2013 Benefit Enrollment Guide - Troy University

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Healthcare Benefits Dental (Blue Cross Blue Shield of AL) In- Network and Out-of-Network Dental Coinsurance Covered Procedures 80% Basic Services • Routine oral examinations (two per calendar year) • Routine Cleanings (two per calendar year) • Topical applications of fluoride (children through age 18, 2x per calendar year) • Space maintainers (through age 18) • Dental X-rays (full mouth 1x during any 36 months in a row, Bitewing 2x in a calendar year) • Sealants* Dental Benefits are available to you and your eligible family members to cover routine care, such as exams, x-rays and cleanings, fillings, and periodontal care. Orthodontia is not included. Under the BCBS of AL Plan, you can go to the dental provider within the Dental PPO Network. If you choose to go to an out-of-network provider, the same percentages will be paid, but you will be responsible for any Reasonable or Customary charges. Dental Summary of Benefits Dental Expenses Plan pays after deductible Basic Services 80% Supplemental Services 80% Periodontic Services 80% Annual Maximum $1,000 per covered person Deductible Individual $25.00 Family $75.00 (Three $25 deductibles per family maximum) • Fillings* • Simple tooth extractions • Repairs to removable dentures *Refer to SPD for limitations 80% Supplemental Services • Oral surgery – tooth extractions and impacted teeth and to treat mouth abscesses • General anesthesia • Treatment of the root tip of the tooth including its removal 80% Periodontic Services • Periodontic exams 2x each 12 months • Removal of diseased gum tissue and reconstructing gums • Removal of diseased bone • Reconstruction of gums and mucous membranes by surgery • Removing plague and calculus below the gum line for periodontal disease Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 6
Healthcare Benefits BlueCard Worldwide ® Healthcare coverage wherever you go. To take advantage of the BlueCard Worldwide Program, whether you are traveling or living abroad, please follow these steps: 1. Before you leave, contact your Blue Plan for coverage details. Coverage outside the United States may be different. 2. Always carry your current Blue SM ID card. 3. In an emergency, go directly to the nearest hospital. 4. If you need to locate a doctor or hospital, or need medical assistance services, call the BlueCard Worldwide Service Center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, seven days a week. An assistance coordinator, in conjunction with a medical professional, will arrange a physician appointment or hospitalization, if necessary. 5. Call the BlueCard Worldwide Service Center at 1-800-810-2583 or collect at 1-804-673-1177 when you need inpatient care. In most cases, you should not need to pay upfront for inpatient care at BlueCard Worldwide hospitals except for the out-of-pocket expenses (noncovered services, deductible, copayment and coinsurance) you normally pay. The hospital should submit your claim on your behalf. In addition to contacting the BlueCard Worldwide Service Center, call your Blue Plan for precertification or preauthorization. Refer to the phone number on the back of your Blue ID card. Note: this number is different from the phone number listed above. 6. You may need to pay upfront for care received from a doctor and/or hospital. Then complete a BlueCard Worldwide International claim form and send it with the bill(s) to the BlueCard Worldwide Service Center (the address is on the form). The claim form is available from your Blue Plan, online at www.BCBS.com/bluecardworldwide, or the BlueCard Worldwide Service Center. To file a claim please do the following: 1. If the BlueCard Worldwide Service Center arranged your hospitalization, the hospital will file the claim for you. You will need to pay the hospital for the out-ofpocket expenses you normally pay. 2. For outpatient and doctor care, or inpatient care not arranged through the BlueCard Worldwide Service Center, you will need to pay the healthcare provider and submit a BlueCard Worldwide International claim form with original bills to the BlueCard Worldwide Service Center. 3. International claim forms are available from your Blue Plan, the Service Center or online at www.bcbs.com/ bluecardworldwide. BlueCard Worldwide Service Center: 1-800-810-2583 or collect:1-804-673-1177 Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 7
Page 1 and 2: 2013 Benefit Enrollment Guide an ov
Page 3 and 4: introduction Enrollment Current Emp
Page 5 and 6: Healthcare Benefits Medical (Blue C
Page 7: Healthcare Benefits Pre-Tax Cafeter
Page 11 and 12: Voluntary Life Insurance Voluntary
Page 13 and 14: travel assistance MEDEX ® Travel A
Page 15 and 16: flexible spending Flexible Spending
Page 17 and 18: etirement Mandatory Retirement Plan
Page 19 and 20: important notices Summary Plan Desc
Page 21 and 22: Troy University-54395/000 Coverage
Page 23 and 24: Common Medical Event If you need dr
Page 25 and 26: Excluded Services & Other Covered S
Page 27 and 28: Questions and answers about the Cov
Page 29 and 30: BlueCard PPO: Troy University Cover

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