retiree benefits reference guide · 2018-09-26 · if your frs check is not sufficient ... the...

2019Plan Year

RetireeBenefits Reference Guide

Table of ContentsOnline Resources:

DCPS Benefits Website: dcps.duvalschools.org/benefits

OCTConnect With Us

3 Key Things to Know

4 Eligibility & Payment

5 How To Enroll

6 How To Enroll

7 Changing Your Coverage

11 Health + Wellness

12 Medical Plans

19 Pharmacy Benefits

21 TRICARE Supplemental Medical

23 Dental Plans

26 Vision Plan

29 Hearing Plan

31 Critical Illness

32 Universal LifeEvents®

33 Universal Life Insurance

34 Pet-Focused Benefits

35 Identity Theft Program

36 Technology Support Program

37 Notices

38 Forms

41 Benefits Directory

https://www.youtube.com/user/JacksonHealthSystem

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https://www.linkedin.com/company/jackson-health-system

dcps.duvalschools.org/benefits

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Welcome To Your 2019 DCPS Retiree Benefits Open EnrollmentOpen Enrollment is a good time to evaluate your health insurance plans and decide whether to make a change. This Open Enrollment is for benefits effective January 1, 2019 through December 31, 2019. If you are satisfied with your current benefit elections, there is nothing more you have to do.

YOU ARE RESPONSIBLE FOR READING YOUR ENROLLMENT MATERIAL IN ITS ENTIRETY, EVEN IF YOU AREN’T MAKING CHANGES.

What’s New• Medical Rates Unchanged• Dental Rates Unchanged • Vision Rates Increase Slightly

Key Things to Know

Important Dates to RememberYour open enrollment dates are:

October 15, 2018 through November 16, 2018

Your period of coverage dates are: January 1, 2019 through December 31, 2019

Important - Please Read!The Florida Blue Plans (No Deductible, Low Deductible or High Deductible) will remain as options to retirees and the retirees’ currently covered spouses and/or covered dependent child(ren) who are under age 65.

• In the event of your death, your covered spouse and/or covered dependent child(ren) may be eligible to continue coverage through COBRA.

• Your premiums will be deducted from your retirement check to assure continued coverage. If your FRS check is not sufficient to handle the amount of the benefit deductions including any increase in rates, missed deductions will be taken from your next FRS check(s).

• FBMC may deduct up to $100 in addition to the monthly premiums if there is an outstanding balance on your account.

• If you have any questions about your retiree benefits, contact the FBMC Service Center at 1-855-5MYDCPS (1-855-569-3277).

Availability of Health Insurance InformationThe Benefit Booklet, Plan Document, Summary of Benefits and Coverage (SBC), and Schedule of Benefits (SOB) can be found online at duvalschool.org/benefits. A paper copy is also available, free of charge by calling 904-390-2351.

RETIREE BENEFIT FAIR You are invited to attend an informational Retiree Benefit Fair:

Date: Wednesday, October 24, 2018 Times: 9 a.m. or 1 p.m. Location: Albert W. Herbert University Center on the University of North Florida campus 12000 Alumni Drive Jacksonville, FL 32224

The information in this guide is a summary and does not include all terms and conditions of the benefits. Please refer to the policy and certificate of coverage for complete details.

Who is Eligible?Retirees – A retiree is a former employee of Duval County Public Schools (DCPS) who has met the definition of retirement under the Florida Retirement System (FRS).

Retiree’s Spouse – a person to whom you are legally married and currently enrolled in a DCPS-sponsored plan.

Retiree’s Child(ren) – biological child, legally adopted child, stepchild, child for whom you have legal guardianship, or foster child and currently enrolled in a DCPS-sponsored plan. Children are eligible for Medical, Vision, and Dental coverage until the end of the month they turn 26.

Disabled Child(ren) – Disabled children are eligible for plan coverage regardless of age (proof of disabled status is required).

Payment and Billing FRS DeductionsPremium payments can be submitted through FRS payroll deduction. FBMC requires a completed and signed FRS payroll deduction authorization form if this method of payment is used. FRS deductions are taken one month prior to the month of coverage.

If you are a new retiree, until FRS deductions begin, payment by personal check or money order is required.

If you are currently under FRS deductions for your insurance and your premium(s) exceed your retirement check, partial deductions will not be taken.

If you have a change in coverage that results in an increase in the premium to be deducted from your FRS retirement benefit, or if there is a delay from when you enroll in a benefit and your premiums start being deducted from your FRS check, you may need to pay the difference by check or money order until your deductions are paid-to-date. FBMC will automatically deduct up to $100.00 monthly in additional funds from your FRS check until your account is paid-to-date if you do not send in payment. If you wish to send in a payment for your premium should you owe a balance due to a new benefit enrollment or change in premium or coverage, please remit your premium(s) to FBMC Benefits Management, Inc.

Be sure to monitor your December 31, 2018 FRS check to verify that your new premium deductions took place. If you have any questions regarding your premiums, please contact FBMC Service Center toll free at 1-855-5MYDCPS (1-855-569-3277).

ACH DeductionsIf you wish to make a payment via an automatic deduction from your bank account, please fill out the ACH Authorization Form that is included in this packet and return to FBMC. ACH deductions will be withdrawn from your account on the 22nd of each month for the total outstanding balance of your account. Please allow two to three business days for the ACH deduction to clear your account.

Direct BillIf you choose Direct Bill, you will receive a monthly statement each month indicating the balance that is due by the end of the month. You must pay your premiums by the 1st of each month, and FBMC must receive your payment no later than the 5th of each month so that your benefits will not be terminated.

Payment not receivedIf payments have still not been received by the end of the month, FBMC will terminate your coverage. If your benefit is terminated with FBMC, you will no longer be able to participate in your retiree benefits plans.

Please send payments to: FBMC Benefits Management, Inc. Retiree and Direct Bill Department PO Box 10789 Tallahassee, FL 32302-2789

If we receive a check from you, and your check does not clear for insufficient funds or a closed bank account, you will receive a notice from us. You will need to re-submit a payment to us within 10 days of receipt of that notice in order for your coverage to remain active.

Changes to CoverageAny changes to your retiree benefit(s) will require your written authorization. As soon as FBMC Benefits Management, Inc., receives your written request and processes your change, any excess premiums will be refunded within 60 days.

If you would like to change or cancel your Allstate Critical Illness, AFLAC, Trustmark or Unum benefits you must contact the provider directly. You can locate their contact information in the provider directory included in this reference guide. To cancel PetPlus, Identity Theft Protection, IT Please Whole-Home Technical Support or Ameritas - SoundCare, use the form in this book.

If you are having FRS deductions for premium payments, any required refunds will be completed as soon as verification is received that FRS has changed your deduction. Any coverage you elect to cancel cannot be reinstated after 30 days.

Please send all written cancellation requests to: FBMC Benefits Management, IncRetiree and Direct Bill Department PO BOx 10789 Tallahassee, FL 32302-2789

Eligibility & Payment

It is your responsibility to respond to insurance companies’ periodic inquiries about dependent eligibility. Failure to provide timely dependent verification information will result in loss of dependent coverage.

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How to EnrollIf you are satisfied with your current benefit elections, there is nothing more you have to do.

Benefit OptionsNo Deductible, Low Deductible, High Deductible Health Plans (Under 65 or Over 65 and Ineligible for Medicare)For current participants who do not wish to make changes, NO FURTHER ACTION IS REQUIRED.• If you would like to change plans (i.e., change from Low

Deductible to No Deductible), you must complete the FBMC enrollment form.

• See the Important Facts About High Deductible Health Plan (HDHP) with HSA section of the 2019 Retiree Benefits Reference Guide before enrolling in the High Deductible Health Plan (HDHP) with HSA.

Dental, Vision, Identity Theft Protection, IT Technology Support, Hearing Aid Benefit, and Pet RxFor current participants, who do not wish to make changes, NO FURTHER ACTION IS REQUIRED.• If you would like to enroll in or change plans (i.e., change

from DeltaCare USA to Delta Dental PPO; add Identity Theft Protection, etc.), you must complete the FBMC enrollment form.

Trustmark Universal LifeFor current participants, who do not wish to make changes, NO FURTHER ACTION IS REQUIRED.• If you would like to enroll in or change plans, you must see an

Enrollment Counselor at the Retiree Fair.

Steps to Complete the FBMC Enrollment Form1. Complete Section 1 (Your personal information).

2. Place a “√” in the box next to the plan you would like to enroll in and enter the appropriate premium amount. Be sure to specify the coverage level (e.g., Retiree and Spouse). Note: Medical Insurance and Standard Life Insurance cannot be elected if previously canceled.

3. Be sure to list all dependents that should be covered under your plan. If you are dropping a dependent, be sure to elect the appropriate benefit level for that option.

4. Sign and date form.

5. Mail the form back to: FBMC Benefits Management, Inc. Retiree and Direct Bill Department PO Box 10789 Tallahassee, FL 32302-2789

TRICARE Supplement PlanFor current participants who do not wish to make changes, NO FURTHER ACTION IS REQUIRED.• You must be a full-time TRICARE eligible participant to enroll in

the TRICARE Supplement Plan.• Contact Employee Benefits at 1-904-390-2351 to schedule

an appointment to complete the TRICARE Supplement Plan application and FBMC enrollment form.

How To Enroll

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©FBMC • DCPSRET/0818

If you have an existing policy with Allstate, Unum, Aflac, or Trustmark and wish to cancel or change coverage, you must contact the providers directly. See the Retiree Reference Guide for contact information. Current premiums for voluntary benefits reflected on Current Benefits statement will continue until notification of a change from the Provider Company.

5. DEPENDENT INFORMATION

DEPENDENT NAME (PRINT CLEARLY)

RELATIONDATE OF BIRTH

MO/DAY/YRSOCIAL SECURITY #

MED

ICA

L

DEN

TAL

DEN

TAL

FAC

ILITY#

VISIO

N

HEA

RIN

G

6. SIGNATUREI UNDERSTAND THAT I CANNOT CHANGE MY ELECTIONS UNDER THIS AGREEMENT DURING THE PLAN YEAR UNLESS THERE IS A PERMITTED MID-PLAN YEAR ELECTION CHANGE EVENT AS DEFINED IN THE FLEXIBLE BENEFITS RETIREE REFERENCE GUIDE. I UNDERSTAND AND AGREE THAT DCPS, THE UNION, AND FBMC BENEFITS MANAGEMENT INC., WILL BE HELD HARMLESS FROM ANY LIABILITY RESULTING FROM EITHER MY PARTICIPATION IN ANY OF THE BENEFITS HEREIN OR MY FAILURE TO SIGN OR ACCURATELY COMPLETE THIS ENROLLMENT FORM.

STATE LAWS REQUIRE AGENCIES THAT ARE REQUIRED TO COLLECT SOCIAL SECURITY NUMBERS (SSN) TO DISCLOSE THE PURPOSE FOR COLLECTING THE SSN. THE DUVAL COUNTY SCHOOL BOARD IS ALLOWED TO COLLECT SSN’S WHEN SPECIALLY AUTHORIZED BY LAW TO DO SO, OR WHEN THE COLLECTION IS IMPERATIVE FOR THE PERFORMANCE OF THE DISTRICT’S DUTIES AND RESPONSIBILITIES. PURSUANT TO FEDERAL AND STATE LAWS, THE DISTRICT IS COLLECTING YOUR SOCIAL SECURITY NUMBER FOR THE PURPOSE OF PROCESSING RETIREE AND DEPENDENT BENEFITS; THIS COLLECTION IS MANDATORY. IF YOU DO NOT PROVIDE US YOUR SSN, DCPS CANNOT PROCESS YOUR APPLICATION/REQUEST. THE DUVAL COUNTY SCHOOL BOARD WILL NOT DISCLOSE YOUR SSN TO ANYONE OUTSIDE OF THE DISTRICT EXCEPT AS AUTHORIZED BY LAW.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. F.S. SECTION 817.234 (1) (B) (2012)RETIREE PARTICIPANT SIGNATURE DATE SIGNED

VISION CARE PREMIUM

Davis Vision

Retiree Only $5.33

CANCEL $ ________Retiree + 1 $11.44

Retiree + Family $16.21

HEARING CARE PREMIUM

Ameritas - SoundCare®

Retiree Only $8.00

CANCEL $ ________Retiree + Spouse $16.00

Retiree + Child(ren) $12.00


IDENTITY THEFT PROTECTION PREMIUM

ID CommanderPremium Plan Retiree Only $7.00 Retiree + Family $15.00

CANCEL $ ________Ultimate Plan Retiree Only

$10.50 Retiree + Family $22.50

IT TECHNOLOGY SUPPORT PREMIUM

IT PleaseUnlimited Support Plan Retiree Only $10.00

CANCEL $ ________Unlimited Plus Support Plan Retiree Only $14.00

PET Rx PREMIUM

Petplus Single Pet $4.50 Multiple Pets $8.50 CANCEL $ ________

TRUSTMARK INSURANCE COMPANY

Universal Life Insurance You must see a Benefits Counselor at the Retiree Beneits Fair to enroll.

Universal LifeEvents You must see a Benefits Counselor at the Retiree Beneits Fair to enroll.

TOTAL $ ________

(Front) (Back)

1. RETIREE INFORMATION

Please see reverse side for remaining Flexible Benefits selections and dependent information.Your signature is required on the back of this form in order to confirm your benefits.

RETURN FORMS TO:FBMC RETIREE & DIRECT BILL - Attn: Mail Slot 32PO Box 10789 Tallahassee, FL 32302-2789FBMC Service Center 1-855-5MY-DCPS (1-855-569-3277)Fax: 866-836-9943

2. INSTRUCTIONSRetirees: This form is only required if you are making changes. If you make any changes, you must complete the enrollment form in its entirety. Medical Insurance and/or Standard Life Insurance cannot be elected if previously canceled. You can cover your dependents under every benefit that specifies dependent coverage, as long as your dependents are currently covered and you participate in the same benefit.

In the event you pass away while covering a dependent spouse and/or child(ren), coverage for the dependent(s) will terminate at the end of the month in which you pass away UNLESS the dependent is also a DCPS retiree. The dependent(s) will be extended the option of continuing coverage through COBRA.

3. MEDICAL BENEFITS - FOR RETIREE UNDER AGE 65 PREMIUM

FLORIDA BLUE

DCPS NO DEDUCTIBLE

DCPS LOW DEDUCTIBLE

DCPS HIGH DEDUCTIBLE

CANCEL $ ________

Retiree Only $691.47 $631.81 $575.26Retiree/Spouse $1,172.79 $1,071.61 $975.70Retiree/Child(ren) $1,048.76 $958.29 $872.52Retiree/Family $1,595.88 $1,458.20 $1,327.69Spouse Only* $691.47 $631.81 $575.26Child(ren) Only* $357.29 $326.48 $297.26

Retiree is over age 65 and ineligible for Medicare (Verification from Social Security Administration must be provided)*Spouse Only and Child(ren) Only rates are only available when the retiree is actively enrolled in one of the AARP Medicare Supplement Plans, UHC Medicare Advantage Plans or UHC PDP Plans and is also covering dependents who are under age 65.

RETIREE HEALTH SAVINGS CONTRIBUTION

Waive - Must be enrolled in High Deductible plan to be HSA eligible PREMIUM

Retiree Contribution (Maximum $3,500 single/$7,000 family) CANCEL $ ________

TRICARE SUPPLEMENTAL MEDICAL RATES

Retiree Only $67.50

CANCEL $ ________Retiree + One $132.50

Retiree + Two or More $178.50

PLEASE WRITE IN ALL CAPITAL LETTERS WITH A PEN.

2019 RETIREE ENROLLMENT FORMDUVAL COUNTY PUBLIC SCHOOLS

January 1, 2019 - December 31, 2019

®

4. GROUP TERM LIFE INSURANCE PREMIUM

GROUP TERM LIFE INSURANCE

Standard Insurance Company CANCEL $ ________

Retiree Only

5. FLEXIBLE BENEFITSIndicate all benefits selections by entering the necessary information below. Dependent eligibility is limited to the same benefit categories and amounts selected by the Retiree. If you elect dependent coverage in any benefits, you must provide dependent information in Section 6 below.

DENTAL CARE DeltaCare USA Delta Dental PREMIUM

(Florida Residents Only)(Non-Florida

Residents Only) PPO

CANCEL $ ________Facility #___________

Retiree Only $19.64 $27.41 $44.08

Retiree + 1 $32.90 $45.65 $87.76

Retiree + Family $48.40 $67.29 $114.39

LAST NAME FIRST NAME MI SSN#

HOME ADDRESS: STREET CITY STATE ZIP

BIRTH DATE: MONTH/ DAY/YEAR MALE FEMALE

MARRIED SINGLE

HOME PHONE # RETIREMENT DATE

CELL PHONE # EMAIL ADDRESS

Sample Enrollment Form - Please make sure to fill out both sides of your enrollment form and sign the back.

CancellationIf you do not wish to continue your Florida Blue Medical, Group Term Life, Dental, Vision, Identity Theft Protection, and/or IT Technology Support, place an “X” in the box next to “cancel” on the enrollment form. If you choose to cancel your coverage, your spouse and/or dependent child(ren) cannot remain on the canceled plan.

If you have an existing policy with Allstate, UnitedHealthCare®, Unum, AFLAC or Trustmark and wish to cancel or change coverage, you must contact the providers directly – see the Retiree Benefits Directory for contact information.

Cancellations completed during Open Enrollment will be processed effective January 1, 2019.

How To Enroll

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Changing Your CoverageChanges during the yearUnder certain circumstances, you may be allowed to change your benefit elections during the plan year (Jan 1 - Dec. 31), such as adding or dropping dependents, depending on whether or not you experience a permitted election change event. Permitted election change events include, but are not limited to, change in marital status, number of dependents, employment status, residence, HIPAA special enrollment rights, etc. See full terms and conditions at dcps.duvalschools.org/benefits. Election changes will be effective on a prospective basis only, meaning that the

District will process all approved mid-year changes on the first day of the month after you have completed a benefits change form and have submitted all required supporting documentation.

You must submit an Election Change Form along with supporting documentation to the Employee Benefits Department within 60 days of a permitted election change event. If your election change request is denied, you will have 30 days from the date you receive the denial to file an appeal with DCPS Employee Benefits.

ALL CHANGES MUST BE MADE WITHIN 60 DAYS OF THE QUALIFYING EVENT

Event Supporting Document Dental and Vision Retiree Group Term Life

I. CHANGE IN STATUSA. Change in Retiree’s Legal Marital Status

1. Gain Spouse (Marriage) • Marriage Certificate; and• Recent IRS Tax Return required (if

married prior to current calendar year)

Retiree may enroll or increase election for newly eligible spouse and dependent children as well as pre-existing dependents; retiree may also revoke or decrease own or dependent’s coverage only when such coverage becomes effective or is increased under the spouse’s plan. HIPAA special enrollment rights may also apply.

Retiree may enroll in coverage when eligibility is affected.

2. Lose Spouse (Divorce, legal separation, annulment, or death of spouse)

• Divorce Decree• Court documentation stating

legally separated or marriage annulled

• Death certificate

Retiree may revoke election only for spouse; retiree may also elect coverage for self or dependents that lose eligibility under spouse’s plan if such individual loses eligibility; retiree may also enroll new and pre-existing dependents so long as at least one dependent has lost coverage under the spouse’s plan. HIPAA special enrollment rights may also apply.

Retiree may cease coverage when eligibility is affected.

B. Change in the Number of Retiree’s Dependents

1. Gain Dependent (Birth, adoption, legal custody)

• Birth Certificate or Hospital Certificate with Foot Prints

• Adoptions papers or placement for adoption papers

• Legal custody papers• Marriage certificate - if spouse (not

retiree ) is legal guardian/ adoptive parent/ custodian / foster parent

Retiree may enroll or increase election for newly eligible dependents and/or enroll any pre-existing dependents; retiree may also revoke or decrease own or dependent’s coverage if retiree or dependent become eligible under spouse’s plan. HIPAA special enrollment rights may also apply

Retiree may increase coverage when eligibility is affected

2. Lose Dependent (Death, dependent no longer meets eligibility requirements)

• Death Certificate• Birth Certificate

Retiree may drop coverage only for the dependent who loses eligibility

Retiree may decrease or cease coverage even when eligibility is not affected

C. Change in Employment Status of Retiree, Spouse, or Dependent that Affects Eligibility

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1. Commencement of Employment by Retiree, Spouse, or Dependent (or Other Change in Employment Status) that Triggers Eligibility

a. Commencement of employment by retiree or other change in employment status (e.g., PT to FT) triggering eligibility under component plan

Letter from employer verifying employment status change

Provided eligibility was gained for this coverage, retiree may add coverage for retiree, spouse, or dependents

No change permitted

b. Commencement of employment by spouse or dependent or other employment event triggering eligibility under their employer’s plan

Letter from employer verifying employment event triggering eligibility under the employer’s plan

Retiree may revoke or decrease election under retiree’s, spouse’s, or dependent’s coverage if retiree, spouse or dependent is added to spouse’s or dependent’s coverage

No change permitted

2. Termination of Employment by Retiree, Spouse or Dependent (or Other Change in Employment Status) That Causes Loss of Eligibility


a. Termination of spouse’s or dependent’s employment (or other change in employment status resulting in a loss of eligibility under their employer’s plan)

Letter from employer verifying employment termination

Retiree may enroll or increase election for retiree, spouse or dependent that loses eligibility under spouse’s or dependent’s employer’s plan; retiree may also enroll previously eligible dependents. HIPAA special enrollment rights may also apply

No change permitted

D. Event Causing Retiree’s Dependent to Satisfy Eligibility Requirements

1. Event by which dependent ceases to satisfy eligibility requirements under another employer’s plan (attaining a specified age, getting married, ceasing to be a student, etc.)

Letter from employer indicating dependent no longer meets eligibility requirements

Retiree may enroll or increase election for affected dependent, retiree may also add previously eligible but not enrolled dependents

No change permitted

E. Change in Place of Residence of Retiree, Spouse, or Dependent

1. Move triggers eligibility Documentation of the move A change in the place of residence of the retiree, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area

No change permitted

2. Move causes loss of eligibility (e.g. retiree or dependent moves outside HMO service area)

Documentation of the move A change in the place of residence of the retiree, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area

No change permitted

Changing Your Coverage

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1. Retiree, spouse, or dependent enrolled in employer’s health plan become entitled to Medicare or Medicaid (other than coverage solely for pediatric vaccines)

• Letter from Florida Kidcare, Medicaid, Medicare or TRICARE verifying enrollment

• Florida Kidcare, Medicaid, Medicare or TRICARE ID card reflecting effective date of coverage

Retiree may cancel or reduce coverage for retiree, spouse, or dependent as applicable

Retiree may cancel or reduce coverage for retiree, spouse, or dependent, as applicable

2. Retiree, spouse, or dependent loses eligibility for Medicare or Medicaid (other than coverage solely for pediatric vaccines.

Letter from Florida Kidcare, Medicaid, Medicare or TRICARE verifying loss of eligibility.

Retiree may elect to commence or increase coverage for retiree, spouse, or dependent, as applicable and add previously eligible (but not yet enrolled) dependents.

Retiree may cancel or reduce coverage for retiree, spouse, or dependent, as applicable.


a. Termination of spouse’s or dependent’s employment (or other change in employment status resulting in a loss of eligibility under their employer’s plan)

Letter from employer verifying employment termination

Retiree may enroll or increase election for retiree, spouse or dependent that loses eligibility under spouse’s or dependent’s employer’s plan; retiree may also enroll previously eligible dependents. HIPAA special enrollment rights may also apply

No change permitted

D. Event Causing Retiree’s Dependent to Satisfy Eligibility Requirements

1. Event by which dependent ceases to satisfy eligibility requirements under another employer’s plan (attaining a specified age, getting married, ceasing to be a student, etc.)

Letter from employer indicating dependent no longer meets eligibility requirements

Retiree may enroll or increase election for affected dependent, retiree may also add previously eligible but not enrolled dependents

No change permitted

E. Change in Place of Residence of Retiree, Spouse, or Dependent

1. Move triggers eligibility Documentation of the move A change in the place of residence of the retiree, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area

No change permitted

2. Move causes loss of eligibility (e.g. retiree or dependent moves outside HMO service area)

Documentation of the move A change in the place of residence of the retiree, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area

No change permitted


F. Change in Coverage Under Other Employer Cafeteria Plan or Qualified Benefits Plan

1. Other employer plan increases coverage

Letter from employer verifying coverage increase.

Retiree may decrease or revoke election for retiree, spouse, or dependents if retiree, spouse, or dependents have elected or received corresponding increased coverage under another employer plan.

2. Other employer’s plan decreases or ceases coverage

Letter from employer verifying decrease or cease of coverage

Retiree may enroll or increase election for retiree, spouse, or dependents if retiree, spouse, or dependents have elected or received corresponding decreased coverage under other employer planOther previously eligible dependents may be enrolled

3. Open Enrollment under other employer plan/different year

Letter from employer verifying open enrollment

Corresponding changes can be made under employer’s plan permitted

4. Loss of group health coverage sponsored by Governmental or Educational Institution

• Letter from Governmental or Educational Institution verifying loss of group health coverage

• Certificate of Creditable Coverage

Retiree may enroll or increase election for retiree, spouse, or dependent if retiree, spouse, or dependent loses group health coverage sponsored by governmental or educational institution

G. Florida Kidcare, Medicaid, Medicare or TRICARE


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2. Special enrollment for acquisition of new dependent by birth, marriage, adoption or placement for adoption. (If newborn or newlyadopted child is enrolled under HIPAA’s special rules, child’s coverage may be retroactive to date of birth, adoption or placement for adoption; retiree may change salary reduction election within 30 days to pay for cost of child’s coverage retroactive to date of birth, adoption or placement for adoption. (For marriage, salary reductions may only be changed prospectively.)

Retiree may elect coverage for retiree, spouse, or dependent. Under the tag-along rule, coverage may also extend to previously eligible (but not yet enrolled) dependents.


H. FMLA Leaves of Absence

1. Retiree’s commencement of FMLA leave.

Documentation verifying retiree is on LOA.

Retiree can make same election changes as retiree on non-FMLA leave. Employer must allow retiree on unpaid FMLA leave either to revoke coverage or to continue coverage, but allow retiree to discontinue payment of his or her share of the contribution during the leave. The employer may recover the retiree’s share of contributions when the retiree returns to work.

2. Retiree’s return from FMLA leave N/A Retiree may make a new election if coverage terminated while on FMLA leave. In addition, an employer may require an retiree to be reinstated in his or her election upon return from leave if retirees who return from a non-FMLA leave are required to be reinstated in their elections

J. Judgment, Decree or Orders

1. Order that requires coverage for the child under retiree’s plan.

Court order. Retiree may change election to provide coverage for the child. Though unclear, it appears tag-along rule concepts may apply.

2. Order that requires spouse, former spouse or other individual to provide coverage for the child.

Court order. Retiree may change election to cancel coverage for the child provided the child is enrolled in the plan of the spouse, former spouse or other individual required to provide coverage.

K. HIPAA Special Enrollment Rights


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Health + Wellness

Health Advocate Solutions is an employer-sponsored program, available at no cost to retirees, their spouses, dependent children, parents and parents-in-law. Services are completely confidential and available 24 hours a day, seven days a week.

Employee Assistance Program (EAP)To access services, call the CARELINE: 1-877-240-6863Or visit: HealthAdvocate.com/members

Counseling and relationship support• You can talk to licensed behavioral health professionals

for support with issues, such as family relationship issues, depression, conflict management, alcohol/substance abuse, stress management, and more

Web-based resources• Child care/parenting/adoption/special needs• Care for older adults• General, family, criminal law• Elder law/estate planning/will preparation• Divorce/mediation• Retirement/other financial planning

Did You Know?The Saving Center offers discounts on products and services, including: travel, gifts, electronics, theme parks, movie tickets, apparel, flowers, jewelry, fitness centers, and more.

District Wellness ProgramOur mission is to provide high-quality comprehensive programs, initiatives and educational opportunities that positively impact individual health and foster a culture of wellness throughout the DCPS community.• Weight management programs • Diabetes management programs • Educational lunch-and-learns• Better You Strides online wellness solution• On-site flu shot clinics/health screenings • Smoking cessation resources

ContactLocation: District Administration Building: 1701 Prudential Drive, 3rd Floor, Room 345 Jacksonville, FL 32207 Phone: 904-390-2351 Website: duvalschools.org/wellness

DCPS Personal Health AdvocateFlorida Blue understands that each person has unique healthcare needs, and navigating the healthcare system is not always easy. To help, we offer a Personal Health Advocate for DCPS members. This is available to you at no extra cost, and can help you:• Locate and research treatments for medical conditions• Find “best-in-class” doctors, specialists and facilities• Navigate within Florida Blue• Get referrals

• Find answers about test results and treatment plansContact Nancy Byers, RN, your Personal Health Advocate, at 904-905-0901 or email [email protected].

Did You Know?If you participate in one of the Diabetes Management Programs you can receive:• FREE diabetic-related generic prescription medications

(cholesterol, blood pressure and diabetic)• FREE approved diabetic supplies (needles and syringes)• FREE insulin• FREE ongoing support from nurse health educators

Florida Blue On-site RepresentativeResa Askew: 904-390-2323

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Florida Blue will continue providing medical administrative services for the new plan year (January – December, 2019) only to those members who are under the age of 65 or for retirees who are over 65 and not Medicare-eligible. The options include No Deductible Health Plan, Low Deductible Health Plan and High Deductible Health Plan. These options are open-access plans that do not require you to choose a primary care physician. You may pick the physician of your choice. However, to receive your maximum benefit, you should select an in-network doctor from participating Florida Blue, Blue Options (Network Blue) providers found at floridablue.com.

DCPS No Deductible Health Plan

Plan Highlights:• Participants have the freedom to choose an in-or out-of-

network provider at the time of service.

• There is no in-network deductible.

• Coinsurance applies to all services that do not have set copays. For example:

• Inpatient and Outpatient Hospitalization • Ambulatory Surgical Center Facility

• All Out-of-Network Services

• Coinsurance and copays (including Rx) count towards the maximum out-of-pocket limit.

DCPS Low Deductible Health Plan

Plan Highlights:• Participants have the freedom to choose an in- or out-of-

network service provider at the time of service.

• Deductibles and coinsurance apply to all services that do not have set copays. For example:• Inpatient Hospitalization

• All Out-of-Network Services

• Deductible, coinsurance and copays (including Rx) count towards the maximum out-of-pocket limit.

DCPS High Deductible Health Plan

Plan Highlights:• Participants have the freedom to choose an in- or out-of-

network service provider at the time of service.

• Deductibles and coinsurance apply to all services including Rx (excluding routine services).

• For coverage other than retiree-only, the family deductible must be met before coinsurance or copayments are applicable.

• After you reach your out-of-pocket maximum, all covered services, including Rx, are paid at 100 percent by the health plan.

• For Medicare Part D coverage, the prescription drug coverage offered by the High Deductible Health Plan is considered non-creditable.

• You may waive the HSA under the HDHP.

• HSA funds may be used based on what’s available in the account.

• Money left in your HSA account rolls over from year to year.

• Changes to your HSA may be made once per month.

• Participant must be under age 65 and not entitled to Medicare to qualify for HSA.

This is an Employer Benefits Highlights Summary and not a contract. All benefits are subject to the provisions and exclusions of the master contract. Please check with your provider for more detailed information.

Medical Plans

www.floridablue.com

myFBMC.com 13

High Deductible Health Plan (HDHP) and Health Savings Account (HSA)

What is a High Deductible Health Plan (HDHP)? The HDHP is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. It gives you greater control over how you spend your health care dollars. This plan blends the best features of a preferred provider organization (PPO) with a tax-advantaged Health Savings Account (HSA) that you can use to pay eligible medical expenses.

Plan BenefitsThe HDHP allows you to use in-network and out-of-network providers. It is always more cost-effective to use in-network doctors, facilities, and other providers.

Here is how the plan works in-network: • You are not required to select a primary care provider (PCP) or

get referrals for in-network specialists.

• You pay 100 percent of the negotiated, discounted fee for all in-network services and prescription drugs until you reach the annual deductible.

• Once you meet the deductible, the plan pays:

• 75 percent of the negotiated, discounted fees for covered in-network in-patient services.

• 80 percent of the negotiated, discounted fees for all other covered in-network services except for prescription drugs (see below).

• Your deductible and coinsurance, including prescription drugs, applies to your out-of-pocket maximum.

• After you reach your out-of-pocket maximum, all covered services, including prescriptions, are paid at 100 percent by the health plan.

Here is how the plan works out-of-network: You pay 100 percent of the eligible fees for all out-of-network services.Note: You will be responsible for all ineligible charges. Ineligible charges do not count towards the deductible and they do not count towards the out-of-pocket maximum.

• Once you meet the out-of-network deductible, the plan pays 50 percent of the allowed amount for covered out-of-network services.

• Your deductible and coinsurance apply to your out-of-pocket maximum.

• After you reach your out-of-pocket maximum, all covered services are paid at 100 percent by the health plan.

Health Savings AccountA Health Savings Account (HSA) is an interest-bearing spending and savings account that you use to pay for eligible healthcare expenses using tax-free dollars. You must be enrolled in the High Deductible Health Plan (HDHP) to contribute to the HSA.

Qualifying for an HSAIn order to open an HSA, you must be “HSA Eligible.” IRS guidelines say that an HSA eligible-individual is anyone who:

• Is covered by an HSA-qualified High Deductible Health Plan (HDHP)

• Cannot be claimed as a dependent by another person

• Isn’t covered by some sort of additional, non-HDHP insurance program

• Is under age 65 and not entitled to Medicare.

Annual HSA ContributionsThe IRS sets limits for how much you can contribute to an HSA in each calendar year. These limits, established by the federal government and subject to change, are tied to the rate of inflation. Over-contributing to your HSA leads to a tax penalty on excessive funds.

2019 contribution limits are $3,500 for single and $7,000 for family.

Catch-Up ContributionsHSA owners age 55 and older can make additional contributions to their HSA called “catch-up contributions.” For 2019, the allowed catch-up contribution is $1,000.


Medical Plans

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Important Facts About High Deductible Health Plan (HDHP) with HSAThe law stipulates that in order to have a Health Savings Account (HSA) you must participate in a qualified High Deductible Health Plan (HDHP). However, if any of the following situations pertain to you, you can participate in the HDHP, but NOT the HSA.

If you enrolled in Medicare or Medicaid, you cannot open an HSA.

If you have Tricare, you cannot have an HSA because Tricare does not offer an HDHP.

If you are receiving medical care from the Veteran’s Administration for a non-service- related disability, you cannot have an HSA.

If you have received any Veterans Administration health benefits in the last three months, you cannot have an HSA. If two family members each have an HDHP, the maximum annual HSA contribution remains the same. In other words, it is not doubled. 2019 limits are $3,000 for single and $7,000 for family coverage.

Flexible Spending Accounts (FSA) which cover all medically necessary expenses make you ineligible for an HSA.

If a spouse participates in a private healthcare plan, Medicare, Medicaid, or Tricare, this will make you ineligible for an HSA if you are also covered.

If you no longer have an HSA qualified HDHP, you cannot contribute to your HSA, but you can maintain and spend the already deposited funds as stipulated by law.


Medical Plans

myFBMC.com 15

PayFlex Health Savings Account (HSA) FAQsHow are funds placed into my HSA?Step 1: Retiree enrolls in HDHP and HSA

Step 2: Retiree opens HSA with bank

Step 3: Retiree contributes funds to HSA account

Step 4: Retiree uses HSA debit card or check to pay for medical expenses.

How may I change my HSA contribution?You may change the amount you contribute to your HSA once a month. To change your HSA contribution, contact FBMC Benefits Management at 1-855-569-3277.

How do I get funds out of my HSA? PayFlex will establish an individual account for you and mail one VISA® Check Card to your home address at no charge. You may order additional cards by contacting PayFlex at 1-844-729-3539. If you choose to use your Check Card, you will need to sign for the transaction like a credit card transaction. Remember, as long as you are taking funds out for qualified medical expenses, you pay no taxes on the funds. However, if you withdraw funds for ineligible expenses, you may have to pay taxes and penalties on those funds, unless you reimburse your HSA for the ineligible amount.

Will I be charged any banking or custodial fees?A $2.50 monthly custodial fee will be applied to the member’s HSA account. A $5.00 monthly fee will be applied if you are no longer enrolled in an employer sponsored HDHP, but continue to maintain your PayFlex HSA account.

How are my HSA funds invested?Your funds will initially be held in an interest-bearing checking account at CitiBank. The bank can provide you with current interest rates for HSAs since these rates are subject to change. As your account balance grows, you may be eligible to place your funds into the HSA Investment Option. Once your balance reaches $1,000 or more, CitiBank will communicate the investment opportunities available to you through their broker.

I currently have an HSA account through Synovus Bank, will PayFlex continue making my HSA contribution to Synovus Bank instead of switching to Citibank?Contributions would only be made to the new PayFlex Citibank account.

What do I do if I continue my HSA contributions with Synovus Bank then later decide to change to CitiBank?An account can be opened at any time through PayFlex Citibank, you would just need to notify FBMC Benefits Management at 1-855-569-3277.


Medical Plans

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Using a High Deductible Health Plan with an HSA

Use It or Save ItYour HSA is your personal account, and you can choose how you want to use it. You can choose to use the funds as you need them for medical care, or pay for medical expenses with other non-HSA funds.

Opening a Health Savings AccountEnrolling in an HDHP will not automatically open your HSA. To open an HSA, you can visit PayFlex’s website: PayFlex.com.

Contributing to Your HSA• The 2019 contribution limits are $3,500.00 for single and

$7,000.00 for family.

• There are a number of ways to make deposits into your HSA:

• Regular Recurring Electronic Deposits Post-tax

• Mail-In Deposits: Fill out an HSA Contribution Form to make a deposit through the mail. Mailing instructions are on the form. These deposits would be post-tax.

Withdrawing from Your HSAYou can access funds in your HSA for qualified medical purposes in the following ways.

• Debit Card: Use your HSA debit card for purchases or to make payments for qualified medical expenses.

• Online Bill Pay: Payments for your account can be made online using the online bill pay feature. Please visit PayFlex.com.

• Request for Check Reimbursement: A reimbursement check can be requested on the PayFlex portal at payflex.com.

Your HSA belongs entirely to you. You may deposit money into your Health Savings Account for future health care expenses.

Banking or Custodial FeesA $2.50 monthly custodial fee will be applied to the member’s HSA account. A $5.00 monthly fee will be applied if you are no longer enrolled in an employer sponsored HDHP, but continue to maintain your PayFlex HSA account.

Paying for Services with Your HSAWith an HSA-based plan, you’ll still have an Insurance ID Card, and you’ll need to make sure that you present this card anytime you go to the doctor or pharmacy. This will ensure that:

1. You always get any network discounts available to you,

2. Your medical provider will file a claim with the insurance company, and

3. The amount you pay will be applied to your deductible.

HSA Paperwork: How to Handle ItSince an HSA is a tax-exempt benefit when used according to the IRS Rules, you’ll need to be able to prove that money you spend from your HSA is for eligible medical expenses, if you’re ever audited. The participant is responsible for all record keeping of money spent from their HSA.


Medical Plans

myFBMC.com 17

2019 MEDICAL PLAN OPTION COMPARISON CHARTSDCPS

NON-CONTRIBUTORY PLAN

DCPS CONTRIBUTORY

PLAN


HEALTH PLAN

(LOW DEDUCTIBLE)(NO IN-NETWORK

DEDUCTIBLE)(HIGH DEDUCTIBLE HEALTH

PLAN)

PER PAY RETIREE DEDUCTIONS MONTHLY RATERetiree Only $631.81 $691.47 $575.26

Retiree & Spouse $1,071.61 $1,172.79 $975.70

Retiree & Child(ren) $958.29 $1,048.76 $872.52

Retiree & Family $1,458.20 $1,595.88 $1,327.69

Spouse Only* $631.81 $691.47 $575.26

Child(ren) Only* $326.48 $357.29 $297.26

BENEFIT CATEGORYHOSPITAL

Inpatient In-Network (Network Blue) Out-of-Network

CYD + 25% CoinsuranceCYD + 50% Coinsurance

20% CoinsuranceCYD + 50% Coinsurance


Out-of-State In-Network Out-of-Network




Outpatient Hospital Facility In-Network Out-of-Network

$250 CopayCYD + 50% Coinsurance



Emergency Room In-Network Out-of-Network

$300 Copay$300 Copay

$250 Copay$250 Copay


ANCILLARY

Urgent Care Center In-Network Out-of-Network

$60 Copay$60 Copay

$35 Copay$35 Copay


Ambulatory Surgical Center Facility In-Network Out-of-Network




Independent Diagnostic Testing Facility (X-Ray / Imaging) In-Network Out-of-Network




Medical Plans

myFBMC.com18

Medical Plans2019 MEDICAL PLAN OPTION COMPARISON CHARTS

DCPS NON-CONTRIBUTORY

PLAN

DCPS CONTRIBUTORY

PLAN


HEALTH PLAN

(LOW DEDUCTIBLE)(NO IN-NETWORK

DEDUCTIBLE)(HIGH DEDUCTIBLE HEALTH

PLAN)

Independent Clinical Lab (Quest Diagnostics is the Participating Clinical Lab) In-Network Out-of-Network




Mammograms $0 Copay $0 Copay $0 Copay

PHYSICIAN

Office Services In-Network Family Physician In-Network Specialist Out-of-Network

$25 Copay$45 Copay

CYD + 50% Coinsurance

$15 Copay$35 Copay


CYD + 20% CoinsuranceCYD + 20% CoinsuranceCYD + 50% Coinsurance

Routine Physicals In-Network Out-of-Network




Physician Services Other than Office Hospital and ER In-Network Family Physician In-Network Specialist Out-of-Network Physician/Specialist

$25 Copay$45 Copay

CYD+ 50% Coinsurance

$15 Copay$35 Copay


CYD + 20% CoinsuranceCYD + 20% CoinsuranceCYD + 50% Coinsurance

PRESCRIPTION DRUGS

Generic Drugs Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Injectables(Out-of-network pharmacy expenses are not covered)

$7 Copay$25 Copay$40 Copay$55 Copay

$7 Copay$25 Copay$40 Copay$55 Copay

CYD + $7 CopayCYD + $25 Copay + 10%

CoinsuranceCYD + $40 Copay + 10%

CoinsuranceCYD + $55 Copay + 10%

Coinsurance

Mail Order (excludes specialty drugs)(Out-of-network pharmacy expenses are not covered)

2 x Retail 2 x Retail 2 x Retail

DED / COINSURANCE / OOP

Calendar Year Deductible (CYD) In-Network (INN) Out-of-Network (OON)

Single/Family$500/$1,000

$1,000/$2,000

Single/Family$0/$0

$500/$1000

Single/Family $1,350/$2,700 $2700/$5200

Coinsurance In-Network Out-of-Network

25% Inpatient/ 20% All others

50% Coinsurance20% Coinsurance50% Coinsurance

25% Inpatient, Outpatient and ER

20% All others50% Coinsurance

Out-of-Pocket Maximum (OOP)(Includes CYD, Copays, Coinsurance) In-Network (Network Blue) Out-of-Network

Single/Family$4,000/$8,000$6,000/$12,000

Single/Family$2,500/$5,000$3,250/$6,500

Single/Family$5,000/$10,000

$10,000/$20,000

myFBMC.com 19

Pharmacy Benefits

Pharmacy Benefits

Prime Therapeutics is the current Pharmacy Benefit Manager for Duval County Public Schools.

Member servicesVisit Prime Therapeutics’ website, myprime.com, to view your plan design and copayment information, search for details on prescription medications, locate a participating pharmacy near you, and manage your home delivery prescriptions. For additional plan inquiries, you may call Member Services directly at 1-800-664-5295. For future reference, this number is listed on the back of your Florida Blue ID card.

Benefit ID cardsPresent your ID card when filling a prescription at the pharmacy. Should you need additional or replacement ID cards, please contact Member Services or visit floridablue.com to either request a new card or print a temporary card.

Covered expensesFederal legend prescription drugs, unless otherwise indicated;• Drugs requiring a prescription under the applicable state law;• Insulin, insulin needs and syringes on prescription; or• Compound medications, of which at least one ingredient is a

federal legend drug.

MedicationsGeneric MedicationsGeneric medications contain the same active ingredients as brand-name medications, are just as safe and effective, and meet the same U.S. Food and Drug Administration standards for quality, strength and purity. However, generic drugs normally cost substantially less than their brand-name counterparts. Therefore, generic drugs offer a simple and safe alternative to help reduce your medication costs. Ask your doctor to see if a generic drug could treat your condition.

Formulary and Non-Formulary MedicationsThe Prime Therapeutics Formulary List is a guide for you and your doctor to refer to when filling out your prescriptions. If there is no generic medication available for your condition, there may be more than one brand name for you and your doctor to consider. Prime Therapeutics provides a list of formulary brand-name

medications to help you and your doctor decide on medications that are clinically appropriate and cost-effective.

If a drug you are taking is not on the formulary list, you may want to discuss alternatives with your doctor or pharmacist. Using drugs on the formulary list will keep your costs lower. A current drug list is available online or upon request by calling Member Services. To avoid paying higher copayments associated with non-preferred drugs, please take this list with you when you visit your doctor so he or she can refer to it when prescribing medications for you and your eligible family participants.

Retail pharmaciesNetwork Retail Pharmacies(Out-of-network pharmacy expenses are not covered)

Prime Therapeutics is a national network comprised of thousands of retail pharmacies. The network includes most major chains, discount, grocery and independent pharmacies, so there is a good chance that your local pharmacy is a participating member of the network. To find a local pharmacy, visit myprime.com and click “Find a Pharmacy” or contact Member Services.

Speciality Pharmacy(Out-of-network pharmacy expenses are not covered)

For specialty medications, please contact AllianceRX Walgreens Prime.

Mail Order(Out-of-network pharmacy expenses are not covered)

AllianceRX Walgreens Prime is designed for plan participants taking maintenance medications, or those medications taken on a regular basis, for the treatment of long-term conditions, such as diabetes, arthritis, or heart conditions. The program provides up to a 90-day supply of medication, delivered directly to your home or other location, postage paid.

In order to fill your prescription, please logon to AllianceRX Walgreens Prime website at AllianceRXwp.com for your order form and payment information. You may also ask your doctor to call 1-800-664-5295 for instruction about faxing in your prescription. Your medication will usually be delivered within five to seven days of AllianceRX Walgreens Prime receiving your order.

This is an Employer Benefits Highlights Summary and not a contract. All benefits are subject to the provisions and exclusions of the master contract

myFBMC.com20

To order refills, call Member Services at 1-800-664-5295, or visit AllianceRXwp.com. Refills are normally delivered within three to five days. If you are a first-time visitor to the site, please take a moment to register and have your member ID and prescription number available.

To ensure timely delivery, place your orders at least two weeks in advance to allow for mail delays and other circumstances beyond our control. If you have any questions concerning your order, or if you do not receive your medication within the designated time frame, please contact Member Services.

If a new medication has been prescribed for you to take immediately, please ask your doctor to issue two prescriptions; one prescription should be written and filled at your local pharmacy and the second should be written for up to a 90-day supply. To fill the latter prescription, please logon to AllianceRX Walgreens Prime website at AllianceRXwp.com for your order form and payment information.

As you manage your prescriptions, be aware that each prescription is filled and checked by highly qualified registered pharmacists to ensure that quantity, quality and strength are accurate. A patient profile is maintained on file to ensure that there are no adverse reactions with other prescriptions you are receiving from retail and/or mail order pharmacies. If any questions arise regarding potential drug interactions or other adverse reactions, AllianceRX Walgreens Prime’s pharmacists will contact either you or your doctor prior to dispensing the medication.

Medication step therapyStep Therapy requires the previous use of one or more drugs before coverage of a different drug is provided. If your health plan’s formulary guide reflects that Step Therapy is used for a

specific drug, your physician must submit a prior authorization request form to the health plan for approval. If the request is not approved, please remember that you always have the option to purchase the medication at your own expense.

Prior authorization Prior authorization is required on some medications before your drug will be covered. If your health plan’s formulary guide indicates that you need a prior authorization for a specific drug, your physician must submit a prior authorization request form to the health plan for approval. If the request is not approved, please remember that you always have the option to purchase the medication at your own expense.

Quantity limits Quantity limits are applied to certain drugs based on the approved dosing limits established during the FDA approval process. Quantity limits are applied to the number of units dispensed for each prescription. If your health plan’s formulary guide reflects that there is a quantity limit for a specific drug, your physician must submit a prior authorization request form to the health plan for approval. If the request is not approved, please remember that you always have the option to purchase the medication at your own expense.

Formulary exception Formulary exceptions are necessary for certain drugs that are eligible for coverage under your health plan’s drug benefit. Your physician must submit a formulary exception form to your health plan for approval. If the request is not approved by the health plan you may still purchase the medication at your own expense. The general form can be used if the drug you are requesting coverage for is not on the formulary list.

(Out-of-Network and Out-of-Country is not covered)

Rx Copay Summary

DCPSNON-CONTRIBUTORY

PLAN

DCPSCONTRIBUTORY

PLAN

DCPS*HDHP

WITH HSARetail Calendar Year Deductible MUST be met then:

Generic - Formulary $7 $7 CYD + $7

Brand - Formulary $25 $25 CYD + $25 + 10% Coinsurance

Non-Formulary $40 $40 CYD + $40 + 10% Coinsurance

Specialty Injectables $55 $55 CYD + $55 + 10% Coinsurance

Maximum Supply One month One month One Month

Mail Order Calendar Year Deductible MUST be met then:

Generic - Formulary $14 $14 CYD + $14

Brand - Formulary $50 $50 CYD + $50 + 10% Coinsurance

Non-Formulary $80 $80 CYD + $80 + 10% Coinsurance

Maximum Supply 90 days 90 days 90 days

*HDHP W/HSA: Rx costs go to deductible. Once deductible is met, then retiree pays copay for generic and copay+10% for all other Rx.

Pharmacy Benefits

myFBMC.com 21

TRICARE Supplemental MedicalWe are pleased to make available the TRICARE Supplement coverage for all eligible retirees entitled to TRICARE. Combined with your TRICARE coverage, the TRICARE Supplement is a valuable asset.

EligibilityEligibility is limited to the following individuals:• Military Retirees• Retired Guard and Reserve members between the ages of 60

and 65 and entitled to retired pay• Retired Guard and Reserve members under age 60 and

enrolled in TRICARE Retired Reserve (TRR)• Spouses/Surviving Spouses (widow or widower) of the above.

These individuals cannot be age 65+ or eligible for Medicare unless they are one of the following:• Age 65 or older but ineligible for Medicare and received

a Statement of Disallowance from the Social Security Administration.

• Age 65 or older but resides outside the United States or its territories (must be eligible for Medicare Part A and enrolled in Medicare Part B).

Active duty spouses and dependents, TRICARE Reserve Select members and dependents and former spouses are no longer eligible.

Dependent eligibility:• Unmarried dependent children under age 21 (23 if a full-time

student)• Under age 26, if enrolled in TRICARE Young Adult (TYA)

program• Incapacitated dependents previously enrolled in an employer

sponsored plan

Plan BenefitsThe TRICARE Supplement Plan provides the following benefits for TRICARE covered services:

When TRICARE Standard/Extra is used:• 50 percent of the TRICARE Standard Outpatient Deductible of

$150 individual (maximum $300 family)• 100 percent of the TRICARE Standard/Extra cost share• 100 percent of Excess Charges up to TRICARE Legal Limits

(non-participating provider expenses)

When TRICARE Prime/Point of Service (POS) is used:• 100 percent of the TRICARE Prime cost share or copayments• 25 percent of the POS deductible of $300 individual (maximum

$600 per family)• 100 percent of the POS cost share• 100 percent of Excess Charges up to the TRICARE Legal Limits

(non-participating provider expenses).

Covered expenses are subject to supplement plan deductible of $100 per individual (maximum $200 per family). Exclusions and limitations apply.

The TRICARE Supplement is portable and there is no pre-existing condition limitation.

The TRICARE Supplement Plan is administered by Selman & Company. Call Center Representatives are available to answer your questions about your TRICARE Supplement Plan at 1-800-638-2610 or via email [email protected].

Tricare Supplemental Rates

MONTHLY RATE

Retiree Only $67.50

Retiree Plus One $132.50

Retiree Plus Two/More $178.50

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TRICARE SUPPLEMENTCoverage Summary

For TRICARE Standard/Extra MembersPlan Deductible - $100 per person

(Maximum $200 Per Family)

For TRICARE PRIME MembersPlan Deductible - $100 per person

(Maximum $200 Per Family)

TRICARE Category StandardFee-for-Service Option

ExtraPreferred Provider

Option

In-NetworkHMO

Out-of-NetworkPoint of Service (POS)

Option

Eligible Children (unmarried) Under age 21 (age 23 if a full-time student);extended to age 26 if enrolled in TYA (unless disabled

and continues TRICARE)

Under age 21 (age 23 if a full-time student);extended to age 26 if enrolled in TYA (unless

disabled and continues TRICARE)

Pre-existing Condition Limitation None None

Fiscal Year Outpatient Deductible(Fiscal year: October 1 - September 30)

TRICARE Standard Outpatient Deductible of $150 per person / $300 per family1

None TRICARE Prime POS Deductible of $300 per

person / $600 per family

Lifetime Benefit Maximum Unlimited Unlimited

Annual TRICARE Enrollment Fee None The TRICARE Prime enrollment fee is not cov-ered by the supplement plan

Pre-Certification Requirements Only as required by TRICARE Only as required by TRICARE

Benefits Below are Subject to the TRICARE Supplement Plan Deductible.

Inpatient Military Hospital Care(for military retirees and dependents)

The daily subsistence fee. The daily subsistence fee.

Inpatient Civilian Hospital Care(for military retirees and dependents)

Your eligible cost share (the lesser of the daily per diem

charge or 25% of billed amount, not to exceed

TRICARE Standard Diagnosis-Related Group

amount).

Your eligible cost share (the lesser of the daily

per diem charge or 25% of TRICARE Extra

contracted rate); 20% of professional fees.

Your eligible TRICARE Prime copayments and cost shares.

Your 50% POS cost share.

Outpatient Hospital Services(Surgery, X-ray, Lab, Office Visits, Well Baby Care, Accident, Emergency Care, Home Health Care)

50% of your TRICARE Outpatient Deductible

amount and your 25% cost share PLUS 100% of

Covered Excess Charges up to Legal Limit.

50% of your TRICARE Outpatient Deductible

and your 20% cost share.

Your eligible TRICARE Prime copayments

and cost share.

TRICARE POS Deductible amount of $75 per person, $150 per family and your 50% POS cost share

PLUS 100% of Covered Excess Charges up to

the Legal Limit.

Prescription DrugsHome Delivery (Mail Order) - up to a 90-day supply

Your copayments ($13 brand name or $43 non-formulary).

Your copayments ($13 brand name/

$43 non-formulary).Not Applicable.

Prescription DrugsCivilian Network Pharmacy -up to a 30-day supply

Your copayments ($5 generic/

$17 brand name/$44 non-formulary).

Your copayments ($5 generic/$17 brand

name/$44 non-formulary).

Not Applicable.

Prescription DrugsCivilian Non-Network Pharmacy upto a 30-day supply

Your Standard Outpatient Deductible plus $17 or 20% or $44 or 20% of the total cost, whichever is greater.

Not Applicable. Not Applicable.25% of the POS

Deductible and your 50% POS cost share.

Outpatient Mental Health(including alcoholism, drug addiction,nervous, mental and emotional disorder)

Up to $500 per person per fiscal year. Up to $500 per person per fiscal year.

Inpatient Mental Health(including alcoholism, drug addiction,nervous, mental and emotional disorder)

Limited to 30 days for adults age 19 or older, or 45 days for children under age 19 per fiscal year. If TRICARE approves benefits beyond these daily

limits, supplemental coverage is limited to the lesser of the number of days TRICARE pays or

90 inpatient per fiscal years.

Limited to 30 days for adults age 19 or older, or 45 days for children under age 19 per fiscal year. If TRICARE approves benefits beyond these daily

limits, supplemental coverage is limited to the lesser of the number of days TRICARE pays or

90 inpatient per fiscal years.

1 Amount applied toward 50% of the fiscal year TRICARE Outpatient Deductible is reimbursed only if the deductible is incurred after the effective date of coverage. After you have satisfied your plan deductible and 50% of the TRICARE Outpatient Deductible, your benefit will be paid.Note: Benefits are payable for covered cost share amounts up to the TRICARE Catastrophic Cap.Refer to the plan brochure for exclusions and limitations. Exclusions may vary by state and underwriter. See your certificate for complete details.

TRICARE Supplemental Medical

myFBMC.com 23

Dental Care

Dental Plans

Dental Care Benefit OptionsDelta Dental Insurance Company offers two choices for dental coverage: • DeltaCare®USA Option (Prepaid) and • Delta Dental PPOSM Option (Indemnity).

The DeltaCare USA Option plan features no deductible and low out-of-pocket costs for your basic dental care, however, you must select a dentist from the provider listing. The PPO Plan allows you the flexibility of choosing an in-network or out-of-network dentist at the time of service.

Selecting a Plan• DeltaCare USA Option – Under this option, each family

member can select a dentist, up to three dentists per family, from the DeltaCare USA Provider List. No claim forms to complete. No copays for basic cleanings.

• Delta Dental PPO Option – Under this option, you can receive services from a PPO Dentist or the dentist of your choice. PPO Dentists will file claims on your behalf and have agreed to charge no more than the predetermined PPO fee schedule. You may be required to pay up-front costs and file a claim form if you use a non-Delta Dental dentist.

• All benefits are subject to limitations and exclusions and governing administrative policies of the plan. The dental health plan contract must be consulted to determine the exact terms and conditions of coverage. An Evidence of Coverage will be sent to you upon enrollment.

Family CoverageThese plans cover:• Your spouse• Your dependent children to the end of the month in which they

reach age 26.• Disabled dependent children are covered as long as disability

remains total. A physician’s statement will be required.

Did You Know?• You can locate a DeltaCare provider by

calling 1-800-422-4234 or a PPO provider by calling 1-800-521-2651. You may also find a provider by using the app, or by going online at deltadentalins.com and clicking the “Find a Dentist” link on the homepage.

• To help you maintain your oral health, Delta Dental offers enhanced benefits for pregnant women. This coverage includes an additional exam, cleaning or periodontal procedure as needed, once pregnancy is confirmed.

• You can use the Dental Care Cost Estimator at deltadental.com to get an estimate on your potential procedure expenses.

• You have access to a Member Online Portal.

Get the AppAccess your insurance and the tools to help you use it anytime, anywhere with the Delta Dental mobile app.

itunes.apple.com/us/app/ delta-dental-mobile/

id632244310?mt=8&ign-mpt=uo%3D4

play.google.com/store/apps/details?id=com.

deltadental.HealthApp

myFBMC.com24

Delta Dental PPO Option Plan How the PPO Program Option Plan worksThe Delta Dental PPO Option Plan allows each person covered under the plan to have the freedom to visit any dentist. There may be a savings advantage to receiving care from a PPO Dentist because your out-of-pocket costs tend to be lower than visiting a non-Delta Dental dentist.

When you visit a PPO Dentist, payment is based on the PPO fee schedule. The PPO Dentist has agreed to accept this fee as the approved amount. Although you are responsible for deductibles, coinsurances and any expenses above the maximum, a PPO Dentist cannot bill you for any covered charges above the approved amount.

In addition to PPO Dentists, Delta Dental has Participating Delta Dental Premier® Dentists. PPO dental providers provide the most savings.

Although you are responsible for deductibles, coinsurances and any expenses above the maximum, Premier dentists have an agreement with Delta Dental not to charge you more than the approved amount.

In Florida, the Delta Dental PPO is underwritten and administered by Delta Dental Insurance Company.

Contact Information for Delta Dental PPOAfter you enroll, you can get answers by calling Delta Dental’s Customer Service department at 800-521-2651, Monday-Friday from 7:15 a.m. to 7:30 p.m. ET. You can print ID cards from the Delta Dental website: deltadentalins.com.

DeltaCare USA Plan How the DeltaCare USA Plan worksThe DeltaCare USA Plan features include:

• No maximum benefit, except for accidental injury• No claim forms to complete• Budgetable and predictable• Co-pay for orthodontics - No waiting periods• No co-pays for basic cleanings (2 per calendar year)• Specialty care is covered by referral from your primary dentist

at the same defined co-pays as general dentists

Accident Injury BenefitAn accidental oral injury is damage to the hard and soft tissue of the mouth caused directly and independently of all other causes by external forces. Damage to the hard and soft tissue of the mouth from normal chewing function is covered under your Plan FLM08 Description of Benefits and Copayments.

Contact Information for DeltaCare USA PlanAfter you enroll, you can get answers by calling Delta Dental's Customer Service department at 800-422-4234, Monday-Friday, from 8 a.m. to 9 p.m. ET. You can print ID cards from the Delta Dental website: deltadentalins.com.

Dental PlansDental Plans

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Dental PlansDELTACARE USA DELTA DENTAL PPO

RATES MONTHLY13B*

*ONLY FOR RETIREES RESIDING OUTSIDE OF FLORIDA

MONTHLY

Retiree* $19.64 $27.41 $44.08

Retiree + One* $32.90 $45.65 $87.76

Retiree + Family* $48.40 $67.29 $114.39 *Premiums may be deducted pre-tax or post-tax.

BENEFIT Calendar Year: January 1, 2019 through December 31, 2019

Dentist Choose A Panel Dentist Use Dentist Of Choice**

Deductible* None $75 Per Year, Individual & $150 Per Year, Per Family

Calendar Year Maximum None $5,000 Per Person

Claim Forms None None If Using Delta Dental Dentists

PROCEDURES YOU PAY PLAN PAYSOffice Visit $0 - $20 100% for PPO & Premier providers

Routine Exams No Cost 100% for PPO & Premier providers

Prophylaxis (Cleaning) Basic - No Cost (2 Per Calendar Yr.)Basic - 100% (Limit 2 In 12 Months) for PPO & Premier

providers

Emergency Treatment $10 (Regular Office Hours) 80%

X-Ray and Complete Series

No Cost (Including Bitewings)1100% (1 Per 36 Months- Full), Under 18: 2 Per 12 Months -

Bitewing, Over 18: 1 Per 12 Months - Bitewing

Fluoride Application No Charge To Age 19 (One Per 6 Months) 100% (2 Per 12 Months, Children Under 19 Only)

BASIC/RESTORATIVE PROCEDURESSimple Extractions $6 80%

Amalgam FillingsNo Cost - 1 Surface Perm,

Resin Based Fillings - Posteriors $15 - $35 80%

Root Canal Anterior2 $75; Molar2 $180 80%

MAJOR PROCEDURES

CrownsCrowns - Porcelain, Base Metal $195; Crowns -

Porcelain, $295 High Noble Metal50%

Dentures Upper/Lower $225 50%

BridgesPorcelain, Base Metal $195 (Per Unit)

Resin, High Noble Metal $295 (Per Unit)50%

Periodontics Scaling And Root Planing $45 Per Quadrant 50%

OrthodonticsStart Up Fee: $350, Routine 24 Month

Fully Banded Case: Adult $2,000, Child $1,80050% Up To $1,000 Lifetime Maximum (After 1 Year Waiting

Period Dependent Children Under Age 19 Only)

Waiting Period N/A Applies To New Participants (Orthodontics Only)

TMJ BENEFITSTMJ N/A 50% Up To $1,000 Lifetime Maximum (Effective October 2006)

* Note the deductible does not apply to diagnostic and preventative services, orthodontics.**PPO Dentists are limited to the PPO fee. Delta Dental Premier® Dentists are limited to the least of: the dentist’s filed fee, submitted fee, or Delta Dental’s MPA (Maximum Plan Allowance) fee. Non-Delta Dental Dentists may balance bill for amounts over Delta Dental’s MPA-TJM Benefits (Maximum Plan Allowance) fee.1. Under the DeltaCare USA plan, bitewing X-rays (code D0274) are limited to not more than one series of four films in any six-month period. 2. Excluding final restoration

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Vision Plan

Get the AppFind a provider, check your claim status, track your glasses order, print an ID card and more with the Davis Vision mobile app.

itunes.apple.com/us/app/davis-vision-member-app/id1292784565?ls=1&mt=8

https://play.google.com/store/apps/details?id=com.davisvision.

memberapp

Davis Vision PlanA comprehensive vision benefit ensuring low out-of-pocket cost to members and their families. Our vision plan helps you care for your eyes while saving you money. Our goal is 100 percent member satisfaction.

• Convenient Network Locations - A national network of credentialed preferred providers throughout the 50 states.

• Freedom of Choice - Access to care through either our network of independent, private practice doctors (optometrists and ophthalmologists) or select retail partners.

The plan offers a network of providers that service your eyecare needs with only a modest member copayment shown in the Schedule of Benefits on the next page.

Out-of-network benefitsThe out of-network-benefit allows you to select any provider and reimburses a fixed dollar amount based on the schedule shown for the out-of-network services*.

You will receive the greatest value and maximize your benefit dollars if you select a provider who participates in the network. However, you may choose an out-of-network provider, but you must pay the provider directly for all charges and then submit a claim for reimbursement to: applicable copayments, up to a maximum of $1,600 in any 12-month period. *This is not a contract: This is a benefits highlights summary. All benefits are subject to the provisions and exclusions of the master contract.

ContactFor more details about the plan, log on to the Open Enrollment section at davisvision.com or call Customer Service at 1-877-923-2847 and 1-800-999-5431 enter Client Code 3651.Vision Care Processing Unit; PO Box 1525; Latham, NY 12110. Did You Know?

You can locate a provider by calling Davis Vision customer service at 1-877-923-2847, using the app, or by logging on to the Open Enrollment section of our Member site at davisvision.com and click “Find a Provider”.

You have access to a Member Online Portal.

Vision Plan Rates

MONTHLY RATE

Retiree $5.33

Retiree + 1 $11.44


Premiums may be paid either “before” or “after” taxes are deducted from your salary.

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Vision PlanThe following chart indicates the benefits the plan pays for the services you receive. For more information, see the Davis plan literature.

SERVICES IN-NETWORK OUT-OF-NETWORK

FREQUENCY

Eye ExaminationEvery January 1,

covered in full after $10 copayment.Up to $35

EYEGLASSESSpectacle Lenses Every January 1,

covered in full for standard single-vision, lined bifocal,

or trifocal lenses after $15 copayment.

Spectacle Lenses (per pair) up to:Single Vision: $25,

Bifocal/progressive: $40, Trifocal: $60, and Lenticular: $100.

Frames $1306 Retail allowance toward any frame from provider, plus 20% off balance2.

Also, up to $180 frame allowance at Visionworks, plus 20% on any overage

OREvery other January 1, covered in full any

fashion or designer frame from Davis Vision’s collection1 (value up to $175).

Up to $50

CONTACT LENSES

IN-NETWORK OUT-OF-NETWORK

Contact Lens Evaluation, Fitting & Follow Up Care

Every January 1, Collection Contacts: Covered In Full

OrNon Collection Contacts:

Standard Contacts: 15% Discount2, Specialty Contacts3: 15% Discount2.

Elective Contacts: up to $150

Medically Necessary Contacts: up to $210

Contact Lenses(In Lieu of Eyeglasses) $150 retail allowance toward provider

supplied contact lenses, plus 15% off balance2 OR Every January 1, covered in full any

contact lenses from Davis Vision’s contact lens collection1.

N/A

1. The Davis Vision Collection is available at most participating independent provider locations. Collection is subject to change. Collection is inclusive of select toric and multifocal contacts.

2. Additional discounts not applicable at Walmart, Sam’s Club or Costco® locations.3. Including, but not limited to toric, multifocal and gas permeable contact lenses.4. For dependent children, monocular patients and patients with prescriptions of 6.00 diopters or greater.5. Transitions® is a registered trademark of Transitions Optical Inc.6. Enhanced frame allowance of $180 only available at Visionworks® locations nationwide.

Davis Vision has made every effort to correctly summarize your vision plan features. In the event of a conflict between this information and your organization’s contract with Davis Vision, the terms of the contract or insurance policy will prevail.

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Vision PlanVISION PLAN VS. WITHOUT VISION PLAN

ADDITIONAL DISCOUNTED LENS OPTIONS & COATINGSMost Popular Options - Savings based on in-network usage and average retail values. WITH VISION PLAN WITHOUT VISION PLAN

Scratch-Resistant Coating $0 $40

Polycarbonate Lenses $04 - $30 $64

Standard Anti-Reflective (AR) Coating $35 $62

Standard Progressives (no-line bifocal) $50 $154

Plastic Photosensitive (Transitions®5) $65 $123

ADDITIONAL OPTIONS

WITH VISION PLAN WITHOUT VISION PLAN

FRAMESFashion Frame (From the Davis Vision Collection)

$0 $125

Designer Frame (From the Davis Vision Collection)

$0 $175

Premier Frame(From the Davis Vision Collection)

$25 $225

LENSESAll Ranges of Prescriptions and Sizes $0 $90

Plastic Lenses $0 $33

Oversized Lenses $0 $20

Tinting of Plastic Lenses $0 $20

Scratch-Resistant Coating $0 $40

Polycarbonate Lenses $01 or $30 $64

Ultraviolet Coating $12 $28

Standard Anti-Reflective (AR) Coating $35 $62

Premium AR Coating $48 $80

Ultra AR Coating $60 $113

Standard Progressive Additional Lenses $50 $154

Premium Progressives (Varilux®2, etc.) $90 $248

Ultra3 Progressive Addition Lenses $140 $430

High-Index Lenses $55 $120

Polarized Lenses $75 $103

Plastic Photosensitive Lenses $65 $123

Scratch Protection Plan Single Vision/Multifocal Lenses

$20/$40 N/A

1. Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions 6.00 diopters or greater.2. Varilux® is a registered trademark of Societe Essilor International.3. Category includes digital free-form progressive lenses.

myFBMC.com 29

Hearing Aid Plans

Ameritas - SoundCare® Life’s getting louder.® Thanks to the cranked up volume of modern life, hearing loss is becoming a major health problem.

Policy features• You have the freedom to choose any hearing provider to receive benefits.• This plan provides access to EPIC, the largest ENT and Audiologist network in the country. The advantage of seeking services through an EPIC provider includes: • No claims to be filed for the member • 30-60 percent discounts for all major hearing aid technology manufacturers (as low as $495) • Open product selection and no off-brand or private label products • Hearing wellness program • EPIC Customer Service line 9 a.m.-9 p.m. ET • Leasing program availability• Hearing Exam: A full audio metric hearing exam is covered at 100% through EPIC providers once every benefit period. This comprehensive exam is also available if you chose not to use EPIC with reimbursement up to $75 per benefit period. • Hearing Aid Maintenance: You are also eligible for 100% of hearing aid maintenance up to $40 per benefit period. Maintenance covers batteries, service contracts, fittings, ear molds and repairs.• No Deductibles: Hearing exams, hearing aids and hearing aid maintenance are all deductible-free.• Hearing Aid Lease Benefit: In addition to this insured benefit, members have access through EPIC to a separate Hear TEK Leasing program to make hearing aid benefits more affordable.Note: While members can use both the insured benefit and also the leasing benefit, the SoundCare plan does not coordinate benefits with the leasing plan. Please see the detailed Hear Tek brochure and FAQ for more information, or contact any EPIC provider for more details.

• Increasing Hearing Benefits: The hearing aid benefit is progressive, rewarding you with benefits that increase over time based on your enrollment effective date. If you require a hearing aid, your DCPS plan covers 50% of the hearing aid cost per ear up to the annual benefit amount. Once you use your hearing aid coverage at any level, you become re-eligible for benefits at the top level, after five years, as long as there is no break in coverage. A reduced benefit

may be available after three years if your hearing suffers deterioration the current aids can’t correct.

Increasing Hearing Aid Maximum BenefitsYear 1 Year 2 Year 3

Comprehensive, full audio metric hearing exam

100% up to $75 per benefit period



Hearing Aid Maintenance (batteries, repairs, service contracts, ear molds)




Hearing Aids

30-60% EPIC discount on hearing aids.

30-60% EPIC discount on hearing aids

30-60% EPIC discount onhearing aids

No insured benefit in Year 1 for hearing aids.

Insured benefit provides 50%, up to $400 per ear, per benefit period for any provider

Insured benefit provides 50%, up to $800 perear, per benefit period for any provider

Hearing Plan

Ameritas SoundCare® Monthly Rates

Retiree $8

Retiree + Spouse $16

Retiree + Child(ren) $12

Retiree + Family $20

Premiums may be paid either “before” or “after” taxes are deducted from your salary.

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If you choose not to use EPIC:2. Select a provider of your choice and make an appointment with

them directly.

3. Visit ameritas.com to obtain a claim form.• Click on the individuals and families tab

• Click on forms under existing customers, dental/vision/hearing

• You will find the Hearing GC393 form within the Claim Forms drop-down menu

4. Take the claim form with you to your hearing provider. You complete Part 1 of the form and your provider completes Part 2.

5. You or your hearing Provider must send the claim form to: Ameritas Life Insurance Corp. Claims Office PO Box 82520 Lincoln, NE 68501 Fax 402-467-7336

6. You are responsible for paying any remaining balance due directly to your provider after your SoundCare benefits have been applied.*

* Insurance benefits for hearing aids are not payable until the expiration of a 45-day trial period. The trial period is required by state mandate unless the member signs a waiver stating they are with their hearing aids.

Eyewear and Rx savingsSave up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide by presenting your Ameritas savings card. Members can also save on prescriptions for your family (even your pets) at Walmart or Sam’s Club pharmacies. You’ll get hundreds of generic prescriptions for only $4.00, plus up to 40% off all other generics and 10-15% off most brand-name prescriptions. These savings arrangements are not insurance and are no additional cost to your planpremium. Access your savings cards by creating a secure member account at Ameritas.com.

Questions?SoundCare customer service representatives are available Monday-Thursday, 7 a.m. to 12 a.m. and Friday, 7 a.m. to 6:30 p.m. (CST) to answer your questions or help you find an EPIC provider. Please call 877-359-8346.

How to use your SoundCare benefits1. Call 877-359-8346 to speak to a SoundCare customer service representative. We’ll offer you the option of working with an EPIC Hearing Health Care counselor to help make finding and receiving care easier. Your SoundCare benefits are the same whether you opt to use EPIC or not.

If you choose to work with EPIC:2. An EPIC hearing counselor will help you to locate an alliance

provider in your area, then EPIC will send you a packet of information.

3. Once you are evaluated by the EPIC provider, the provider will coordinate your care directly with EPIC.

4. You will not need to complete or submit any claim forms. EPIC will submit the claims directly to Ameritas for you, including for the ordering of your hearing devices.*

5. EPIC can typically offer you substantial cost savings on your hearing devices. You are responsible for paying any remaining balance due directly to the EPIC provider after your SoundCare benefits have been applied.

Hearing Plan

myFBMC.com 31

The Trustmark Critical Illness Plan can provide a benefit ranging from $5,000 - $100,000. This plan gives you the flexibility of using the money at your own discretion.

The plan provides an immediate pre-selected lump sum cash benefit upon first diagnosis1 of a covered critical illness or cancer after the plan’s effective date. Your benefit is paid in full regardless of whether you have started treatment and allows you to decide how to use your benefit money.

Who is eligible?• All retirees (to age 70) may apply for coverage increases

during the annual enrollment who have previously purchased cancer and/or critical illness coverage through Trustmark may apply for an increase up to a total of $100,000 of coverage. The $100,000 is a combination of current critical illness and cancer and/or critical illness coverage (including the EZ Value Plan) and new critical illness coverage.

• Retirees with existing cancer coverage through Trustmark may continue their current plans.

Issue Ages• Retirees (18 through 70)• Spouse (18 through 70)• Children (day newborn released from hospital through 26)

Plan Features • The Critical Illness Plan includes cancer coverage. See your

enrollment counselor for further details.

• Waiver of Premium Rider available.

• You may add the EZ Value Plan option to this plan, which automatically increases your coverage annually on each of the first five policy anniversaries. The increase is equal to the amount of protection an additional $1 per week of deduction would purchase.*

* Maximum issue age is 60.1 As defined by policy/group certificate. Most states define eligibility as

first diagnosis. First diagnosis means the first time a physician identifies a covered condition from its signs or symptoms. If you’ve been diagnosed with a covered condition prior to having coverage, you may not be eligible for a benefit.

Optional Health Screening BenefitPays the cost of one screening test per calendar year ($50 or $100 benefit maximum). Eligible tests include:

Low Dose Mammography

Pap Smear (women over age 18)

Hemoccult Stool Specimen

Prostate Specific Antigen

Colonoscopy

Flexible Sigmoidoscopy

Stress Test on a Bicycle or Treadmill

Fasting Blood Glucose Test

Blood Test for Triglycerides

Serum Cholesterol Test to determine levels of HDL and LDL

Bone Marrow Testing

Breast Ultrasound

CA 15-3 (blood test for breast cancer)

CA 125 (blood test for ovarian cancer)

CEA (blood test for colon cancer)

Chest X-ray

Serum Protein Electrophoresis (blood test for myeloma)

Thermography

What premiums will I pay for this plan?Premiums are based on age, coverage selected and tobacco use. Speak with your enrollment counselor for more information.

How do I make changes to my election?You may elect to change your policy after it goes into effect by calling the Trustmark Service Center at 1-800-918-8877.

What if I have questions about my certificate?You can get answers about your certificate by calling Trustmark Customer Service at 1-800-918-8877.

Plan ProviderTrustmark Insurance Company, Lake Forest, Illinois, underwrites this plan. The A.M. Best Company, an organization that compares and rates the financial strength and performance of insurance companies, rates Trustmark “A-” Excellent. This information is being provided to retirees by Duval County Public Schools in advance of more complete information from the insurer.

Policy Form CACI-82001

Critical IllnessFor Current Participants Only

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How Living Benefits Add Up

EXAMPLE: $100,000 DEATH BENEFIT

MAXIMUM BENEFIT AMOUNT

Long-Term Care Insurance Rider (LTC)2 - Pays a monthly benefit equal to 4% of your death benefit for up to 25 months. The Long-Term Care Insurance Rider accelerates the death benefit and proportionately reduces it.

$100,000

Benefit Restoration Insurance Rider - Restores the death benefit2 that is reduced by the Long-Term Care Insurance Rider, so your family receives the full death benefit amount when they need it most.

$100,000

Total Maximum Benefit - Living Benefits may double the value of your life insurance.

$200,000

2 The LTC Benefit is an acceleration of the death benefit and is not Long-Term Care Insurance. It begins to pay after 90 days of confinement or services, and to qualify you must meet conditions of eligibility for benefits. Pre-existing condition limitation may apply. Your policy will contain complete details.

Universal LifeEvents®

Trustmark Universal LifeEvents® Insurance PlanHow does Universal LifeEvents® work?LifeEvents combines two important benefits into one affordable product. With LifeEvents, your benefits may be paid as a Death Benefit, as Living Benefits under the Long-Term Care Insurance Rider, or as a combination of both. Let’s take a closer look.

Death benefitMost people buy life insurance for the financial security of the death benefit, and it’s easy to see why. A death benefit puts money in your family’s hands quickly when they need it most. It’s money they may use any way they want to help cover short- and long-term expenses, such as funeral costs, rent or mortgage, debt, tuition, and more.

Long-Term Care Insurance RiderThis benefit makes it easy to accelerate the death benefit to help pay for home healthcare, assisted living, nursing care and/or adult day care services when you are chronically ill, should you or your covered spouse ever need them.

The Universal LifeEvents® AdvantageUniversal LifeEvents is unique. It’s designed to match your needs throughout your lifetime, so you have the benefits you need, when you need them most. See for yourself:

Working years — Universal LifeEvents pays a higher death benefit during working years when expenses are high and your family needs maximum protection. Then at age 70, when expenses typically reduce, Universal LifeEvents reduces the death benefit amount to better fit your needs; however, your benefits for the Long-Term Care Insurance Rider never reduce 1.

Throughout retirement — Universal LifeEvents pays a consistent level of benefits for long-term care during retirement, which is when you may be most susceptible to becoming chronically ill and may need long-term care services.

Features you’ll appreciate• Lifelong protection • Options available for family coverage • Accelerated Death Benefit Insurance Rider for Terminal Illness• Guaranteed renewable — Guaranteed coverage, as long as

your premiums are paid. Your premium may change if the premium for all certificates in your class changes.

• EZ Value — Automatically raises your benefits to keep pace with your increasing needs, without additional underwriting.

Separately priced benefits• Accidental death benefit – Doubles the death benefit if death

occurs by accident prior to age 75.• Children’s term life insurance rider – Covers newborns to age

23.• Waiver of premium – Waives premium payments if your doctor

determines you are totally disabled.

Contact informationTrustmark Insurance CompanyCustomer ServiceMon. - Thurs., 8 a.m. - 8 p.m. ET Fri. 8 a.m. - 7 p.m. EST1-800-918-8877Trustmark Claims1-877-201-9373, Option 2trustmarksolutions.com

1Death benefit reduces to one-third at the latter of age 70 or the 15th policy anniver-sary. Issue age is 18-64.

Only Available During Open Enrollment

myFBMC.com 33

Trustmark Voluntary Universal Life Insurance PlanWouldn’t you like to know that your loved ones will be taken care of should something happen to you? The Voluntary Universal Life Plan features progressive coverage for your peace of mind.

Wouldn’t you like to have life insurance last through your retirement? A plan that features portable coverage and cash values that can increase during your lifetime?

Who is eligible?• Retirees up to age 75, spouse 18-70 and children birth-23 are

eligible to apply for coverage.

• As a retiree of Duval County Public Schools, you can continue the Voluntary Universal Life you were enrolled in as an active employee, or apply for increased coverage of existing policies.

What does the plan offer?Voluntary Universal Life Insurance offers the following benefits: • Death Benefit• LTC Living Benefits• EZ Value Plan Option*• Death Benefit Restoration Rider• Optional Waiver of Premium• Optional Child Term Rider• Optional Accidental Death Benefit

How do I apply?Have your Enrollment Counselor, who is a Florida-licensed agent, complete the Universal Life Insurance plan application.

Flexible Permanent CoverageUniversal Life Insurance enables you to vary your premiums, coverage and cash value accumulation as your needs change. You can adjust the death benefit and premium upward and downward throughout your lifetime, subject to certain limits.

What premiums will I pay?You select the coverage and premium that best fit your budget and family needs.

How do I make changes to my election?You may elect to change your policy after it goes into effect by calling the Trustmark Service Center at 1-800-918-8877.

Plan ProviderTrustmark Insurance Company, Lake Forest, Illinois, underwrites this plan. The A.M. Best Company, an organization that compares and rates the financial strength and performance of insurance companies, rates Trustmark “A-” Excellent. This information is being provided to you by Duval County Public Schools in advance of more complete information from the insurer.

Universal Life Insurance is available on a post-tax basis, and a separate application is required. To apply have your enrollment counselor, who is a Florida-licensed agent, fill out the Universal Life Insurance Plan application.Note: If you need to make any changes throughout the year or would like answers about your certificate, you must contact Trustmark Customer Service at 1-800-918-8877.

Policy Form UL-205 Rider Forms HH/LTC.205, BRR.205, ABR.205, ADB.205, CT.205 and WP.205.

* Existing EZ Value participants ages 18-60 may extend to the 10-year increase options (with medical questions) if they choose to do so.

Universal Life InsuranceOnly Available To Retirees Up To Age 75

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CATEGORY SAMPLE PRODUCTS

AVERAGE VETERINARY

PRICE

PETPLUS WHOLE SALE

PrescriptionsRimadyl

100mg 30 caplets

$64$40

Save $288/year

Heartworm Preventatives

Heartguard Plus

Chewables 6 month supply for up to 25

lbs

$42$23

Save $38/year

Flea & Tick Preventatives

FrontlinePlus 6 month

Supply for 35-88 lbs

$104$58

Save $92/year

Prescription Diet Foods

Hill’s prescription Diet Canned

Dog Food 12/13 oz cans

$54$36

Save $221/year

Pet-Focused Benefits

PetPlusBrought to you by Pet Assure Corporation

PetPlus is a wholesale online pricing club that will save retirees money on all prescriptions and preventatives including flea and tick preventatives, heartworm preventatives, and dietary supplements. PetPlus is available at a low cost per month.

Plan benefits• Savings: 100 percent saving guarantee; covers flea & tick preventatives, Rx medications, vitamins and supplements, heartworm products and speciality/Rx food.

• Ask-A-Vet Helpline: Access to veterinary specialists 24/7 via email, chat or phone, allowing you to save between $300 to $800 a year on avoidable vet visits.

Convenience: PetPlus will get the prescription script; no need to call or ask the vet; free delivery always, no restrictions; convenient Rx pick up at local pharmacies nationwide.

Is PetPlus insurance?No! With PetPlus, retirees get wholesale pricing on prescriptions, preventatives and other products which are almost never covered by insurance. It’s instant savings without any paperwork.

Are there any exclusions?No, there are absolutely no exclusions. Retirees can enroll any dog or cat.

When can retirees start using their membership?Immediately! All participating retirees will receive instructions how to activate their online account before the benefit start date. Just login to the PetPlus account, register pets, and start shopping immediately.

PetPlus Rates MONTHLY RATE

PetPlus Single Pet $4.50

PetPlus Multiple Pets $8.50

myFBMC.com 35

ID Commander Identity theft is the fastest growing crime in America, with an identity stolen once every four seconds.

Plan benefitsID Commander, a leader in proactive identity theft protection, uses a variety of industry-leading tools to help protect you from the threat of identity theft:

• Advanced Identity Monitoring and Alerts• $1 Million Identity Theft Insurance Policy, with $0 deductible• Full-service Identity Restoration• 24/7 Lost Wallet Assistance• Award-winning Computer Protection Software

ID Commander’s comprehensive identity theft protection plans are available to both individuals and families, with complete access to benefits the moment membership begins. The ID Commander Family Protection Plan provides a truly managed household program and empowers individual family members with the tools and data they need to proactively manage the health and well-being of their identities.

If the worst happens, and you become the victim of identity theft while covered by ID Commander, we will restore your identity and any related credit accounts to pre-theft status. No limits, no fine print, no “service guarantee.” In addition, if you suffer any covered out-of-pocket expenses as a result of a breach, you’re covered by a real insurance policy that will put money in your hands for qualified losses.

Take command of your future with ID Commander – sign up today!

Protection Plan ComparisonPremium Protection PlanRestoration:

• Full-service identity restoration• 24/7 lost wallet assistance• $1 million insurance policy• Identity safety resource center

Detection:• Internet surveillance monitoring and alerts• Social Security monitoring and alerts• Change of address monitoring and alerts

Ultimate Protection PlanRestoration:• Full-service identity restoration• 24/7 lost wallet assistance• $1 million insurance policy• Identity safety resource center

Detection:• Internet surveillance monitoring and alerts• Social security monitoring and alerts• Change of address monitoring and alerts• Court/criminal monitoring and alerts• Sex offender monitoring and alerts• Payday loan monitoring and alerts

Protection:• Computer Detection Software

Identity Theft ProgramID Commander Rates

MONTHLY RATES

PREMIUM ULTIMATE

Retiree Only $7.00 $10.50

Retiree + Family $15.00 $22.50

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Technology Support ProgramIT Please - Whole-Home Technical Support ProgramIT Please is a whole-home technology support program that gives members unlimited 24/7/365 remote support access via the internet, chat, or phone, for everything from virus removal and wireless network troubleshooting to gaming console setup.

Product Details• 24/7 Remote Technical Support - Experienced and qualified

technicians are standing by 24/7 to instantly resolve your technical issue. Technicians will utilize cutting edge technology to fix your computer over the internet.

• On-site Support - We have over 14,000 technicians who can be dispatched to your home or office as soon as the same business day.

• Antivirus Software - BitDefender Total Security will protect you from viruses, Trojans, spyware and other malicious software.

• Online Data Backup - Our data back up service provides secure, enterprise-class remote data backup solutions.

• Self-Help Database - Our self-help database contains more than 120,000 use solutions to common computer problems.

• Best Practices Assessment - You will receive an online analysis of your computing environment and recommendations to improve performance and security.

Devices Supported• Desktop and Laptop• Computers (PC and Mac)• Smartphones and PDAs• Digital Cameras• Printers/Scanners• Routers• Modems• Mass Storage Devices• Gaming Consoles

Software Supported:• Microsoft 365• Adobe Acrobat• Adobe Photoshop• Lotus• SmartSuite• Open Office• Microsoft Office (Excel, Word, Project, Access, etc.)• Windows Media Player• Quicken• Corel Office Suite• QuickBooks

Services Supported:• Data transfer and backup • Broadband/DSL install• Network (wireless or wired) install or troubleshooting• VolP install• Audio and video component installation• PDA/Blackberry install or troubleshooting • Off-site data backup install and configuration

• Desktop/Laptop setup and configuration• Desktop/Laptop memory upgrade and install• Desktop/Laptop CD or DVD drive install• Desktop/Laptop hard drive install• Desktop I/0 gaming card install configuration• Software install and configuration• Basic digital imaging (photo) training• Digital music training (setup sold separately)• Data or document recovery• Virus removal and performance optimization

Systems Supported• Windows 10• Windows 8 • Windows 7• Windows Vista• WindowsXP• Windows 2000• Windows ME• Windows 98• Windows NT• Windows 95• Mac OS• LINUX

System Utilities Supported• BitDefender• AVG Anti-Virus• Norton Clean Sweep• Partition Magic• Norton Utilities• Dr. Solomon’s• Norton Anti-Virus• Windows Themes• WinZip• Lavasoft

Unlimited Support Plan• Unlimited remote support• On-site support (up to 50 percent off retail rates)• Self-help solution library• Best practices assessment• Computer protection software

Unlimited Plus Support Plan• Unlimited remote support• On-site support (up to 50 percent off retail rates)• Self-help solution library• Best practices assessment• Computer protection software• Secure data backup (100GB)

IT Please Rates MONTHLY RATEUnlimited Support Plan $10.00

Unlimited Plus Support Plan $14.00

myFBMC.com 37

NoticesCOBRA OVERVIEW

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event, also called a “qualifying event.” After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event.

HIPAA PRIVACY

The Plan complies with the privacy requirements of the Health Insurance Portability and Accountability Act of (HIPAA). These requirements are described in a Notice of Privacy that was previously given to you. A copy of this notice is available upon request.

HIPAA SPECIAL ENROLLMENT NOTICE

If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

To request special enrollment or obtain more information, contact your Plan Administrator.

myFBMC.com38

Forms

FBMC Service Center 1-855-5MY-DCPS (1-855-569-3277)Mon. - Fri., 7 a.m. - 7 p.m. ET

Fax: 866-836-9943 • myFBMC.com

Please print your NEW name exactly as it is on your Social Security card.

OLD NAME: ___________________________________________________________________________

NEW NAME: ___________________________________________________________________________

SOCIAL SECURITY NO: _______________________________________________________________

REPRESENTATIVE SIGNATURE ___________________________________________Date _________________

Notice of Social Security DisclosureState laws require agencies that are required to collect employee Social Security numbers (SSN) to disclose the purpose for collecting the SSN. The Duval County School Board is allowed to collect SSN’s when specially authorized by law to do so or when the collection is imperative for the performance of the District’s duties and responsibilities. Pursuant to Federal and State Laws, the District is collecting your Social Security number for the purpose of processing retiree and dependent benefits; this collection is Mandatory. If you do not provide your SSN, Duval County School Board cannot process your application/request. The Duval County School Board will not disclose your SSN to anyone outside of the District except as authorized by law.

©FBMC l DCPSRET_CANCELATION FORM/0818

FBMC Retiree & Direct Bill Attn: Mail Slot 32PO Box 10789 •Tallahassee, FL 32302-2789

®

DCPS RETIREE NAME CHANGE FORM

myFBMC.com 39

Forms

NAME: _______________________________________________________________________________

SOCIAL SECURITY #: ________________________________________________________________

NEW ADDRESS: _______________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

NEW PHONE #: ________________________________________________________________________

REPRESENTATIVE SIGNATURE ___________________________________________Date _________________

Notice of Social Security DisclosureState laws require agencies that are required to collect employee Social Security numbers (SSN) to disclose the purpose for collecting the SSN. The Duval County School Board is allowed to collect SSN’s when specially authorized by law to do so or when the collection is imperative for the performance of the District’s duties and responsibilities. Pursuant to Federal and State Laws, the District is collecting your Social Security number for the purpose of processing retiree and dependent benefits; this collection is Mandatory. If you do not provide your SSN, Duval County School Board cannot process your application/request. The Duval County School Board will not disclose your SSN to anyone outside of the District except as authorized by law.

©FBMC l DCPS_RETADDRESS CHANGE FORM/0818




®

DCPS RETIREE ADDRESS CHANGE FORM

myFBMC.com40

NAME: _______________________________________________________________________________

SOCIAL SECURITY NO: _______________________________________________________________

I elect to cancel the insurance coverage(s) indicated below, effective:(end of month)

Indicate Coverage LevelHEALTH OPTIONAL INSURANCES (Self/Spouse/Child(ren)

___Self ___Dental _____________________________

___Spouse ___Vision Care _____________________________

___Dependents ___AHL Group Hospital Indemnity _____________________________

___AHL Individual Hospital Indemnity ______________________________

___Unum Long Term Care _____________________________

___ID Commander _____________________________

___IT Please ______________________________

___Standard Life Group Term Insurance _____________________________

___PetPlus _____________________________

___SoundCare Hearing _____________________________

You must contact the provider company to cancel any of the following plans:• Allstate Benefits Critical Illness - 1-800-348-4489• AFLAC Cancer/Hospital Intensive Care: 1-800-992-3522• Trustmark Accident/Cancer/Universal Life: 1-800-918-8877• Unum Whole Life: 1-800-635-5597

Reason for Cancellation:________________________________________________________________________________________

________________________________________________________________________________________

Signature ________________________________________________ Date _________________________

Notice of Social Security DisclosureState laws require agencies that are required to collect employee Social Security numbers (SSN) to disclose the purpose for collecting the SSN. The Duval County School Board is allowed to collect SSN’s when specially authorized by law to do so or when the collection is imperative for the performance of the District’s duties and responsibilities. Pursuant to Federal and State Laws, the District is collecting your Social Security number for the purpose of processing employee and dependent benefits; this collection is Mandatory. If you do not provide your SSN, Duval County School Board cannot process your application/request. The Duval County School Board will not disclose your SSN to anyone outside of the District except as authorized by law.

Forms

©FBMC l DCPSRET_CANCELATION FORM/0818




®

CANCELLATION OF DCPS RETIREE INSURANCE

myFBMC.com 41

Benefits DirectoryBENEFITS MANAGEMENT COMPANY

FBMC Benefits Management, Inc.Service CenterMon. - Fri., 7 a.m. - 7 p.m. ET1-855-5MY-DCPS (1-855-569-3277)

EMPLOYER

Duval County Public SchoolsEmployee Benefits DepartmentMon. - Fri., 7:30 a.m. - 4:30 p.m. ET1-904-390-2351duvalschools.org/benefits

PROVIDER COMPANIES

Allstate Benefits,AHL American Heritage Life Ins. Co. (Hospital Indemnity Insurance)(Critical Illness Insurance)Group# 63103Claims (AWD)Mon. - Fri., 8 a.m. - 8 p.m. ET1-800-348-4489allstatebenefits.com

American Family Life AssuranceCompany of Columbus (AFLAC)(Personal Cancer Expense*)(Hospital Intensive Care*)Customer ServiceMon. - Fri., 8 a.m. - 8 p.m. ET1-800-992-3522aflac.com* New AFLAC policies are no longer sold.

If you are a current AFLAC customer, you may continue the policy currently in force.

Health Advocate (Employee Assistance Program) 24-Hour Careline 1-877-240-6863 healthadvocate.com/members

Ameritas Hearing Customer Service Mon. - Thurs., 7 a.m. - 12 a.m. Fri., 7 a.m. - 6:30 p.m. CST 1-877-359-8346 ameritas.com

Davis VisionClient Code# 3651Customer ServiceMon. - Fri., 8 a.m. - 11 p.m. ET1-877-923-2847davisvision.com

Delta Dental DeltacareGroup# FL76905 Customer ServiceMon. - Fri., 8 a.m. - 9 p.m. ET1-800-422-4234deltadentalins.com

Delta Dental PPOGroup# FL16797Customer ServiceMon. - Fri., 7:15 a.m. - 7:30 p.m. ET1-800-521-2651deltadentalins.com

Florida BlueGroup# 78155Customer ServiceMon.-Thurs., 8 a.m. - 6 p.m. ET.Fri., 9 a.m. - 6 p.m. ET1-800-664-5295floridablue.comOn site Representative:Resa Askew, 1-904-390-2323 Personal Health Advocate: Nancy Beyers, RN 904-905-0901

Florida Retirement System (FRS)1-844-377-1888myfrs.com

IDCommander (Identity Theft)Membership Services Mon. - Fri., 9 a.m. - 6 p.m. ET1-855-592-7941Benefits Enrollment Helpline Mon. - Fri., 9 a.m. - 6 p.m. ET1-855-592-7944 idcommander.com

ITPlease (Technology Support)Membership Services Mon. - Fri., 9 a.m. - 6 p.m. ET.1-888-384-7935Benefits Enrollment Helpline Mon. - Fri., 9 a.m. - 6 p.m. ET1-855-592-7944 itplease.com

OptumRX (UHC Plans)PO Box 2975Mission, KS 66201-93751-877-889-5802 (TTY: 1-866-394-7218)24 hours a day, 7 days a week

www.duvalschools.org

http://www.allstatenetwork.com

www.aflac.com

www.deltadentalins.com

www.deltadentalins.com

www.floridablue.com

myFBMC.com42

PetPlus is brought to you by Pet AssurePet Assure Customer ServiceMon. - Fri., 9 a.m. - 6 p.m. [email protected]

Prime Therapeutics(Under 65 Pharmacy Plan)Customer Service 24 hours1-888-849-7865myprime.com

Selman & Company (TRICARE Supplement)Customer ServiceMon. - Fri., 9 a.m. - 7 p.m. ET1-800-638-2610selmanco.com

Standard Insurance Company(Group Term Life)Group #158390Mon. - Fri., 9 a.m. to 8 p.m. ET1-800-348-3226standard.com

Trustmark Insurance Co.(Critical Illness)(Universal Life)(Universal Life Events)Customer ServiceMon. - Thurs., 8 a.m. - 8 p.m. ETFri., 8 a.m. - 7 p.m. EST1-800-918-8877Claims 1-877-201-9373, Option 2trustmarksolutions.com

UnitedHealthcare® Insurance Company Customer Service 1-877-776-1466. TTY 711, 8 a.m. - 8 p.m. Local time, 7 days a week

Benefits DirectoryUnum Life Insurance Co. of America(Long-Term Care*)1-800-227-4165Mon. - Fri., 8 a.m. - 8 p.m. ET1-800-421-0344unum.com *New Unum LTC policies are no longer sold. If you are a current Unum LTC customer, you may continue the policy currently in force.

(Whole Life Insurance)Group# 40033Customer ServiceMon. - Fri., 8 a.m. - 8 p.m. ET1-800-635-5597unum.com

Zurich North America(Voluntary Accidental Death andDismemberment)Group# GTU 5091403Customer Service1-866-841-4771 or 1-800-887-911124 hours a day, 7 days a weekzurichna.com

www.myprime.com

www.trustmarkinsurance.com

www.unum.com

www.unum.com

www.zurichna.com

©FBMC l FBMC/DCPS_RETIREEEGUIDE/0618

Information contained herein does not constitute an insurance certificate or policy.Certificates or policies will be provided to participants following the start of the plan year, if applicable.

Contract Administrator FBMC Benefits Management, Inc.PO BOX 10789, TALLAHASSEE, FL 32302-2789FBMC Service Center 1-855-5MY-DCPS (1-855-569-3277)Mon. - Fri,, 7 a.m. - 7 p.m. ETmyFBMC.com

retiree benefits reference guide · 2018-09-26 · if your frs check is not sufficient ... the...

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