SYRACUSE UNIVERSITY Onboarding Information

Transcription

1 2015 Onboarding Information

2 CONTACT INFORMATION POMCO Delta Dental WageWorks Express Scripts MetLife Auto/Home: , x1 Life Conversion: SEBF Dental/Vision The Standard TIAA-CREF CUSE (2873) Vision Service Plan (VSP) Nurse Line Syracuse University Human Resources Benefits Service Center Dependent and Remitted Tuition Employment/Staff Relations Faculty and Staff Assistance Program Harassment and Discrimination Student Employment Services WorkLife and Organizational Development

3 WELCOME TO SYRACUSE UNIVERSITY It is our pleasure to welcome you to Syracuse University. This packet has been prepared to guide you through the benefits we offer our employees and to provide a reference for your questions. Beyond the basics found in this packet, the Human Resources website, offers specific information on policies and procedures and is continually updated with the most current benefit information. In addition to the Onboarding session you are attending, you will be invited to attend either the faculty or staff orientation where you will learn more about the campus and explore your role as part of the University community. We hope you find this packet a valuable resource as you begin your Syracuse University career. Sincerely, Human Resources Service Center Page 1 January 2015

4 First Week: First Month: NEW EMPLOYEE TO-DO S Complete a TIAA-CREF waiver form, if applicable. Complete Employment Eligibility Verification (I-9) at Human Resources. Obtain an SU Identification Card from the Office of Housing, Meal Plan, and I.D. Card Services at 206 Steele Hall. Schedule your Hazard Communication Training online at Attend a post-employment health check, if applicable. Activate your NetID at: so that you have access to online resources and services such as: , electronic documents, and MySlice, the University web portal that allows you access to SU s annual benefits Open Enrollment and other employee services. To register for FAB General Overview training, if applicable, please go to For additional training regarding the General Ledger Financial Reports, please contact General Accounting at or genacctg@syr.edu. Review benefits information and enroll as soon as possible. IMPORTANT: You must enroll within the first 31 days of employment. Attend New Employee Orientation, if applicable: Location: Goldstein Student Center Room 201AB&C Page 2 January 2015

5 TABLE OF CONTENTS New Employee To-Do s... 2 Retirement Planning... 5 Group Health Insurance... 6 SUBlue and SUOrange Schedule of Benefits and Employee Cost Sharing... 9 SUPro Schedule of Benefits and Employee Cost Sharing Group Dental & Vision Insurance Flexible Spending Accounts (FSA) The University Wellness Initiative Group Life Insurance Accidental Death and Dismemberment (AD&D) Insurance Will Preparation Service Dependent Life Insurance Disability Benefits Plan for EXEMPT Employees (Salary Continuation) Disability Benefits Plan for NON-EXEMPT Employees Workers Compensation Voluntary Long Term Disability Insurance Remitted Tuition Benefits Dependent Tuition Benefits Paid Time Off for Staff Employees Leave of Absence MetLife Home and Auto Insurance Home Mortgage Program Identification Cards Faculty and Staff Assistance Program (FSAP) Adoption Assistance Lesbian, Gay, Bisexual and Transgender (LGBT) Resource Center Worldwide Travel Protection Notice of Special Enrollment Rights Continuation of Health Coverage/COBRA Notice of Privacy Practices Notice Regarding the Women s Health and Cancer Rights Act of Summary of Benefits and Coverage Information Security WorkLife at SU Benefit Providers Contact Information University Contact Information Page 3 January 2015

6 2015 BENEFITS PLAN OVERVIEW The following pages summarize your Syracuse University benefit options. Every effort has been made to ensure this information is accurate. However, the benefits are governed by legal documents (which, in certain circumstances, may include insurance contracts). If there is any difference between the information in the Onboarding book and the official documents, the official documents will control. Eligible employees electing to participate in SU benefit plans, programs or policies are bound by the terms of the governing plan, program and policy documents. If you have any questions regarding the plans, programs or policies, you may request a copy of the governing document by contacting the HR Service Center at or hrservic@syr.edu. As is the case with all benefits offered by SU, (1) the SU administrator of the applicable benefit plan, program or policy has the discretionary authority to interpret the terms of that plan, program or policy, and such interpretation will be binding on all interested parties to the est extent permitted by law, and (2) the University reserves the right to modify or terminate its benefit plans, programs and/or policies at any time. Syracuse University is proud of the comprehensive benefits package provided to eligible faculty and staff. This section discusses these benefits in detail and further information is provided on the HR website. Page 4 January 2015

7 RETIREMENT PLANNING Noncontributory Retirement Plan Upon completion of your first year of employment, Syracuse University will contribute the equivalent of 10% of your base salary (with a maximum annual contribution of $26,500) toward your retirement annuity and will continue this contribution annually, if eligible. Once eligible, the University contribution will default into a T. Rowe Price Target Date Fund that is administered through the Teachers Insurance and Annuity Association and College Retirement Equities Fund (TIAA-CREF). The Target Date Funds are a group of funds managed by T. Rowe Price based on your age and expected retirement date. If you have an existing account with TIAA-CREF, they may contact you directly for further information. Once enrolled, you can make changes to these funds by contacting TIAA-CREF by phone at or online at: You may also schedule a one-on-one appointment with a TIAA-CREF advisor by calling for meetings on campus, or at the local TIAA-CREF office at 250 South Clinton Street, Suite 310 in Syracuse. Waiving the one-year waiting period The one-year waiting period is waived for faculty and staff joining the University from another accredited four-year institution that confers a baccalaureate degree. In order to waive the University s one-year waiting period you must meet the criteria provided on the waiver form. Please find the waiver form to be completed by you and your previous employer at: Once the waiver form has been completed by your previous employer, you should review it for accuracy, sign and date it, and return it to the Human Resources Service Center. This can be accomplished by fax ( ) or (hrservic@syr.edu). This waiver will go into effect when the completed form is returned, reviewed and processed by the HR Service Center. Please keep in mind that there is no retroactive contribution of the University s 10% contribution. Voluntary Retirement Plan Upon employment, you are eligible to participate in the University s Voluntary Retirement Plan through TIAA-CREF up to the maximum amount established by law. To enroll, complete the Voluntary Salary Reduction Form online at: Voluntary contributions may be made to either a pre-tax Traditional 403(b) or a post-tax Roth 403(b). More information on these plans is available online at: Page 5 January 2015

8 Group Health Insurance Health Care Upon employment, Syracuse University offers three health insurance options: SUBlue, SUOrange, and SUPro. All three health plans are administered through POMCO and prescription drug benefits are administered by Express Scripts, formerly Medco. The premiums you pay for medical coverage include the prescription drug benefit coverage. Medical Benefits SUBlue is a point of service plan (POS) that allows members to receive services from any provider subject to certain plan restrictions. There are three levels of coverage in the SUBlue plan as follows: o o o Level One - Services must be performed by a provider that participates with the POMCO-PHCS/MultiPlan network, regardless of their location, and coordinated by your Primary Care Physician (PCP). Level Two - Services are performed by any provider participating in the POMCO-PHCS/MultiPlan network but are not coordinated by your PCP. Level Three - Services are performed by a provider that does not participate in the POMCO-PHCS/MultiPlan network. SUOrange coverage is nearly identical to SUBlue coverage except that services are restricted to those providers that participate directly with POMCO-PHCS/Multiplan network (Level One coverage only). SUPro In general, the same services covered under SUBlue and SUOrange are also covered under SUPro but with a different copayment/ structure. There are no referrals needed to see a specialist under SUPro. However certain services require prior authorization. There are two levels of coverage in the SUPro plan as follows: o o Level One - Services must be performed by a provider that participates with the POMCO-PHCS/MultiPlan network, regardless of their location. Coordination with your Primary Care Physician (PCP) is not required. Level Two - Services are performed by a provider that does not participate in the POMCO-PHCS/MultiPlan network. Coverage for International Travel: When traveling outside the United States, whether on University business or not, coverage will be deemed Level One (in-network) for SUBlue and SUPro. For information on how to submit a claim for services received internationally, contact POMCO at GO1-SU44. Page 6 January 2015

9 Prescription Drug Benefits Generics To encourage the appropriate use of generics, if a generic equivalent is available and you choose to have the brand name drug, or your doctor prescribes the script Dispense As Written (DAW), you will be required to pay the difference between the actual cost of the brand name drug and the amount the plan would have paid for the generic equivalent. Biotech/Specialty drugs Prescription drugs in the Biotech/Specialty class, required to be filled through mail order, will be limited to a 30-day supply per refill. The payment schedule is the same as the mail order schedule according to the medical plan to which you subscribe. Retail 90-Day Network Subscribers may fill a 90-day supply at a local participating pharmacy in addition to the mail order option. The payment schedule is the same as the retail pharmacy schedule according to the medical plan to which you subscribe. See the HR website ( for pharmacies participating in this program. Express Scripts By Mail If you take certain prescription medications on an ongoing basis, you can fill your prescriptions using Express Scripts By Mail, which offers convenient mail order service with free standard shipping. Once you start, you can refill and renew your prescriptions at the Express Scripts website. Your mail order prescriptions can be sent to Express Scripts by fax, by mail or online. o Fax: Ask your doctor to obtain fax forms and instructions directly by calling EASYRX1 ( ). IMPORTANT: This number is for physicians only. Only your physician may fax the completed form to Express Scripts. Please note: a special fax form is required in the state of Virginia. If you or your doctor are located in Virginia, ask your doctor to obtain the correct form by calling the number listed above. o Mail: Mail in a prescription your physician has written using the mail order form available online at In most cases, your physician can prescribe a 90-day supply, with up to three refills. o Online: Visit the Express Scripts website at and register as a new user to fill your prescription online. Page 7 January 2015

10 2015 Monthly Employee Health Plan Contributions SUBlue SUOrange SUPro Schedule A Schedule B Schedule A Schedule B Schedule A Schedule B Employee $ $ $ $ $ $ Employee + Spouse/ Domestic Partner $ $ $ $ $ $ Employee + Child(ren) $ $ $ $ $ $ Employee + Spouse/ Domestic Partner + Child(ren) $ $ $ $ $ $ Contributions listed here are based on the 12-month calendar year. The actual deduction from your paycheck depends on your deduction cycle. Contributions for domestic partners and their children are paid on an after-tax basis. Benefits Eligibility Please refer to the University s Benefits Eligibility Policy online at to determine if your dependents are eligible for coverage. Schedule B Contributions Eligible employees default into the Schedule A contribution rates for medical coverage unless they qualify, apply and are approved for Schedule B contributions. Applications must be received within 31 days of your date of hire. Eligibility for this program is based on household income and household size according to the chart below: Household Size Household Income 1 Less than $35,000 2 Less than $47,000 3 Less than $59,000 4 and up Less than $72,000 Household size is the number of individuals declared on the most recent Federal Income Tax Returns for you and, if applicable, your spouse or domestic partner. Also included in household size are your children who are not declared on your tax return but are either under age 19 and living with you or age 19 or older and enrolled on your medical plan. Household income is the combined adjusted gross income disclosed on the Federal Income Tax Returns for you, and if applicable, for your spouse or domestic partner and your children age 19 or older, if they are enrolled on your medical plan. Additional information about Schedule B contributions, including the application form, is available online at: Page 8 January 2015

11 SUBLUE AND SUORANGE: SCHEDULE OF BENEFITS 2015 EMPLOYEE COST SHARING SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Cost Sharing Definitions Annual Deductible 1 No deductible No deductible $300 per individual with a maximum of $1,000 family No deductible Coinsurance No 10% allowable amount 30% allowable amount plus the difference between provider s charge and the allowable amount (exceptions noted below) No Annual Out-of- Pocket Maximum 2 $2,000 per individual with a maximum of $4,000 for a family $4,000 per individual with a maximum of $8,000 for a family $6,000 per individual with a maximum of $12,000 for a family $2,000 per individual with a maximum of $4,000 for a family Your Institutional Covered Services INPATIENT HOSPITAL Inpatient hospital $350 copay per admission $350 copay per admission plus Deductible, $350 copay per admission, and $350 copay per admission Nursery care No copay; paid in Coinsurance Deductible and OUTPATIENT HOSPITAL Surgery $200 copay $200 copay plus Deductible, $200 copay, and $200 copay Pre-surgical testing No copay; paid in Coinsurance Deductible and Page 9 January 2015

12 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Routine mammography screenings (one per calendar year for ages 35 and older with exceptions if high risk) No copay; paid in Deductible and Routine prostate cancer screenings (one per calendar year for ages 50 and older with exceptions if high risk) No copay; paid in Deductible and Routine cervical cancer screenings (one per calendar year for ages 18 and older) No copay; paid in Deductible and Colonoscopies No copay; paid in Deductible and Diagnostic machine tests, x-rays, and radiology services (including MRIs, PET and CT scans) $40 copay $40 copay plus Deductible, $40 copay, and $40 copay Diagnostic laboratory tests No copay; paid in Coinsurance Deductible and Occupational therapy (for situations not covered through a governmental program) $25 copay $25 copay plus Deductible, $25 copay, and $25 copay Page 10 January 2015

13 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Physical therapy $25 copay $25 copay plus Deductible, $25 copay, and $25 copay Speech therapy (for situations not covered through a governmental program) $25 copay $25 copay plus Deductible, $25 copay, and $25 copay Respiratory, radiation, cardiac therapies and chemotherapy No copay; paid in Coinsurance Deductible and HOSPITAL EMERGENCY ROOM Hospital emergency room $150 copay $150 copay $150 copay $150 copay (includes out of network coverage) ADDITIONAL INSTITUTIONAL PROVIDERS Ambulatory surgery center $150 copay $150 copay plus Deductible, $150 copay, and $150 copay Birth center No copay; paid in Coinsurance Deductible and Skilled nursing facility (180 inpatient days) $350 copay per admission $350 copay per admission plus Deductible, $350 copay per admission, and $350 copay per admission Home health agency No copay; paid in Coinsurance Deductible and Hospice No copay; paid in Coinsurance Deductible and Page 11 January 2015

14 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Inpatient mental health disorder care (facility charge) General hospital or psychiatric facility Partial hospitalization $350 copay per admission A separate copay will apply to partial hospitalization if the patient is discharged to a new facility after inpatient hospitalization. $350 copay per admission plus A separate copay will apply to partial hospitalization if the patient is discharged to a new facility after inpatient hospitalization. Deductible, $350 copay per admission, and A separate copay will apply to partial hospitalization if the patient is discharged to a new facility after inpatient hospitalization. $350 copay per admission A separate copay will apply to partial hospitalization if the patient is discharged to a new facility after inpatient hospitalization. Inpatient substance use disorder detoxification and rehabilitation General hospital or certified alcohol/ substance abuse facility program Partial hospitalization $350 copay per admission; A separate copay will apply to partial hospitalization if the patient is discharged to a new facility after inpatient hospitalization. $350 copay per admission plus ; A separate copay will apply to partial hospitalization if the patient is discharged to a new facility after inpatient hospitalization. Deductible, $350 copay per admission, and ; A separate copay will apply to partial hospitalization if the patient is discharged to a new facility after inpatient hospitalization. $350 copay per admission; A separate copay will apply to partial hospitalization if the patient is discharged to a new facility after inpatient hospitalization. Outpatient treatment for substance use disorders $40 copay $40 copay plus Deductible, $40 copay, and $40 copay Your Professional Provider Covered Services Surgery and assistance at surgery No copay; paid in Coinsurance Deductible and Breast reconstruction surgery No copay; paid in Coinsurance Deductible and Page 12 January 2015

15 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Second opinion No copay; paid in Deductible plus the difference between provider s charge and allowable amount Anesthesia No copay; paid in Coinsurance Deductible and Maternity No copay; paid in Coinsurance Deductible and PROFESSIONAL PROVIDER INPATIENT VISITS Inpatient hospital visits by physician or other professional provider No copay; paid in Coinsurance Deductible and Inpatient substance use disorder hospital visits by physician or other professional provider No copay; paid in Coinsurance Deductible and Inpatient skilled nursing facility visits by physician or other professional provider No copay; paid in Coinsurance Deductible and Inpatient mental health disorder care visits by physician or other professional provider No copay; paid in Coinsurance Deductible and Page 13 January 2015

16 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral PROFESSIONAL PROVIDER VISITS Office visits $25 copay (PCP) or $40 copay (Specialist) $40 copay plus Deductible, $40 copay, and $25 copay (PCP) or $40 copay (Specialist) Well child visits Birth to 2 nd birthday - 9 visits No copay; paid in Deductible plus the difference between provider s charge and allowable amount 2 nd birthday to 7 th birthday - 5 visits 7 th birthday to 19 th birthday - 1 visit per calendar year Routine physical (one per calendar year) No copay; paid in Deductible plus the difference between provider s charge and allowable amount Routine cervical cancer screening (annual routine pap smear) No copay; paid in Deductible and Allergy testing and treatment $25 copay (PCP) or $40 copay (Specialist) $40 copay plus Deductible, $40 copay, and $25 copay (PCP) or $40 copay (Specialist) Consultation service, office $40 copay (Specialist) $40 copay plus Deductible, $40 copay, and $40 copay (Specialist) Consultation service, hospital No copay; paid in Coinsurance Deductible and Page 14 January 2015

17 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Urgent care $50 copay $50 copay plus Deductible, $50 copay, and $50 copay Kidney Dialysis (member with ESRD must sign up for Medicare upon becoming eligible) No copay; paid in Coinsurance Deductible and Outpatient treatment for mental health disorders (1 therapy visit per day) $40 copay (Specialist) $40 copay plus Deductible, $40 copay, and $40 copay (Specialist) Private duty nursing No copay; paid in Coinsurance Deductible and Diabetes education $25 copay (PCP) or $40 copay (Specialist) $40 copay plus Deductible, $40 copay, and $25 copay (PCP) or $40 copay (Specialist) Acupuncture $40 copay $40 copay plus Deductible, $40 copay, and $40 copay Chiropractic services $40 copay No Coverage No Coverage $40 copay Routine vision exam (one exam in 24 consecutive months) $40 copay (Specialist) No Coverage No Coverage $40 copay (Specialist) Page 15 January 2015

18 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Routine hearing exam (one exam in 24 consecutive months) $40 copay (Specialist) No Coverage No Coverage $40 copay (Specialist) THERAPY Occupational therapy (for situations not covered through a governmental program) $25 copay $25 copay plus Deductible, $25 copay, and $25 copay Physical therapy $25 copay $25 copay plus Deductible, $25 copay, and $25 copay Speech therapy (for situations not covered through a governmental program) $25 copay $25 copay plus Deductible, $25 copay, and $25 copay Respiratory, radiation, and cardiac therapies and chemotherapy No copay; paid in Coinsurance Deductible and DIAGNOSTIC SERVICES Diagnostic machine tests, x-rays and radiology services (including MRIs, PET and CT scans) $40 copay $40 copay plus Deductible, $40 copay, and $40 copay Diagnostic laboratory No copay; paid in Coinsurance Deductible and Page 16 January 2015

19 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Routine mammography screenings (one per calendar year for ages 35 and older with exceptions if high risk) No copay; paid in Deductible and Routine prostate cancer screenings (one per calendar year for ages 50 and older with exceptions if high risk) No copay; paid in Deductible and Routine cervical cancer screenings (one per calendar year for ages 18 and older) No copay; paid in Deductible and Colonoscopies No copay; paid in Deductible and Additional Health Services Ambulance $100 copay $100 copay $100 copay $100 copay (includes out of network coverage) Diabetic equipment and supplies $20 copay $20 copay plus Deductible, $20 copay, and $20 copay Durable medical equipment 10% allowable amount 20% allowable amount Deductible and 40% allowable amount plus the difference between provider s charge and allowable amount 10% allowable amount Page 17 January 2015

20 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Breastfeeding Equipment Rental or Purchase No copay; paid in Rental Coverage Only: Deductible and 40% of allowable amount plus the difference between the actual charge and the Allowed Charge. Hearing Aids Across All Levels: Maximum benefit of $750 for a single hearing aid and $1,500 for binaural hearing aids; limited to once every three years Contracted Model: 50% of the billed charge or the allowable amount (whichever is less) Non- Contracted Model: 50% of the billed charge or the allowable amount (whichever is less) plus the difference between the actual charge and the allowable amount. Contracted Model: 50% of the billed charge or the allowable amount (whichever is less) Non-Contracted Model: 50% of the billed charge or the allowable amount (whichever is less) plus the difference between the actual charge and the allowable amount. Deductible and 50% of the billed charge or the allowable amount (whichever is less) plus the difference between the actual charge and the allowable amount. Contracted Model: 50% of the billed charge or the allowable amount (whichever is less) Non-Contracted Model: 50% of the billed charge or the allowable amount (whichever is less) plus the difference between the actual charge and the allowable amount. Medical supplies No copay; paid in Coinsurance Deductible and Prosthetic devices No copay; paid in Coinsurance Deductible and Page 18 January 2015

21 SUBlue (Levels One, Two, and Three) SUOrange Level One POMCO/PHCS/ MultiPlan With Referral Level Two POMCO/PHCS/ MultiPlan Without Referral Level Three Out of Network Level One POMCO/PHCS/ MultiPlan With Referral Prescription Drugs Covered through Express Scripts Covered through Express Scripts Covered through Express Scripts Covered through Express Scripts 1 Level Three coverage requires the employee to pay an annual deductible before any other cost sharing is determined. The annual deductible is $300 per individual with a maximum of $1,000 for a family. After the annual deductible is satisfied, the employee must pay the copay, if applicable. The is then applied to the balance of the allowable amount. The employee is also responsible for the difference between the provider s charge and the allowable amount as defined by POMCO. 2 Out-of-pocket maximum refers to the maximum amount of out-of-pocket expenses an employee would pay in a calendar year. The out-of-pocket expenses are defined as the deductibles,, and copayment amounts, exclusive of amounts for prescription medicines. The differences between provider charges and the allowable amounts under level three are not subject to the out-of-pocket maximum. Each medical program is governed by the plan document. If there is any difference between the information on these summary sheets and the plan document, the plan document will rule. Annual Deductible Out-of-Pocket Maximum Retail: Generic Retail: Brand Formulary Retail: Brand Non-Formulary Prescription Drugs No Deductible $2,000 per individual with a maximum of $4,000 for a family 20% * 25% 45% Mail Order: Generic $20* Mail Order: Brand Formulary $50 Mail Order: Brand Non-Formulary $90 Specialty Mail Order (All) Same as Mail Order except 30 day supply Contraceptives Follows above schedule for retail and mail order * Generic Prescription Drugs: $0 copay (Certain Age/Gender Restrictions Apply) Smoking Cessation Drugs Fluoride Women s Contraceptives Vitamin D Supplements Folic Acid Iron Supplements Aspirin Preparatory Prescriptions associated with Colonoscopies Page 19 January 2015

22 SUPro: Schedule of Benefits 2015 EMPLOYEE COST SHARING SU Pro (In-Network and Out-of-Network) In-Network POMCO/PHCS/Multiplan Out-of-Network Cost Sharing Definitions Annual Deductible 1 Coinsurance $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable amount for hearing aids - or - 20% of allowable amount for all other services $300 per individual with a maximum of $1,000 for a family 5% of allowable amount for inpatient hospitalization - or - 30% of allowable amount for all other services - plus - Difference between submitted charges and allowable amount Annual Out-of-Pocket Maximum 2 All preventive services covered in $1,500 per individual with a maximum of $3,000 for a family Your Institutional Covered Services $6,000 per individual with a maximum of $12,000 for a family INPATIENT HOSPITAL Inpatient hospital Deductible plus Deductible plus Nursery care Deductible plus Deductible plus OUTPATIENT HOSPITAL Surgery Deductible plus Deductible plus Pre-surgical testing Deductible plus Deductible plus Routine mammography screenings (one per calendar year for ages 35 and older with exceptions if high risk) No ; paid in Deductible plus Page 20 January 2015

23 SU Pro (In-Network and Out-of-Network) Routine prostate cancer screenings (one per calendar year for ages 50 and older with exceptions if high risk) Routine cervical cancer screenings (one per calendar year for ages 18 and older) In-Network POMCO/PHCS/Multiplan No ; paid in No ; paid in Out-of-Network Deductible plus Deductible plus Colonoscopies No ; paid in Deductible plus Diagnostic machine tests, x-rays, and radiology services (including MRIs, PET and CT scans) Deductible plus Deductible plus Diagnostic laboratory tests Deductible plus Deductible plus Occupational therapy (for situations not covered through a governmental program) Deductible plus Deductible plus Physical therapy Deductible plus Deductible plus Speech therapy (for situations not covered through a governmental program) Deductible plus Deductible plus Respiratory, radiation, cardiac therapies and chemotherapy Deductible plus Deductible plus HOSPITAL EMERGENCY ROOM Hospital emergency room Deductible plus In-network deductible plus innetwork ADDITIONAL INSTITUTIONAL PROVIDERS Ambulatory surgery center Deductible plus Deductible plus Page 21 January 2015

24 SU Pro (In-Network and Out-of-Network) In-Network POMCO/PHCS/Multiplan Out-of-Network Birth center Deductible plus Deductible plus Skilled nursing facility (180 inpatient days) Deductible plus Deductible plus Home health agency Deductible plus Deductible plus Hospice Deductible plus Deductible plus Inpatient mental health disorder care (facility charge) - General hospital or psychiatric facility - Partial hospitalization Inpatient substance use disorder detoxification and rehabilitation - General hospital or certified alcohol/substance abuse facility program - Partial hospitalization Outpatient treatment for substance use disorders Deductible plus Deductible plus Deductible plus Deductible plus Deductible plus Deductible plus Your Professional Provider Covered Services Surgery and assistance at surgery Deductible plus Deductible plus Breast reconstruction surgery Deductible plus Deductible plus Second opinion Deductible plus Deductible plus Anesthesia Deductible plus Deductible plus Maternity No ; paid in Deductible plus Page 22 January 2015

25 SU Pro (In-Network and Out-of-Network) In-Network POMCO/PHCS/Multiplan Out-of-Network PROFESSIONAL PROVIDER INPATIENT VISITS Inpatient hospital visits by physician or other professional provider Deductible plus Deductible plus Inpatient substance use disorder hospital visits by physician or other professional provider Inpatient skilled nursing facility visits by physician or other professional provider Deductible plus Deductible plus Deductible plus Deductible plus Inpatient mental health disorder care visits by physician or other professional provider Deductible plus Deductible plus PROFESSIONAL PROVIDER VISITS Office visits Deductible plus Deductible plus Well child visits Birth to 2 nd birthday - 9 visits 2 nd birthday to 7 th birthday - 5 visits 7 th birthday to 19 th birthday - 1 visit per calendar year No ; paid in Deductible plus Routine physical (one per calendar year) Routine cervical cancer screening (annual routine pap smear; one per calendar year) No ; paid in No ; paid in Deductible plus Deductible plus Allergy testing and treatment Deductible plus Deductible plus Consultation service, office Deductible plus Deductible plus Page 23 January 2015

26 SU Pro (In-Network and Out-of-Network) In-Network POMCO/PHCS/Multiplan Out-of-Network Consultation service, hospital Deductible plus Deductible plus Urgent care Deductible plus Deductible plus Kidney dialysis (with ESRD, member must sign up for Medicare upon becoming eligible) Deductible plus Deductible plus Outpatient treatment for mental health disorders Deductible plus Deductible plus Private duty nursing Deductible plus Deductible plus Diabetes education Deductible plus Deductible plus Acupuncture Deductible plus Deductible plus Chiropractic services Deductible plus Deductible plus Routine vision exam (one exam in 24 consecutive months) Routine hearing exam (one exam in 24 consecutive months) Deductible plus Deductible plus Deductible plus Deductible plus THERAPY Occupational therapy (for situations not covered through a governmental program) Deductible plus Deductible plus Physical therapy Deductible plus Deductible plus Speech therapy (for situations not covered through a governmental program) Respiratory, radiation, and cardiac therapies and chemotherapy Deductible plus Deductible plus Deductible plus Deductible plus Page 24 January 2015

27 SU Pro (In-Network and Out-of-Network) In-Network POMCO/PHCS/Multiplan Out-of-Network DIAGNOSTIC SERVICES Diagnostic machine tests, x-rays and radiology services (including MRIs, PET and CT scans) Deductible plus Deductible plus Diagnostic laboratory Deductible plus Deductible plus Routine mammography screenings (one per calendar year for ages 35 and older with exceptions if high risk) Routine prostate cancer screenings (one per calendar year for ages 50 and older with exceptions if high risk) Routine cervical cancer screenings (one per calendar year for ages 18 and older) No ; paid in No ; paid in No ; paid in Deductible plus Deductible plus Deductible plus Colonoscopies No ; paid in Deductible plus Additional Health Services Ambulance Deductible plus In-network deductible plus innetwork Diabetic equipment and supplies Deductible plus Deductible plus Durable medical equipment Deductible plus Deductible plus Breastfeeding Equipment Rental or Purchase Hearing Aids Maximum benefit of $750 for a single hearing aid and $1,500 for binaural hearing aids; limited to once every three years No ; paid in Contracted Model: 50% of the submitted charge or the allowable amount (whichever is less) Non-Contracted Model: 50% of the submitted charge or the allowable amount (whichever is less) plus the difference between the submitted charge and the allowable amount. Rental Coverage Only: Deductible plus Deductible and 50% of the submitted charge or the allowable amount (whichever is less) plus the difference between the submitted charge and the allowable amount. Page 25 January 2015

28 SU Pro (In-Network and Out-of-Network) In-Network POMCO/PHCS/Multiplan Out-of-Network Medical supplies Deductible plus Deductible plus Prosthetic devices Deductible plus Deductible plus Prescription medicines Covered through Express Scripts Covered through Express Scripts 1 Coverage requires the employee to pay an annual deductible before any other cost sharing is determined. The annual in-network deductible is $200 per individual with a maximum of $400 for a family. The annual out-of-network deductible is $300 per individual with a maximum of $1,000 for a family. After the annual deductible is satisfied, the employee must pay the, if applicable. The is then applied to the balance of the allowable amount. For out-of-network services, the employee is also responsible for the difference between the provider s charge and the allowable amount based on participating providers in the POMCO network. 2 Out-of-pocket maximum refers to the maximum amount of out-of-pocket expenses an employee would pay in a calendar year. The out-of-pocket expenses are defined as the deductibles and amounts, exclusive of amounts for prescription medicines. The differences between provider charges and the allowable amounts under the out-of-network level are not subject to the out-of-pocket maximum. Each medical program is governed by the plan document. If there is any difference between the information on these summary sheets and the plan document, the plan document will rule. Page 26 January 2015

29 Prescription Drugs Annual Deductible Out-of-Pocket Maximum No Deductible $2000 single/$4000 family Retail Generic Retail Brand Formulary Retail Brand Non-Formulary 15% * 25% 40% Mail Generic Mail Brand Formulary Mail Brand Non-Formulary Lesser of $15 or 15% * Lesser of $45 or 25% Lesser of $90 or 40% Specialty Mail Order (All) Same as Mail Order except 30 day supply Contraceptives Follows above schedule for retail and mail order *Generic Prescription Drugs: $0 copay (Certain Age/Gender Restrictions Apply) Smoking Cessation Drugs Women s Contraceptives Folic Acid Aspirin Fluoride Iron Supplements Vitamin D Supplements Preparatory Prescriptions associated with Colonoscopies Page 27 January 2015

30 GROUP DENTAL & VISION INSURANCE Upon employment, Syracuse University offers dental and vision coverage that is administered through Delta Dental and Vision Service Plan (VSP) respectively. There are two dental plan options to choose from: Preventive and Comprehensive. Enrollment in the dental plan with or without vision is a two-year commitment. The vision benefit is tied to your dental plan and is not available as a separate option Monthly Employee Contributions for Dental With or Without Vision Preventive Preventive Plus Vision Comprehensive Comprehensive Plus Vision Employee $8.89 $14.02 $30.33 $35.46 Employee + Spouse/ Domestic Partner $21.77 $32.05 $70.16 $80.44 Employee + Child(ren) $24.58 $35.72 $69.30 $80.44 Employee + Spouse/ Domestic Partner + Child(ren) $40.60 $58.40 $ $ Contributions listed here are based on the 12-month calendar year. The actual deduction from your paycheck depends on your deduction cycle. Contributions for domestic partners and their children are paid on an after-tax basis. Service Employees Benefit Fund Dental & Vision Plans Employees represented by the SEIU bargaining unit have the choice of participating in either the University s dental with or without vision plan as identified above, or the Service Employees Benefit Fund (SEBF) dental with or without vision plan. The SEBF plan is administered by the union and coverage is provided through SEBF Dental and Davis Vision respectively. Enrollment in the SEBF plan is a one-year commitment. The vision benefit is tied to your dental plan and is not available as a separate option Monthly Employee Contributions for SEBF With or Without Vision Basic Basic Plus Comprehensive Comprehensive Plus Vision Vision Employee $13.68 $18.09 $18.85 $23.26 Employee + 1 $28.97 $38.87 $33.13 $43.03 Family $42.41 $52.31 $49.15 $59.05 Contributions listed here are based on the 12-month calendar year. The actual deduction from your paycheck depends on your deduction cycle. Contributions for domestic partners and their children are paid on an after-tax basis. Page 28 January 2015

31 SUMMARY OF UNIVERSITY DENTAL BENEFITS Syracuse University offers the Delta Dental PPO SMi plan ( PPO plan ) underwritten and administered by Delta Dental of New York, Inc. ( Delta Dental ). You can visit any licensed dentist under this PPO plan, but you ll maximize plan value by using a PPO dentist. PPO dentists have agreed to accept PPO contracted fees, or reduced rates, and can t balance bill you for additional fees. The PPO plan includes an added cost-savings safety net the Delta Dental Premier 1 network ( Premier ). Premier is the nation s largest dental network with more than 80% of dentists nationwide ii and is the next best option if you can t find a PPO dentist. Premier dentists contracted fees are moderately higher than PPO dentists contracted fees; however, they will not bill you above their contracted fees, so you will usually save more compared to a non-participating dentist. LIMITATIONS AND EXCLUSIONS Certain limitations and exclusions apply. iii For example, non-covered services include: appearance only, preventive plaque control programs and Orthodontics. Additionally, procedures provided or devices started prior to the date you are eligible to receive services or prior to the plan s effective date are not covered. PRE-TREATMENT ESTIMATE If your proposed cost of dental care exceeds $300, Delta Dental recommends that you ask your dentist to request a pre-treatment estimate from them before you agree to receive the prescribed treatment. The pre-treatment estimate provides you up-front with an estimate of what will be paid by the Plan and the difference you will need to pay based on your plan benefits. Additionally, they can calculate how your plan s deductible, and maximums will affect your share of the cost of treatment. Pre-treatment estimates usually take about two to three weeks and are valid for 365 days. iv ONLINE SERVICES Visit Delta Dental s website at deltadentalins.com to locate participating dentists by location, specialty and network type; obtain eligibility and benefit information; check the status of a claim or see if your current dentist is a participating dentist. No online access? A Delta Dental Customer Service representative is available to assist you at Page 29 January 2015

32 PAYMENT FOR SERVICES The chart below illustrates payment responsibilities based on your choice of dentist. Delta Dental PPO Dentist Delta Dental Premier Dentist Non-Participating Dentist Plan Allowance Dentists are paid PPO contracted fees. Your costs are usually lowest. Dentists are paid Premier contracted fees. Your costs are usually moderate. Claims for services provided by non-participating dentists will be processed using a maximum fee level that may be higher than Delta Dental s maximum plan allowance. Your costs are usually highest. Payment Responsibilities By agreement, participating dentists must accept contracted fees as payment in for covered services. Delta Dental s benefit is a percentage of the maximum plan allowance, which may require a amount. Deductibles may also apply. You are also responsible for costs related to services that are not covered. The benefit payment is sent directly to you. v You are responsible for any applicable and/or deductibles, plus any difference between Delta Dental s payment (the maximum plan allowance) and the amount billed that exceeds this allowance. You are also responsible for costs related to services that are not covered. Benefits Summary Under the Delta Dental Plans: Plan Annual Deductible Per Person Family Deductible Deductible for Diagnostic and Preventive Services Annual Maximum Per Person Preventive $0 $0 Waived $500 Comprehensive $50 (does not apply to preventive services) $150 (does not apply to preventive services) Waived $2,000 The chart on the following page illustrates for each covered procedure in accordance with Delta Dental s payout level. Page 30 January 2015

33 Service ix Examples of Covered Services Delta Dental PPO Dentist vi Paid by Delta Dental Paid by Patient Preventive Plan Coverage Delta Dental Premier Dentist vii Paid by Delta Dental Paid by Patient Non-Participating Dentist viii Paid by Delta Dental Diagnostic Exam & x-rays 100% 0% 100% 0% 100% 0% Preventive TMJ Fluoride treatments (to age 19), teeth cleaning, sealants (to age 14) Temporomandibular joint dysfunction treatment Paid by Patient 100% 0% 100% 0% 100% 0% 50% 50% 50% 50% 50% 50% Additional Coverage for Comprehensive Plan Only Basic Fillings 80% 20% 60% 40% 60% 40% Restorative Oral Surgery Extractions 80% 20% 60% 40% 60% 40% Endodontics Root canal therapy 80% 20% 60% 40% 60% 40% Periodontics Treatment of gum disorders 80% 20% 60% 40% 60% 40% Prosthodontics Dentures, bridgework 50% 50% 50% 50% 50% 50% Major Restorative Stainless Steel Crowns Crowns 50% 50% 50% 50% 50% 50% On temporary teeth (only for children) 80% 20% 60% 40% 60% 40% 1 Delta Dental PPO and Delta Dental Premier are open networks that allow enrollees to visit any licensed dentist, either in the PPO network, where you will save the most on out-of-pocket costs, the moderate cost Premier network or outside the Delta Dental network, where there are no cost protections. Enrollees who visit a network dentist receive the advantages of no billing beyond the charges allowed by the plan and the submission of claims by dentists. In Texas, Delta Dental Insurance Company offers Dental Provider Organization (DPO) plans. 2 NetMinder Dental Network Trend Report, March Please refer to your plan booklet and corresponding attachments for a complete list of your plan s services, limitations and exclusions. 4 Pre-treatment estimates are typically valid for 365 days. Please refer to your plan booklet for your plan s benefits, limitations and exclusions. 5 Unless your plan allows you to assign the benefits to your dentist Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and the maximum plan allowance for non-participating dentists. Percentage is based on Delta Dental s allowance or the dentist s actual fee, whichever is less (allowed amount). Delta Dental s payment under the plan, plus the patient payment, equals the allowed amount, which is accepted by Delta Dental participating dentists as payment. Participating dentists are paid directly by Delta Dental and, by agreement, cannot bill you more than the applicable, deductible or charges where maximums have been exceeded for covered services. By selecting a participating dentist, you can limit your out-ofpocket costs. For services performed by non-participating dentists, Delta Dental sends the benefit payment directly to you. You are responsible for paying the non-participating dentist s submitted fee, which may include amounts in addition to your share of Delta Dental s allowed amount. 6 Limitations and/or waiting periods may apply for some benefits; some services may be excluded from your plan. Please refer to your plan booklet and corresponding attachments for a complete list of your plan s services, limitations and exclusions. Page 31 January 2015

34 SUMMARY OF UNIVERSITY VISION BENEFITS The following is a summary of vision services and benefits provided through VSP: Coverage Frequency Co-pay Plan Information Exam Prescription Glasses (lenses) Every calendar year Every calendar year $15 Routine exam only $25 Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Prescription Glasses (frames)* Every other calendar year n/a $150 allowance for frame of your choice 20% off the amount over your choice Lens Options Every calendar year $55 $95-$105 $150-$175 Standard progressive lenses Premium progressive lenses Custom progressive lenses Contact Lens Care* Every calendar year up to $60 $130 allowance for contacts. Copay applies to contact lens exam (fitting and evaluation). If you choose contact lenses you will be eligible for a frame one calendar year from the date the contact lenses were obtained. Current soft contact lens wearers may qualify for a special program that includes a contact lens exam and initial supply of replacement lenses. Additional Coverage Diabetic Eyecare Plus Program Extra Discounts and Savings Glasses and Sunglasses Laser Vision Correction 20% off additional glasses and sunglasses, including lens options, from any VSP doctor within 12 months of your last Well Vision Exam Average 15% off the regular price or 5% off the promotional price. Discounts only available from contracted facilities. If you see a non-vsp provider, you ll receive a lesser benefit. Before seeing a non-vsp provider, call VSP at for more details. Out-of-Network Reimbursement Amounts: Exam... Up to $45 Lined trifocal lenses... Up to $65 Single vision lenses... Up to $30 Frame... Up to $70 Lined bifocal lenses... Up to $50 Contacts... Up to $105 Progressive lenses. Up to $50 *Either frames or contact lenses are covered in a calendar year. If you choose contact lenses, you will be eligible for a frame one calendar year from the date the contact lenses were obtained. Page 32 January 2015