Table of Content
- Header
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Page
- Welcome to your 2023 Progressive Quality Care Benefits
- How to Enroll
- Eligibility & Qualifying Events
- Medical
- Prescriptions
- Virtual Visits
- Dental
- Vision
- Voluntary Life
- Disability
- Voluntary Accident
- Employee Contributions
- Understanding your Benefits
- Additional Resources
- Company Time off and Holidays
- Carrier Contacts
- Contact Us
- Footer
Welcome to your 2023 Progressive Quality Care Benefits
To Our Employees:
We have made a conscious decision to offer you benefits because we care about you and your families, and we want to do everything we can to make sure you are taken care of.
Once again this year, we conducted a thorough review of options available to us and we think we’ve come up with the best possible package. But the process doesn’t stop here—we need you to take an active role in understanding and selecting your benefit options. A strong grasp of the plans available to you will best allow both you and this organization to get the most bang for our buck.
To help you gain that strong understanding, please read this kit carefully and consult us with any questions.
Thank you for all that you do for us!
Eligibility & Qualifying Events
The Benefit choices you make during your initial enrollment or annual open enrollment remain in effect for the entire year.
EMPLOYEE ELIGIBILITY
You are eligible to participate if you are full-time and work a minimum of 30 hours per week. Your coverage will be effective the first of the month following ninety-days of service. If you were hired on the first of the month, then your benefits are effective on the date of hire.
DEPENDENT ELIGIBILITY
You may also enroll eligible dependents for benefits coverage. A ‘dependent’ is defined as the legal spouse, domestic partner and/or ‘dependent child(ren)’ of the plan participant or the spouse.
You can, however, modify your elections under certain circumstances, called "Qualifying Events" These are events such as marriage, divorce, birth or adoption of a child, loss of eligibility under another plan. If you experience a qualifying event, you may make changes to your benefits within 30 days.
What is a Qualifying Life Event?
• Marriage
• Divorce
• Birth/Adoption of a child
• Death of a spouse or other enrolled dependent
• Change in spouse’s benefits or employment status
• A dependent becomes eligible for Medicare or Medical
Medical
Progressive Quality Care offers 4 plan options through Anthem BC BS.
You have the option to choose between 3 PPO plans and a HSA plan. A PPO option offers the freedom to see any provider when you need care. When you use providers from within the PPO network, you receive benefits at the discounted network cost. Most expenses, such as office visits, emergency room and prescription drugs are covered by a copay. Other expenses are subject to a deductible and coinsurance.
Utilizing In-Network providers will allow for the highest level of coverage. In-Network providers agree to accept Anthem's contract rate as the final charge and the member is not balanced billed.
Medical Summary
Prescriptions
TRADITIONAL DRUGS
TIER 1 (GENERIC) | Lowest copay: Most drugs in this category are generic drugs. Members pay the lowest copay for generics, making these drugs the most cost-effective option for treatment.
TIER 2 | Higher copay: This category includes preferred, brand name drugs that don't yet have a generic equivalent. These drugs are more expensive than generics, and a higher copay.
TIER 3 | Highest copay: In this category are nonpreferred brand name drugs for which there is either a generic alternative or a more cost-effective preferred brand. These drugs have the highest copay. Make sure to check for mail order discounts that may be available.
SPECIALTY DRUGS
TIER 4 | Lowest Specialty Drug copay: Tier 4 specialty drugs are generally more effective and less expensive than nonpreferred specialty drugs in tier 5.
WHERE CAN I FIND A DRUG LIST?
Typically, a full listing of covered drugs is found on your provider’s website. A drug list, also called a formulary, is a list of generic and brand-name drugs covered by a health plan. Although a drug may be on the drug list, it might not be covered under every plan. Review the plan materials for details on specific benefits.
You can use drug lists to see if a medication is covered by your health insurance plan. You can also find out if the medication is available as a generic, needs prior authorization, has quantity limits and more.
What is Coverage Review or Prior Authorization?
Your plan uses coverage management programs to help ensure you receive the prescription drugs you need at a reasonable cost. Coverage management programs include
- Prior Authorization
- Step Therapy
- Quantity Duration.
Each program determines whether your use of certain medications meets your plan’s conditions of coverage. In some cases, a coverage review may be necessary to determine whether a prescription can be covered under your plan.
The differences in prescription drug costs are summarized here:
RX Summary
Virtual Visits
A virtual visit lets you see and talk to a doctor from your mobile device or computer. When you use one of the provider groups in our virtual visit network, you have benefit coverage for certain non-emergency medical conditions. Costs must be paid by you at the time of the virtual visit and will apply toward your deductible and out-of-pocket maximum.
WHEN CAN I USE A VIRTUAL VISIT?
When you have a non-emergency condition and:
- your doctor is not available;
- you become ill while traveling;
- When you are considering visiting a hospital emergency room for a non-emergency health condition.
*Your covered children may also use Virtual Visits when a parent or legal guardian is present for the visit.
Examples of Non-Emergency Conditions:
- Bladder infection
- Seasonal flu
- Sinus
- Sore throat
- Stomach
- Rash
- Bronchitis
- Diarrhea
- Fever
- Pink eye
HOW DOES IT WORK?
The first time you use a Virtual Visits provider, you will need to set up an account with that Virtual Visits provider group. You will need to complete the patient registration process to gather medical history, pharmacy preference, primary care physician contact information, and insurance information.
Each time you have a virtual visit, you will be asked some brief medical questions, including questions about your current medical concern. If appropriate, you will then be connected using secure live audio and video technology to a doctor licensed to deliver care in the state you are in at the time of your visit. You and the doctor will discuss your medical issue, and, if appropriate, the doctor may write a prescription* for you.
Virtual Visits doctors use e-prescribing to submit prescriptions to the pharmacy of your choice. Costs for the virtual visit and prescription drugs are based on, and payable under, your medical and pharmacy benefit. They are not covered as part of your Virtual Visits benefit.
*Prescription services may not be available in all states.
HOW DO I GET ACCESS?
Learn more about Virtual Visits and access direct links by downloading the Sydney App from your phone.
Dental
Dental Benefits through Anthem provide comprehensive coverage to help you and your family maintain good dental health. Your coverage will be greater when you visit a participating in-network dentist, you will have lower out-of-pocket costs, no balance billing, and claims will be submitted by your dentist on your behalf.
PREVENTION FIRST!
Your dental health is an important part of your overall health. Make sure you take advantage of your preventive dental visits.
Preventive care services are covered at 100% if you visit an In-Network provider. They are also not subject to the annual deductible.
A comparison of the options is below:
Dental Summary
Vision
Progressive Quality Care offers vision coverage through Anthem to help pay for eye exams, prescription glasses and contact lenses. You receive a higher level of benefits when you see a provider in network, however, out-of-network coverage is provided but may only be handled as reimbursements in some situations. Please note: Members may choose between prescription glasses (lenses and frame) and contact lenses, not both.
DID YOU KNOW?
- Eye exams can help detect serious eye and general health conditions sooner: high blood pressure, diabetes, heart disease, high cholesterol
- Babies should receive their first professional eye exam at 6 months
- 80% of learning in the first 12 years comes through the eyes
To find out if your provider is in-network, please visit the website below.
Vision Benefit Summary
Voluntary Life
As an active employee of Progressive Quality Care, Inc. you have access to a voluntary term life insurance policy from Mutual of Omaha. You will be required to provide proof of good health by completing an Evidence of Insurability (EOI) form for any amount in excess of the Guarantee Issue amount.
Voluntary - Employee Paid Life
Coverage is also available for your spouse and/or child dependents, but only after you've elected coverage for yourself. A sudden accident or death can leave you or your loved ones in a vulnerable position. Employees have the opportunity to enroll in Term Life and Accidental Death & Dismemberment insurance which will supplement lost income in the event of an accident or death. Review the full benefit summary below for additional details.
Employee: Minimum $10,000; GI is 5 times annual salary, up to $200,000; Maximum $500,000, in increments of $10,000, but no more than 5 times annual salary
Spouse: Minimum $5,000; GI is 100% of employee's benefit, up to $30,000; maximum 50% of employee's benefit, up to $250,000
Children: Minimum $2,000; GI is 100% of employee's benefit; Maximum 50% of employee's benefit, up to $10,000
Who's Your Beneficiary?
Naming a beneficiary is a crucial part of electing life insurance. Also, don't forget to update your primary or secondary beneficiary if you experience a life event, such as a divorce or birth of a child.
*Guaranteed Issue (GI) and Evidence of Insurability (EOI)
When you are first eligible (at hire) for Voluntary Life and AD&D, you may purchase up to the Guaranteed Issue (GI) for yourself and your spouse without providing proof of good health (EOI). Any amount elected over the GI will require EOI. You will also be required to complete an EOI if you initially waived this benefit. If you elect optional life coverage, and are required to complete an EOI, it is your responsibility to complete the EOI and send to the provider (address will be listed on your form). In addition, your spouse will need to provide EOI to be eligible for coverage amounts over GI, or if coverage is requested at a later date.
Disability
Short Term Disability
Everyday illnesses or injuries can interfere with your ability to work. Even a few weeks away from work can make it difficult to manage household costs. Short Term Disability coverage provides financial protection for you by paying a portion of your income, so you can focus on getting better and worry less about keeping up with your bills. Your coverage pays 60% of your income to a maximum of $1,000 per week.
Long Term Disability
Insurance through Mutual of Omaha can pay you a weekly benefit if you have a covered disability that keeps you from working. Long Term Disability insurance can replace part of your income while you recover.
*If you initially waived these benefits in the past, you may be required to complete and Evidence of Insurability (EOI).
LTD Benefit Features
- Benefit begins after 90 day elimination period if remain disabled
- Benefit equal to 50% of monthly income – benefit is taxable income
- Monthly maximum benefit is $3,000
- Pre-existing condition limitations apply for first 12 months
Voluntary Accident
Accident Insurance
A serious injury can cost you a lot of money - not only in medical bills but in things like income from lost work hours. Some injuries are minor, but others are debilitating and require significant medical care. If you get hurt, accident insurance pays you money that you can use to cover personal expenses, bills, and out-of-pocket medical costs.
Who Gets Paid?
You get paid. When you have a covered accident or injury, your health insurance company pays your doctor or hospital, but your accident insurance company pays you.
What’s Covered?
Not all accidents are “qualifying injuries.” The kinds of accidents that are covered can vary by plan, but accident insurance plans typically cover things like: Examples of what's covered.
- Emergency Room Visits
- Ambulance & Emergency Helicopter Transportation
- Hospital Admissions & Per Diem Charges
- Intensive Care & Rehabilitation Unit Care
- Diagnostic Exams
- Follow-up Treatments & Physical Therapy
Understanding your Benefits
Additional Resources
Carrier Contacts
Medical, Dental; Anthem (Group #L08927) | 1.877.722.6030
- Website: www.anthem.com
- Pharmacy Member Services: 1.877.722.6030
- Home Delivery Pharmacy: 1.833.320.1180
- Specialty RX Pharmacy: 1.833.255.0645
- Sydney Mobile App: Download on: Google Play or the Apple App Store.
Dental; Anthem | 1.877.722.6030
- Website: www.anthem.com
Vision; Anthem | 1.877.722.6030
- Website: www.anthem.com
Voluntary STD & LTD; Mutual of Omaha | 1.800.775.5433
- Website: www.mutualofomaha.com
Voluntary Accident; Mutual of Omaha | 1.800.775.8805
- Website: www.mutualofomaha.com
Contact Us
As you consider your benefit options, please be sure to review all available information. If you don't understand your benefits or need any assistance, please contact Human Resources.
Additional Contacts
Nick Sever
Account Manager I
nicholas.sever@nfp.com
216-238-7922