following ages:

0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 26. Vision screening for all children.

Your MEC Coverage is ACA Compliant

Be Prepared – Carry Your MEC Card

Contact Us Customer Service: 888.505.7724 Email: [email protected] Or fill out form online at: https://sbmabenefits.com/contact/ Health Portal sbmabenefits.com Click on Employee at bottom of the page (green button)

HowtolocatedoctorsforthePHCSmultiplan

Or call 1-866-981-7427 and hold for a representative.

• From here, you can search by doctor name.• Click “specific services”• Click “multi-plan”• Click “Select Network”• Click “Find Provider”• Go to website: multiplan.com

MEC PLUSBENEFIT SUMMARY

*MEC Plus excludes out-of-network services and covers ONLY the medical above services above. This plan does not coveremergency room care, hospitalization, surgical services, advanced imaging or brand name / specialty prescription drugs.

**For more information regarding the Telehealth Program call 1800MD at (800) 530-8666 or visit www.1800md.com

SBMA-MECPLUSTM-02202019

MEDICAL BENEFITS MEC PLUS*Annual Deductible $0Out-of-Pocket Maximum $1,850 individual / $3,700 familyPreventive / Wellness Covered 100%Primary Care / Specialist Office Visits $15 copayUrgent Care $50 copayEmergency Room / Hospital Not CoveredLaboratory Services $50 copayX-Rays $50 copayTelehealth Program** IncludedGeneric Prescription Drugs $5 copay

http://www.multiplan.com/

http://www.1800md.com/

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Typewriter

*Please note: Every enrolled employee will have $50.00 deducted from the first paycheck of every month. For cost convenience if you elect any type of family coverage the additional cost will be broken up weekly.

Covered Services for Adults

1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

2. Alcohol Misuse screening and counseling3. Aspirin use to prevent cardiovascular disease for men and women

of certain ages4. Blood Pressure screening for all adults5. Cholesterol screening for adults of certain ages or at higher risk6. Colorectal Cancer screening for adults over 507. Depression screening for adults8. Diabetes (Type 2) screening for adults with high blood pressure9. Diet counseling for adults at higher risk for chronic disease10. Hepatitis C screening for adults at increased risk, and one time for

everyone born 1945 – 196511. HIV screening for everyone ages 15 to 65, and other ages at

increased risk12. Immunization vaccines for adults —doses, recommended ages, and



14. Obesity screening and counseling for all adults15. Sexually Transmitted Infection (STI) prevention counseling for

adults at higher risk16. Syphilis screening for all adults at higher risk17. Tobacco Use screening for all adults and cessation interventions for

tobacco users

Covered Services for Women

1. Anemia screening on a routine basis for pregnant women2. Breast Cancer Genetic Test Counseling (BRCA) for women at higher

risk for breast cancer3. Breast Cancer Mammography screenings every 1 to 2 years for

women over 404. Breast Cancer Chemoprevention counseling for women at higher

risk5. Breastfeeding comprehensive support and counseling from trained

providers, and access to breastfeeding supplies, for pregnant and nursing women

6. Cervical Cancer screening for sexually active women7. Chlamydia Infection screening for younger women and other

women at higher risk8. Contraception: Food and Drug Administration-approved

contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

9. Domestic and interpersonal violence screening and counseling for all women

10. Folic Acid supplements for women who may become pregnant11. Gestational diabetes screening for women 24 to 28 months

pregnant and those at high risk of developing gestational diabetes12. Gonorrhea screening for all women at higher risk13. Hepatitis B screening for pregnant women at their first prenatal visit14. HIV screening and counseling for sexually active women15. Human Papillomavirus (HPV) DNA Test every 3 years for women

with normal cytology results who are 30 or older

Covered Services for Women (continued)

16. Osteoporosis screening for women over age 60 depending on risk factors

17. Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk

18. Sexually Transmitted Infections counseling for sexually active women19. Syphilis screening for all pregnant women or other women at

increased risk20. Tobacco Use screening and interventions for all women, and

expanded counseling for pregnant tobacco users21. Urinary tract or other infection screening for pregnant women22. Well-woman visits to get recommended services for women under

65

Covered Services for Children

1. Alcohol and Drug Use assessments for adolescents2. Autism screening for children at 18 and 24 months3. Behavioral assessments for children at the following ages: 0 to 11

months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.4. Blood Pressure screening for children at the following ages: 0 to 11

months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.5. Cervical Dysplasia screening for sexually active females6. Depression screening for adolescents7. Developmental screening for children under age 38. Dyslipidemia screening for children at higher risk of lipid disorders

at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

9. Fluoride Chemoprevention supplements for children withoutfluoride in their water source

10. Gonorrhea preventive medication for the eyes of all newborns11. Hearing screening for all newborns12. Height, Weight and Body Mass Index measurements for children at

the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11to 14 years, 15 to 17 years.

13. Hematocrit or Hemoglobin screening for children14. Hemoglobinopathies or sickle cell screening for newborns15. HIV screening for adolescents at higher risk16. Hypothyroidism screening for newborns17. Immunization vaccines for children from birth to age 18 - doses,

recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Hemophilus influenzae type b, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Meningococcal, Pneumococcal, Rotavirus, Varicella

18. Iron supplements for children ages 6 to 12 months at risk for anemia

19. Lead screening for children at risk of exposure20. Medical History for all children throughout development at the

following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

21. Obesity screening and counseling22. Oral Health risk assessment for young children Ages: 0 to 11

months, 1 to 4 years, 5 to 10 years.23. Phenylketonuria (PKU) screening for this genetic disorder in

newborns24. Sexually Transmitted Infection (STI) prevention counseling and

screening for adolescents at higher risk25. Tuberculin testing for children at higher risk of tuberculosis at the


26. Vision screening for all children.

This plan provides no coverage for sickness, hospitalization or surgical benefits. Benefits are not limited to the schedule above. For more information on covered services visit: https://www.healthcare.gov/coverage/preventive-care-benefits/

MEC COVEREDPREVENTIVE SERVICES

SBMA-MPSL-02202019

https://www.healthcare.gov/coverage/preventive-care-benefits/

www.1800MD.com6408 Bannington Road ChaRlotte, nC 28226 tel: 704.247.9186 Fax: 704.926.2045

As a nationally recognized telehealth provider, our national network of board certified physicians diagnose illnesses, recommend treatment and prescribe medications when appropriate to its members over the telephone, through secure bi-directional video and email. All of our physicians are fully credentialed through a process that includes a thorough review of medical licenses, training and education, work and malpractice history.

1-800MD provides fast and convenient access to quality medical care 24 hours a day, 7 days a week and 365 days a year throughout the United States. 1-800MD is a convenient and inexpensive alternative to non-emergent Emergency Room visits, non-critical care clinics, or when you don’t have access to your primary care provider (PCP).

1-800MD provides medical diagnosis and treatment for common ailments such as:

• Allergies• Arthritic Pain• Bronchitis• Certain Rashes• Cold/Flu Symptoms• Ear Infections• Gastroenteritis• Headaches/Migraine• Insect Bites

• Sinus Infections• Sprains/Strains• Respiratory Infections• Stomach Ache/Diarrhea• Sore Throat• Urinary Tract Infection• Minor Burns• General Information

• Many other non-emergency medical illnesses

1-800MD saves time, saves money and provides members with peace of mind

According to research conducted by the Wellness Council of America (2008), 70% of in-office doctor’s visits could have been handled by a phone call or e-mail.

Over 90% of survey respondents said that 1-800MD physicians spent an appropriate amount of time with them and answered all their questions, saving them time, money and a trip to the ER or doctor’s office.

1-800MD provides access to physicians 24/7 via the phone for diagnosing and treating acute care illnesses.

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Call Today To learn How 1-800Md Can Help your CoMpany


How It Works:

•

A member requests a physician consultation by telephone or email by calling1 -800-530-8666 or on line at www.1800MD.com.

•

Over the phone or online, Member completes or updates their personal health history and disclosure (PHH) form.

• The physician is contacted via our automated system, reviews the member’s personalhealth history and disclosure form prior to the consultation.

• The physician calls the patient generally within 15 minutes, guaranteed within 1 hour.

• The physician conducts the consultation and recommends appropriate treatment.

• When appropriate the physician will e-prescribe prescription medications directly to thepatient’s pharmacy of choice. We have over 60,000 pharmacies in our database.

• Doctor completes a patient consultation form and updates the electronic medical record(EMR).

• A completed encounter is generated and available to the patient via the online portal.

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1-800-530-8666www.1800md.com

Your Prescription Benefit Plan through SmithRx. SmithRx is your new prescription benefit provider. SmithRx is dedicated to giving you the best service and resources to help you and your family make better healthcare decisions.

Using Your Prescription Drug Card at Retail You will receive a prescription card from your employer. Please present your new prescription card along with your prescription to any of our 67,000+ retail pharmacies every time you fill your prescription. You can access a participating pharmacy list at www.mysmithrx.com.

Using Your Home Delivery Benefit Taking advantage of your home delivery benefit may enable you to receive up to a 90-day supply of your brand maintenance medication(s) at a discounted price through Magellan Rx Home. Just ask your physician to write two prescriptions: one for a 30-day supply to get you started (to be filled at your local pharmacy), and one for a 90-day supply, plus additional refills (to be filled at the home delivery pharmacy). To get started you can:

• E-prescribe or Fax: Have your doctor e-prescribe or fax your prescription to(866) 642-5620. Faxed prescriptions may only be sent by a doctor’s office andmust include patient information and diagnosis for timely processing.

• Mail: Mail us your 90-day prescription, completed order formwith payment to: PO Box 620968, Orlando, FL 32862

Please note: For prompt delivery, please provide your payment informationby mailing in your completed order form or by calling 1 (800) 424-5894.

Online Tools at www.mysmithrx.com Secure online connection, protecting your confidentiality and providing:

• Drug formulary & lookup tools• Trusted drug and health condition information & education• Real-time benefit information• View and download pharmacy claims• Find a participating pharmacy• Download claim reimbursement, prior authorization request,

specialty pharmacy enrollment, and mail order forms

Formulary Changes To help provide our customers with access to safe, high-quality and cost-effective prescription benefits, it is necessary to classify some drugs as preferred and others as non-preferred drugs on the SmithRx formulary. Access our full formulary at www.mysmithrx.com to see how your medication is classified.

2018 SmithRx. All rights expressly reserved. For support, call (844) 454-5201 any time.

Understanding Your Prescription Benefit ProgramProviding you with the tools and resources to help you make better drug therapy decisions

Additional requirements for coverage or limits on certain medications may include:

Your Plan may have additional requirements for coverage or limits for select prescription medications. These requirements and limits ensure that members use these medications in the most effective way and also help the Plan control medication costs. A team of practicing physicians and pharmacists developed these requirements and limits to help your Plan provide quality coverage to members. Please consult the formulary on our website for more information.

Quantity LimitsFor certain medications, your Plan may limit the amount of the medication that will be covered per prescription or for a defined period of time. For example, your Plan may provide up to 30 units per 30-day period for a formulary medication.

Step TherapyIn some cases, your Plan requires you to first try one medication to treat your medical condition before it will cover another medication for that condition. For example, if Drug A and Drug B both treat your medical condition, your Plan may require your physician to prescribe Drug A first. If Drug A does not work for you, then your Plan will cover Drug B.

Prior AuthorizationIf your physician prescribes a medication requiring a prior authorization, you will need to go through a prior authorization process. We review requests for these selected medications to help ensure appropriate and safe use of medications for your medical condition(s). Your physician can call, fax, or submit prior authorization requests electronically. For a list of select medications that require prior authorization, please contact Customer Service at (844) 454-5201.

Albertsons

Bashas’ United Drug

Baylor Scott and White

Pharmacy Bi-Mart

Brookshire Pharmacy

City Market

Costco Pharmacy

Dierberg Pharmacy

Dillon Pharmacy

Duane Reade

Food City Pharmacy

Food Lion Pharmacy

Fred Meyer Pharmacy

Fred’s Pharmacy

Fry’s Food and Drug

Giant Eagle Pharmacy

Giant Pharmacy

Hannaford Food and Drug

Harps Pharmacy

Harveys Supermarket

H-E-B Grocery

Henry Ford Medical Center Pharmacy

Homeland Pharmacy

Hy-Vee

Ingles Markets Pharmacy

King Soopers Pharmacy

Kinney Drugs

Kmart Pharmacy

Knight Drugs

Kroger Pharmacy

Long’s Drugs

Medicap Pharmacy

Medicine Shoppe Pharmacy

Meijer Pharmacy

Navarro Discount Pharmacy

Pick N Save Pharmacy

Publix Super Market

Quality Food Center

Ralphs Pharmacy

Rite Aid Pharmacy

Safeway Pharmacy

Sav-Mor

Schnuck Market

Shoprite Pharmacy

Smith’s Pharmacy

Stop & Shop Pharmacy

Target

Tom Thumb Pharmacy

U Save It

Vons Pharmacy

Walgreens

Walmart

Wegman Food Market

Winn Dixie

This is a list of the national chain pharmacies that participate in the SmithRx commercial pharmacy network. Many of the independent pharmacies across the United States also participate in our network. This list is subject to change. To determine if a pharmacy is in our network, please log into the portal at portal.mysmithrx.com/login.

National Chain Pharmacy Listing

Singlecare partners with pharmacies nationwide to get you affordable prices on your prescriptions. With 35,000 pharmacies nationwide you can save up to 80% on 50,000 drugs*. Download the app – available on the App Store and Google Play:

Then it’s easy - Three Steps

STEP ONE STEP TWO STEP THREE Find your prescription Compare pricing Present prescription at the pharmacy https://www1.singlecare.com/ Select pharmacy Present coupon at the pharmacy Enter prescription name and click ‘Search’ Click ‘Get Free Coupon’ Save at the pharmacy

Have questions? Give Singlecare a call at: 844-234-3057 or email them by using their online contact form: https://support.singlecare.com/customer/portal/emails/new

*Prescription savings vary by prescription and by pharmacy, and may reach up to 80% off cash price.

Prescription Discount

With most of our benefits: � Benefits are paid directly to you,

unless you specify otherwise. � You’re paid regardless of any

insurance you have with other companies.

� Coverage is available for your spouse and dependent children.

Choose the benefits that are right for you

such as heart attacks, strokes, cancer, etc.out-of-pocketexpenses upon diagnosis of a specified critical illness

Critical Illness Insurance helps pay for covered

confinement, doctor visits, diagnostic exams, surgeries, etc. Hospital/Medical Bridge Insurance provides benefits for hospital

can result from a covered accidental injury. Accident Insurance helps offset unexpected medical expenses that

Affordable Voluntary Coverage

Life Insurance

lora_watson

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To enroll call: Lora Watson 281-881-2386

HEALTH INSURANCE ENROLLMENT & ACKNOWLEDGEMENT GUIDE

This notification is to inform you that you, and your qualified dependents, are eligible for benefits under your employer’sopen enrollment.

Should you choose to decline coverage, please complete the acknowledgement and check the box at the bottom of thispage. Then you may disregard all remaining contents of this guide. If you choose to decline, you will not be able to enroll inbenefits until the next open enrollment period or due to a qualifying event.

MINIMUM ESSENTIAL COVERAGE (MEC)

According to the Affordable Care Act (ACA), more commonly referred to as Obamacare, all individuals must be offered at least Minimum Essential Coverage (MEC). MEC covers 17 preventative services for adults, 22 additional services for women and 26 services for children.

MEC Plus: Covers preventive services 100% and provides additional medical services such as office visits, urgent care, labs, x-rays and generic prescription drugs offered at various copays. Note: MEC Plus does not cover hospitalization, surgical procedures, emergency room or out-of-network services. MEC Plus includes telemedicine through 1800MD™.

ACKNOWLEDGEMENT OF RECEIPT

I, , hereby acknowledge receipt of the offer of health benefits.

I have been provided with the Enrollment Guide and with the information pertaining to the benefit plan offering. I havebeen offered a plan for myself and my qualified dependents that provides Minimum Essential Coverage (MEC).

I authorize my employer to make salary reductions on a pre-tax basis for my portion of the group insurance premiums. Iunderstand that:

• I cannot change this election during the plan year unless I have a change in status as provided in the InternalRevenue Code and Regulations.

• My Social Security benefits may be reduced by this election.• This election replaces any previous elections and will terminate on the earlier of (1) when I am no longer being

paid compensation in an amount at least equal to my total salary reduction or (2) termination of the plan.• My employer may reduce or cancel this election if necessary to comply with provisions of the Internal Revenue

Code.

I understand if I decline medical coverage I will not be able to enroll in benefits until the next open enrollment period ordue to a qualifying event.

Signature ______________________________________ Date ______ / ______ / ____________

Name _________________________________________________ Social Security Number _________ - ______ - ____________

DECLINE COVERAGE

SBMA-PLMECCP-032019

Name _______________________________________

Social Security Number __ __ __ - __ __ - __ __ __ __

Date of Birth __ __ / __ __ / __ __ __ __ Sex M F

Relationship Spouse Child

Name __________________________________________ Social Security Number __ __ __ - __ __ - __ __ __ __

Employer Name __________________________________ Hire Date __ __ / __ __ / __ __ __ __


Address ________________________________________ Phone Number __ __ __ - __ __ __ - __ __ __ __

City ___________________ State __ __ Zip __ __ __ __ __ Email _____________________________________

EMPLOYEE INFORMATION

DEPENDENT INFORMATION

Name________________________________________




Name _______________________________________




Name________________________________________




MEDICAL PLAN MEC Plus

Employee Only Employee + Spouse

Employee + Children Employee + Family

I declare the information provided above is complete and accurate. I understand an agent or broker cannot guarantee coverage, revise rates, benefits or provisions without written approval from SBMA. Please review pricing and benefit summaries prior to finalizing your selections.

Signature ______________________________________________ Date __ __ / __ __ / __ __ __ __

ENROLLMENT APPLICATION

EMPLOYEE DECLARATION

SBMA-PLMECA-032019

MEC PLUSBENEFIT SUMMARY

To locate providers participating in the MultiPlan PHCS network call (888) 263-7543 or visit www.multiplan.com and click “Find a Provider” located in the top right-hand corner of the page and follow the steps below.

1. After acknowledging you have read the disclaimer at the bottom of the screen, click on the green “Select Network” button.

2. When selecting your network, choose “PHCS,” then “Specific Services.”3. Enter one of the search criteria suggested in the search box to begin your search.4. If your browser settings don’t allow your location to be detected, enter a zip code.

*MEC Plus excludes out-of-network services and covers ONLY the medical above services above. This plan does not coveremergency room care, hospitalization, surgical services, advanced imaging or brand name / specialty prescription drugs.

**For more information regarding the Telehealth Program call 1800MD at (800) 530-8666 or visit www.1800md.com

SBMA-MECPLUSTM-02202019

MEDICAL BENEFITS MEC PLUS*Annual Deductible $0Out-of-Pocket Maximum $1,850 individual / $3,700 familyPreventive / Wellness Covered 100%Primary Care / Specialist Office Visits $15 copayUrgent Care $50 copayEmergency Room / Hospital Not CoveredLaboratory Services $50 copayX-Rays $50 copayTelehealth Program** IncludedGeneric Prescription Drugs $5 copay

http://www.multiplan.com/

http://www.1800md.com/

Covered Services for Adults

1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

2. Alcohol Misuse screening and counseling3. Aspirin use to prevent cardiovascular disease for men and women

of certain ages4. Blood Pressure screening for all adults5. Cholesterol screening for adults of certain ages or at higher risk6. Colorectal Cancer screening for adults over 507. Depression screening for adults8. Diabetes (Type 2) screening for adults with high blood pressure9. Diet counseling for adults at higher risk for chronic disease10. Hepatitis C screening for adults at increased risk, and one time for

everyone born 1945 – 196511. HIV screening for everyone ages 15 to 65, and other ages at

increased risk12. Immunization vaccines for adults —doses, recommended ages, and



14. Obesity screening and counseling for all adults15. Sexually Transmitted Infection (STI) prevention counseling for

adults at higher risk16. Syphilis screening for all adults at higher risk17. Tobacco Use screening for all adults and cessation interventions for

tobacco users

Covered Services for Women

1. Anemia screening on a routine basis for pregnant women2. Breast Cancer Genetic Test Counseling (BRCA) for women at higher

risk for breast cancer3. Breast Cancer Mammography screenings every 1 to 2 years for

women over 404. Breast Cancer Chemoprevention counseling for women at higher

risk5. Breastfeeding comprehensive support and counseling from trained

providers, and access to breastfeeding supplies, for pregnant and nursing women

6. Cervical Cancer screening for sexually active women7. Chlamydia Infection screening for younger women and other

women at higher risk8. Contraception: Food and Drug Administration-approved

contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

9. Domestic and interpersonal violence screening and counseling for all women

10. Folic Acid supplements for women who may become pregnant11. Gestational diabetes screening for women 24 to 28 months

pregnant and those at high risk of developing gestational diabetes12. Gonorrhea screening for all women at higher risk13. Hepatitis B screening for pregnant women at their first prenatal visit14. HIV screening and counseling for sexually active women15. Human Papillomavirus (HPV) DNA Test every 3 years for women

with normal cytology results who are 30 or older

Covered Services for Women (continued)

16. Osteoporosis screening for women over age 60 depending on risk factors

17. Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk

18. Sexually Transmitted Infections counseling for sexually active women19. Syphilis screening for all pregnant women or other women at

increased risk20. Tobacco Use screening and interventions for all women, and

expanded counseling for pregnant tobacco users21. Urinary tract or other infection screening for pregnant women22. Well-woman visits to get recommended services for women under

65

Covered Services for Children

1. Alcohol and Drug Use assessments for adolescents2. Autism screening for children at 18 and 24 months3. Behavioral assessments for children at the following ages: 0 to 11

months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.4. Blood Pressure screening for children at the following ages: 0 to 11

months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.5. Cervical Dysplasia screening for sexually active females6. Depression screening for adolescents7. Developmental screening for children under age 38. Dyslipidemia screening for children at higher risk of lipid disorders

at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

9. Fluoride Chemoprevention supplements for children withoutfluoride in their water source

10. Gonorrhea preventive medication for the eyes of all newborns11. Hearing screening for all newborns12. Height, Weight and Body Mass Index measurements for children at

the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11to 14 years, 15 to 17 years.

13. Hematocrit or Hemoglobin screening for children14. Hemoglobinopathies or sickle cell screening for newborns15. HIV screening for adolescents at higher risk16. Hypothyroidism screening for newborns17. Immunization vaccines for children from birth to age 18 - doses,

recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Hemophilus influenzae type b, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Meningococcal, Pneumococcal, Rotavirus, Varicella

18. Iron supplements for children ages 6 to 12 months at risk for anemia

19. Lead screening for children at risk of exposure20. Medical History for all children throughout development at the


21. Obesity screening and counseling22. Oral Health risk assessment for young children Ages: 0 to 11

months, 1 to 4 years, 5 to 10 years.23. Phenylketonuria (PKU) screening for this genetic disorder in

newborns24. Sexually Transmitted Infection (STI) prevention counseling and

screening for adolescents at higher risk25. Tuberculin testing for children at higher risk of tuberculosis at the


26. Vision screening for all children.

This plan provides no coverage for sickness, hospitalization or surgical benefits. Benefits are not limited to the schedule above. For more information on covered services visit: https://www.healthcare.gov/coverage/preventive-care-benefits/

MEC COVEREDPREVENTIVE SERVICES

SBMA-MPSL-02202019

https://www.healthcare.gov/coverage/preventive-care-benefits/


As a nationally recognized telehealth provider, our national network of board certified physicians diagnose illnesses, recommend treatment and prescribe medications when appropriate to its members over the telephone, through secure bi-directional video and email. All of our physicians are fully credentialed through a process that includes a thorough review of medical licenses, training and education, work and malpractice history.

1-800MD provides fast and convenient access to quality medical care 24 hours a day, 7 days a week and 365 days a year throughout the United States. 1-800MD is a convenient and inexpensive alternative to non-emergent Emergency Room visits, non-critical care clinics, or when you don’t have access to your primary care provider (PCP).

1-800MD provides medical diagnosis and treatment for common ailments such as:

• Allergies• Arthritic Pain• Bronchitis• Certain Rashes• Cold/Flu Symptoms• Ear Infections• Gastroenteritis• Headaches/Migraine• Insect Bites

• Sinus Infections• Sprains/Strains• Respiratory Infections• Stomach Ache/Diarrhea• Sore Throat• Urinary Tract Infection• Minor Burns• General Information

• Many other non-emergency medical illnesses

1-800MD saves time, saves money and provides members with peace of mind

According to research conducted by the Wellness Council of America (2008), 70% of in-office doctor’s visits could have been handled by a phone call or e-mail.

Over 90% of survey respondents said that 1-800MD physicians spent an appropriate amount of time with them and answered all their questions, saving them time, money and a trip to the ER or doctor’s office.

1-800MD provides access to physicians 24/7 via the phone for diagnosing and treating acute care illnesses.

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Call Today To learn How 1-800Md Can Help your CoMpany


How It Works:

•

A member requests a physician consultation by telephone or email by calling1 -800-530-8666 or on line at www.1800MD.com.

•

Over the phone or online, Member completes or updates their personal health history and disclosure (PHH) form.

• The physician is contacted via our automated system, reviews the member’s personalhealth history and disclosure form prior to the consultation.

• The physician calls the patient generally within 15 minutes, guaranteed within 1 hour.

• The physician conducts the consultation and recommends appropriate treatment.

• When appropriate the physician will e-prescribe prescription medications directly to thepatient’s pharmacy of choice. We have over 60,000 pharmacies in our database.

• Doctor completes a patient consultation form and updates the electronic medical record(EMR).

• A completed encounter is generated and available to the patient via the online portal.

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1-800-530-8666www.1800md.com

Your Prescription Benefit Plan through SmithRx. SmithRx is your new prescription benefit provider. SmithRx is dedicated to giving you the best service and resources to help you and your family make better healthcare decisions.

Using Your Prescription Drug Card at Retail You will receive a prescription card from your employer. Please present your new prescription card along with your prescription to any of our 67,000+ retail pharmacies every time you fill your prescription. You can access a participating pharmacy list at www.mysmithrx.com.

Using Your Home Delivery Benefit Taking advantage of your home delivery benefit may enable you to receive up to a 90-day supply of your brand maintenance medication(s) at a discounted price through Magellan Rx Home. Just ask your physician to write two prescriptions: one for a 30-day supply to get you started (to be filled at your local pharmacy), and one for a 90-day supply, plus additional refills (to be filled at the home delivery pharmacy). To get started you can:

• E-prescribe or Fax: Have your doctor e-prescribe or fax your prescription to(866) 642-5620. Faxed prescriptions may only be sent by a doctor’s office andmust include patient information and diagnosis for timely processing.

• Mail: Mail us your 90-day prescription, completed order formwith payment to: PO Box 620968, Orlando, FL 32862

Please note: For prompt delivery, please provide your payment informationby mailing in your completed order form or by calling 1 (800) 424-5894.

Online Tools at www.mysmithrx.com Secure online connection, protecting your confidentiality and providing:

• Drug formulary & lookup tools• Trusted drug and health condition information & education• Real-time benefit information• View and download pharmacy claims• Find a participating pharmacy• Download claim reimbursement, prior authorization request,

specialty pharmacy enrollment, and mail order forms

Formulary Changes To help provide our customers with access to safe, high-quality and cost-effective prescription benefits, it is necessary to classify some drugs as preferred and others as non-preferred drugs on the SmithRx formulary. Access our full formulary at www.mysmithrx.com to see how your medication is classified.

2018 SmithRx. All rights expressly reserved. For support, call (844) 454-5201 any time.

Understanding Your Prescription Benefit ProgramProviding you with the tools and resources to help you make better drug therapy decisions

Additional requirements for coverage or limits on certain medications may include:

Your Plan may have additional requirements for coverage or limits for select prescription medications. These requirements and limits ensure that members use these medications in the most effective way and also help the Plan control medication costs. A team of practicing physicians and pharmacists developed these requirements and limits to help your Plan provide quality coverage to members. Please consult the formulary on our website for more information.

Quantity LimitsFor certain medications, your Plan may limit the amount of the medication that will be covered per prescription or for a defined period of time. For example, your Plan may provide up to 30 units per 30-day period for a formulary medication.

Step TherapyIn some cases, your Plan requires you to first try one medication to treat your medical condition before it will cover another medication for that condition. For example, if Drug A and Drug B both treat your medical condition, your Plan may require your physician to prescribe Drug A first. If Drug A does not work for you, then your Plan will cover Drug B.

Prior AuthorizationIf your physician prescribes a medication requiring a prior authorization, you will need to go through a prior authorization process. We review requests for these selected medications to help ensure appropriate and safe use of medications for your medical condition(s). Your physician can call, fax, or submit prior authorization requests electronically. For a list of select medications that require prior authorization, please contact Customer Service at (844) 454-5201.

Albertsons

Bashas’ United Drug

Baylor Scott and White

Pharmacy Bi-Mart

Brookshire Pharmacy

City Market

Costco Pharmacy

Dierberg Pharmacy

Dillon Pharmacy

Duane Reade

Food City Pharmacy

Food Lion Pharmacy

Fred Meyer Pharmacy

Fred’s Pharmacy

Fry’s Food and Drug

Giant Eagle Pharmacy

Giant Pharmacy

Hannaford Food and Drug

Harps Pharmacy

Harveys Supermarket

H-E-B Grocery

Henry Ford Medical Center Pharmacy

Homeland Pharmacy

Hy-Vee

Ingles Markets Pharmacy

King Soopers Pharmacy

Kinney Drugs

Kmart Pharmacy

Knight Drugs

Kroger Pharmacy

Long’s Drugs

Medicap Pharmacy

Medicine Shoppe Pharmacy

Meijer Pharmacy

Navarro Discount Pharmacy

Pick N Save Pharmacy

Publix Super Market

Quality Food Center

Ralphs Pharmacy

Rite Aid Pharmacy

Safeway Pharmacy

Sav-Mor

Schnuck Market

Shoprite Pharmacy

Smith’s Pharmacy

Stop & Shop Pharmacy

Target

Tom Thumb Pharmacy

U Save It

Vons Pharmacy

Walgreens

Walmart

Wegman Food Market

Winn Dixie

This is a list of the national chain pharmacies that participate in the SmithRx commercial pharmacy network. Many of the independent pharmacies across the United States also participate in our network. This list is subject to change. To determine if a pharmacy is in our network, please log into the portal at portal.mysmithrx.com/login.

National Chain Pharmacy Listing