RETIREE BENEFIT HIGHLIGHTS - Hollywood, FL
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2018 | RETIREE BENEFIT HIGHLIGHTS
City of Hollywood | Retiree Benefit Highlights | 2018
Table of Contents
Contact Information 1
Introduction 2
Notices 2
Online Benefit Enrollment 2
Group Insurance Eligibility 3
Medical Insurance 4
Other Available Plan Resources 4
Cigna – OAP In-Network Plan At-A-Glance 5
Cigna – OAP Plan At-A-Glance 6
Dental Insurance 7
Cigna – Dental PPO Low Plan At-A-Glance 8
Cigna – Dental PPO High Plan At-A-Glance 10
Vision Insurance 11
VSP – Vision Plan Option 1 At-A-Glance 12
VSP – Vision Plan Option 2 At-A-Glance 14
VSP – Vision Plan Option 3 At-A-Glance 16
Retiree Basic Life 17
Notes 17-20
This booklet is merely a summary of benefits. For a full description, refer to the plan document. Where conflict exists between this summary and the plan document, the plan document controls.
The City of Hollywood reserves the right to amend, modify or terminate the plan at any time. This booklet should not be construed as a guarantee of employment.
City of Hollywood | Retiree Benefit Highlights | 2018
Contact Information
Tammie Hechler Phone: (954) 921-3218
City of Hollywood
Director of Human Resources Email: thechler@hollywoodfl.org
(888) 5-BenTek (523-6835)
Online Employee Benefit Center BenTek Email: support@mybentek.com
www.mybentek.com/hollywood
Customer Service: (800) 244-6224
Medical Insurance Cigna
www.cigna.com
Prescription Drug Coverage Customer Service: (800) 835-3784
Cigna Home Delivery Pharmacy
& Mail-Order Program www.cigna.com
Customer Service: (800) 244-6224
Dental Insurance Cigna
www.cigna.com
Customer Service: (800) 877-7195
Vision Insurance VSP
www.vsp.com
Customer Service: (800) 796-3872
Retiree Basic Life Symetra
www.symetra.com
1
City of Hollywood | Retiree Benefit Highlights | 2018
Online Benefit Enrollment
The City provides retirees with an online benefits enrollment platform
through BenTek’s Employee Benefits Center (EBC). The EBC provides
benefit-eligible retirees the ability to select or change insurance
benefits online during the annual open enrollment period, new hire
orientation, or qualifying events.
Introduction Accessible 24 hours a day throughout the year, retiree may log in and
The City of Hollywood provides a comprehensive compensation package review comprehensive information regarding benefit plan(s) and view
including group insurance benefits. The Retiree Benefit Highlights Booklet and print an outline of benefit elections for retiree and dependent(s).
provides a general summary of these benefit options as a convenient reference. Retiree has access to important forms and carrier links, can report
Please refer to the City's policies or applicable collective bargaining agreements qualifying life events and review and make changes to life insurance
and/or Certificates of Coverage for detailed descriptions of all available retiree beneficiary designations.
benefit programs and stipulations therein. If further explanation or assistance
is needed regarding claims processing, please refer to the customer service
phone numbers under each benefit description heading or contact Human
Resources for further information.
Notices
Medicare Part D Creditable Coverage
The City of Hollywood’s prescription drug coverage(s) is considered Creditable
Coverage under Medicare Part D. If you or your dependents are or will be eligible To Access the Employee Benefits Center:
for Medicare, you may obtain more information by requesting a Medicare Part
99
Log on to www.mybentek.com/hollywood
D Disclosure of Creditable Coverage Notice.
99
Sign in using a previously created username and password or
More information is available on the above Notices by contacting Human click "Create an Account" to set up a username and password.
Resources. 9 9
If retiree has forgotten username and/or password, click
on the link “Forgot Username/Password” and follow the
instructions.
9 9
Once logged on, navigate to the menu in order to review
current elections, learn about benefit options, and make
elections, changes or beneficiary designations.
For technical issues directly related to using the EBC please
call (888) 5-BenTek (523-6835) or email BenTek Support at
support@mybentek.com, Monday through Friday, during regular
business hours from 8:30 a.m. to 5:00 p.m.
To access group insurance benefits online, log on to:
www.mybentek.com/hollywood
Please Note: Link must be addressed exactly as written (Due to security reasons,
the website cannot be accessed by Google or other search engines.)
2City of Hollywood | Retiree Benefit Highlights | 2018
Group Insurance Eligibility
JANUARY The City of Hollywood group insurance plan Disabled Dependents
01 year is January 1 through December 31. Coverage for an unmarried dependent child may be continued beyond age 26 if:
• The dependent is physically or mentally disabled and incapable of
self-sustaining employment (prior to age 26); and
Dependent Eligibility • Primarily dependent upon the retiree for support; and
A dependent is defined as the legal spouse or domestic partner and/or • The dependent is otherwise eligible for coverage under the group
dependent child(ren) of the participant, spouse or domestic partner. The term medical plan; and
“child” includes any of the following: • The dependent has been continuously insured; and
• A natural child • Coverage with City began prior to age 26.
• A stepchild Proof of disability will be required upon request. Please contact Human
• A legally adopted child Resources if further clarification is needed.
• A newborn child (up to the age of 18 months old) of a covered
Medicare Eligible
dependent (Florida)
• A child for whom legal guardianship has been awarded to the Prior to a non-Medicare eligible retiree reaching age 65, Cigna processes claims
participant or the participant’s spouse or domestic partner as the primary insurer. Upon a retiree reaching age 65, becoming Medicare
eligible or qualifying for early Medicare eligibility due to disability, claims are
processed with Medicare as the primary insurer and Cigna as the secondary, if
Dependent Age Requirements the member is not actively working.
Medical Coverage: A dependent child may be covered through If eligible for Medicare and not actively working, it is important that the retiree
the end of the month in which the child turns age 26. An over-age sign up for Medicare Part A and Part B to ensure that claims are processed
dependent may continue to be covered on the medical plan to the correctly.
end of the calendar year in which the child reaches age 30, if the
Once a retiree is enrolled in Medicare Part A and Part B, the City’s medical plan
dependent meets the following requirements:
coverage will change from primary to secondary. This means Medicare will
• Unmarried with no dependents; and process claims before Cigna will process claims.
• A Florida resident, or full-time or part-time student; and
If a retiree missed the initial social security application period, the retiree will
• Otherwise uninsured; and be assessed penalties by Social Security and the effective date of coverage will
• Not entitled to Medicare benefits under Title XVIII of the be much later.
Social Security Act, unless the child is disabled.
Please note: In order to avoid penalties with Medicare, an eligible retiree must
Dental Coverage: A dependent child may be covered through the end
sign up for Part B when first eligible.
of the month in which the child turns age 26.
Vision Coverage: A dependent child may be covered through the end Social Security Administration
of the month in which the child turns age 26. Customer Service: (800) 772-1213 | www.socialsecurity.gov
3City of Hollywood | Retiree Benefit Highlights | 2018
Medical Insurance Other Available Plan Resources
The City offers medical insurance through Cigna to benefit-eligible retirees. For Cigna offers all enrolled retirees and dependents additional services and
information about the medical plan, please refer to the Summary of Benefits discounts through value added programs. For more details regarding
and Coverage document or contact Cigna's customer service. Please refer to other available plan resources, please refer to the summary of benefits and
the separate rate sheet for Open Access Plan (OAP) and Open Access Plus In- coverage document, contact Cigna’s customer service at (800) 244-6224, or
Network Plan (OAPIN) costs for your specific retiree classification. visit www.cigna.com.
Cigna | Customer Service: (800) 244-6224 | www.cigna.com Healthy Rewards
Cigna’s Healthy Rewards is provided automatically at no additional cost and
offers access to discounted health and wellness programs at participating
Summary of Benefits and Coverage providers. Member can log on to www.mycigna.com and select Healthy
A Summary of Benefits & Coverage (SBC) for the medical plan is provided as a Rewards to learn more about these programs or call (800) 870-3470.
supplement to this booklet being distributed to retirees during open enrollment. The 99
Vision Care
summary is an important item in understanding the benefit options. A free paper copy 99
Lasik Vision Correction Services
of the SBC document may be requested or is available as follows:
99
Fitness Club Discounts
99
Nutrition Discounts
From: Human Resources
99
Hearing Care
Address: 2600 Hollywood Blvd., Ste. 206
Hollywood, FL 33022
The myCigna Mobile App
Phone: (954) 921-3218
The myCigna mobile app is an easy way to organize and access important
At Website URL: www.mybentek.com/hollywood
health information. Anytime. Anywhere. Download it today from the App
StoreSM or Google Play™. With the myCigna mobile app, member can:
The SBC is only a summary of the plan’s coverage. A copy of the plan document, policy,
or certificate of coverage should be consulted to determine the governing contractual • Find a doctor, dentist or health care facility
provisions of the coverage. A copy of the group certificate of coverage can be reviewed • Access maps for instant driving directions
and obtained by contacting Human Resources.
• View ID cards for the entire family
If there are questions about the plan offerings or coverage options, please contact
Human Resources. • Review deductibles, account balances and claims
• Compare prescription drug costs
• Speed-dial Cigna Home Delivery Pharmacy™Store and organize all
important contact info for doctors, hospitals, and pharmacies
• Add health care professionals to contact list right from a claim or
directory search
• And, much more!
24 Hour Help Information Hotline (800) CIGNA-24
The Cigna 24-Hour Health Information Line provides access to helpful, reliable
information and assistance from qualified health information nurses on a wide
range of health topics 24 hours a day, any day of the year. Not sure what to do
when a child has a fever in the middle of the night? Not sure if treatment from
a doctor is necessary for an injury? There are over 1,000 topics in the Health
Information Library that include free audio, video and printed information on
aging, women’s health, nutrition, surgery and specific medical conditions to
help member weigh the risks and advantages of treatment options. The call is
free and is strictly confidential.
4City of Hollywood | Retiree Benefit Highlights | 2018
Cigna – OAP In-Network Plan At-A-Glance
Network Open Access Plus
Calendar Year Deductible (CYD) In-Network
Single $500
Family $1,500
Locate a Provider Coinsurance
To search for a participating provider, Member Responsibility 20%
contact Cigna's customer service or visit
www.cigna.com. When completing the Calendar Year Out-of-Pocket Limit
necessary search criteria, select Open Single $3,000
Access Plus network.
Family $9,000
What Applies to the Out-of-Pocket Limit? Deductible, Coinsurance and Copays (Excludes Rx)
Physician Services
Primary Care Physician (PCP) Office Visit $30 Copay
Plan References Specialist Office Visit $40 Copay
*Quest Diagnostics and LabCorp are Non-Hospital Services; Freestanding Facility
the preferred labs for bloodwork through
Cigna. When using a lab other than Clinical Lab (Blood Work): Quest or LabCorp* No Charge
LabCorp or Quest, please confirm they X-rays $50 Copay
are contracted with Cigna’s Open Access
Plus Network prior to receiving services. Advanced Imaging (MRI, PET, CT) – Per Scan $50 Copay
Outpatient Surgery at Surgical Center $250 Copay Per Visit
Physician Services at Surgical Center No Charge
Urgent Care (Per Visit) $75 Copay
Hospital Services
Important Notes Inpatient Hospital (Per Admission) $500 Copay
• There is a separate $50/$150 calendar Outpatient Hospital (Per Visit) $250 Copay
year deductible to be met before Rx
benefits begin. Inpatient Physician Services at Hospital $40 Copay + 20% After CYD
• There is a separate $1,500/$4,500 Emergency Room (Per Visit; Waived if Admitted) $200 Copay
per plan year, Pharmacy Out of Pocket
Limit, that does not accumulate Mental Health/Alcohol & Substance Abuse
towards the Medical Calendar Year Out Inpatient Hospitalization (Per Admission) $500 Copay
of Pocket Limit.
Outpatient Services (Per Visit) $40 Copay
• Services received by providers and
facilities not in the Open Access Plus Prescription Drugs (Rx)
Network will be denied.
Calendar Year Deductible for Rx Costs $50 Per Covered Person
Calendar Year Out of Pocket Limit for Rx Costs Single: $1,500 Family: $4,500
Generic 20% After CYD
Preferred Brand Name 20% After CYD
Non-Preferred Brand Name 20% After CYD
Mail Order Drug (90 Day Supply) $25 / $75 / $150 Copay
5City of Hollywood | Retiree Benefit Highlights | 2018
Cigna – OAP Plan At-A-Glance
Network Open Access Plus
Calendar Year Deductible (CYD) In-Network Out-of-Network*
Single None $500
Family None $1,500
Coinsurance
Locate a Provider
Member Responsibility 0% 40%
To search for a participating provider,
Calendar Year Out-of-Pocket Limit contact Cigna's customer service or visit
www.cigna.com. When completing the
Single $1,500 $3,000 necessary search criteria, select Open
Family $3,000 $6,000 Access Plus network.
What Applies to the Out-of-Pocket Limit? Deductible, Coinsurance and Copays (Excludes Rx)
Physician Services
Primary Care Physician (PCP) Office Visit $40 Copay 40% After CYD
Specialist Office Visit (No Referral Required) $40 Copay 40% After CYD
Plan References
Non-Hospital Services; Freestanding Facility *Out-Of-Network Balance Billing:
Clinical Lab (Blood Work): Quest or LabCorp** No Charge 40% After CYD For information regarding Out-of-
X-rays $50 Copay 40% After CYD Network Balance billing that may be
charged by an out-of-network provider,
Advanced Imaging (MRI, PET, CT) – Per Scan $50 Copay 40% After CYD please refer to the Summary of Benefits
Outpatient Surgery at Surgical Center $50 Copay 40% After CYD and Coverage document.
Physician Services at Surgical Center $40 Copay $40 Copay
**Quest Diagnostics and LabCorp are
Urgent Care (Per Visit) $40 Copay 40% After CYD the preferred labs for bloodwork through
Cigna. When using a lab other than
Hospital Services LabCorp or Quest, please confirm they
are contracted with Cigna’s Open Access
Inpatient Hospital (Per Admission) $250 Copay $750 Per Admission Deductible
Plus Network prior to receiving services
Outpatient Hospital $100 Copay $300 Per Admission Deductible
Inpatient Physician Services at Hospital No Charge No Charge
Emergency Room (Per Visit; Waived if Admitted) $50 Copay $50 Copay
Mental Health/Alcohol & Substance Abuse
Inpatient Hospitalization (Per Admission) $250 Copay $750 Per Admission Deductible Important Notes
Outpatient Services (Per Visit) No Charge 40% After CYD • There is a separate $50 per person
calendar year deductible to be met
Prescription Drugs (Rx) before Rx benefits begin.
Calendar Year Deductible for Rx Costs $50 Per Covered Person • There is a separate $1,000 / $3,000
per calendar year, Pharmacy Out
Calendar Year Out of Pocket Limit for Rx Costs Single: $1,000 Family: $3,000 Single: $1,000 Family: $3,000
of Pocket Limit for in-network and
Generic 20% After CYD 50% After CYD out-of-network combined, that does
Preferred Brand Name 20% After CYD 50% After CYD not accumulate towards the Medical
Calendar Year Out of Pocket Limit.
Non-Preferred Brand Name 20% After CYD 50% After CYD
Mail Order Drug (90 Day Supply) $20 / $50 / $80 Copay Not Covered
6City of Hollywood | Retiree Benefit Highlights | 2018
Dental Insurance
Cigna Dental PPO Low Plan
The City provides dental insurance through Cigna to benefit eligible-retirees. Out-of-Network Benefits
For more detailed information about the dental plans, please refer to the
Out-of-network benefits are used when members receive services by a non-
separate rate sheet for Cigna Dental PPO Low and High Plan costs for your
participating Total PPO provider. Cigna reimburses out-of-network services
specific retiree classification.
based on what it determines is the Maximum Reimbursable Charge (MRC). The
In-Network Benefits MRC is defined as the most common charge for a particular dental procedure
performed in a specific geographic area. If services are received from an out-
The PPO plan provides benefits for services received from in-network and out- of-network dentist, the member will pay the out-of-network benefit plus the
of-network providers. It is also an open access plan which allows for services to difference between the amount that Cigna reimburses (MRC) for such services
be received from any dental provider without having to select a Primary Dental and the amount charged by the dentist. This is known as balance billing.
Provider (PDP) or obtain a referral to a specialist. The network of participating Balance billing is in addition to any applicable plan deductible or coinsurance
dental providers the plan utilizes is the Cigna Total PPO network. These responsibility.
participating dental providers have contractually agreed to accept Cigna’s
contracted fee or “allowed amount.” This fee is the maximum amount a Cigna Calendar Year Deductible
dental provider can charge a member for a service. The member is responsible
for a Calendar Year Deductible (CYD) and then coinsurance based on the plan’s The dental PPO Low plan requires a $25 individual or a $75 family deductible
charge limitations. to be met for in-network or out-of-network services before most benefits will
begin. The deductible is waived for preventive services.
Please Note: Total DPPO dental members have the option to utilize a dentist that
participates in either Cigna’s Advantage Network or DPPO Network. However, members Calendar Year Benefit Maximum
that use the Cigna Advantage Network will see additional cost savings from the added
The maximum benefit (coinsurance) the dental PPO Low plan will pay for
discount that is allowed for using an Advantage network provider. Members are
responsible for verifying whether the treating dentist is an Advantage Dentist or a DPPO
each covered member is $1,000 for in-network or out-of-network services
Dentist. combined. All services accumulate towards the benefit maximum.
Cigna | Customer Service: (800) 244-6224 | www.cigna.com
7City of Hollywood | Retiree Benefit Highlights | 2018
Cigna – Dental PPO Low Plan At-A-Glance
Network Cigna Total DPPO
Calendar Year Deductible (CYD) In-Network and Out-of-Network Combined
Per Member $25
Per Family $75
Calendar Year Benefit Maximum
Locate a Provider
Per Member (Includes Class I Services) $1,000
To search for a participating provider,
Class I Services: Diagnostic & Preventive Care In-Network Out-of-Network* contact Cigna's customer service or visit
www.cigna.com. When completing the
Routine Oral Exam (2 Per Calendar Year) necessary search criteria, select Cigna
Routine Cleanings (2 Per Calendar Year) Plan Pays: 80% Dental PPO or EPO network.
Plan Pays: 100%
Deductible Waived
Bitewing X-rays (2 Per Calendar Year) Deductible Waived
(Subject to Balance Billing)
Complete X-rays (1 Set Every 36 Consecutive Months)
Class II Services: Basic Restorative Care
Fillings
Simple Extractions
Plan References
*Out-Of-Network Balance Billing: For
Endodontics (Root Canal Therapy) Plan Pays: 70% After CYD
Plan Pays: 80% After CYD information regarding out-of-network
Periodontics (Subject to Balance Billing) balance billing that may be charged
by an out-of-network provider for
General Anesthesia/Intravenous Sedation (Limitations Apply)
services rendered, please refer to the
Oral Surgery Out-of-Network Benefits section on the
previous page.
Class III Services: Major Restorative Care
Crowns
Plan Pays: 50% After CYD
Dentures Plan Pays: 50% After CYD
(Subject to Balance Billing)
Bridges
Class IV Services: Orthodontia Important Notes
Lifetime Maximum $1,000 • It is recommended for members to
request their provider to obtain a
Plan Pays: 50% After CYD Predetermination of Benefits when
Benefit (Child(ren) Up To Age 19) Plan Pays: 50% After CYD
(Subject to Balance Billing)
services are expected to exceed $200
in costs.
• Each covered family member may
receive two (2) routine cleanings per
calendar year under the preventive
benefit.
• Late entrant provisions, age limitations
and waiting periods may apply.
8City of Hollywood | Retiree Benefit Highlights | 2018
Dental Insurance
Cigna Dental PPO High Plan
The City offers dental insurance through Cigna to benefit-eligible retirees. For Out-of-Network Benefits
more detailed information about the dental plans, please refer to the separate
Out-of-network benefits are used when members receive services by a non-
rate sheet for Cigna Dental PPO Low and High Plan costs for your specific retiree
participating Total PPO provider. Cigna reimburses out-of-network services
classification.
based on what it determines is the Maximum Reimbursable Charge (MRC). The
In-Network Benefits MRC is defined as the most common charge for a particular dental procedure
performed in a specific geographic area. If services are received from an out-
The PPO plan provides benefits for services received from in-network and out- of-network dentist, the member will pay the out-of-network benefit plus the
of-network providers. It is also an open access plan which allows for services to difference between the amount that Cigna reimburses (MRC) for such services
be received from any dental provider without having to select a Primary Dental and the amount charged by the dentist. This is known as balance billing.
Provider (PDP) or obtain a referral to a specialist. The network of participating Balance billing is in addition to any applicable plan deductible or coinsurance
dental providers the plan utilizes is the Cigna Total PPO network. These responsibility.
participating dental providers have contractually agreed to accept Cigna’s
contracted fee or “allowed amount.” This fee is the maximum amount a Cigna Calendar Year Deductible
dental provider can charge a member for a service. The member is responsible
The dental PPO High plan requires a $25 individual or a $75 family deductible
for a Calendar Year Deductible (CYD) and then coinsurance based on the plan’s
to be met for in-network or out-of-network services before most benefits will
charge limitations.
begin. The deductible is waived for preventive services.
Please Note: Total DPPO dental members have the option to utilize a dentist that
participates in either Cigna’s Advantage Network or DPPO Network. However, members Calendar Year Benefit Maximum
that use the Cigna Advantage Network will see additional cost savings from the added The maximum benefit (coinsurance) the dental PPO High plan will pay for
discount that is allowed for using an Advantage network provider. Members are
each covered member is $2,000 for in-network or out-of-network services
responsible for verifying whether the treating dentist is an Advantage Dentist or a DPPO
Dentist.
combined. All services accumulate towards the benefit maximum.
Cigna | Customer Service: (800) 244-6224 | www.cigna.com
9City of Hollywood | Retiree Benefit Highlights | 2018
Cigna – Dental PPO High Plan At-A-Glance
Network Cigna Total DPPO
Calendar Year Deductible (CYD) In-Network and Out-of-Network Combined
Per Member $25
Per Family $75
Calendar Year Benefit Maximum
Locate a Provider
Per Member (Includes Class I Services) $2,000
To search for a participating provider,
Class I Services: Diagnostic & Preventive Care In-Network Out-of-Network* contact Cigna's customer service or visit
www.cigna.com. When completing the
Routine Oral Exam (2 Per Calendar Year) necessary search criteria, select Cigna
Routine Cleanings (2 Per Calendar Year) Plan Pays: 80% Dental PPO or EPO network.
Plan Pays: 100%
Deductible Waived
Bitewing X-rays (2 Per Calendar Year) Deductible Waived
(Subject to Balance Billing)
Complete X-rays (1 Set Every 36 Consecutive Months)
Class II Services: Basic Restorative Care
Fillings
Simple Extractions
Plan References
*Out-Of-Network Balance Billing: For
Endodontics (Root Canal Therapy) Plan Pays: 70% After CYD
Plan Pays: 80% After CYD information regarding out-of-network
Periodontics (Subject to Balance Billing) balance billing that may be charged
by an out-of-network provider for
General Anesthesia/Intravenous Sedation (Limitations Apply)
services rendered, please refer to the
Oral Surgery Out-of-Network Benefits section on the
previous page.
Class III Services: Major Restorative Care
Crowns
Plan Pays: 50% After CYD
Dentures Plan Pays: 50% After CYD
(Subject to Balance Billing)
Bridges
Class IV Services: Orthodontia Important Notes
Lifetime Maximum $2,000 • It is recommended for members to
request their provider to obtain a
Plan Pays: 50% After CYD Predetermination of Benefits when
Benefit (Child(ren) Up To Age 19) Plan Pays: 50% After CYD
(Subject to Balance Billing)
services are expected to exceed $200
in costs.
• Each covered family member may
receive two (2) routine cleanings per
calendar year under the preventive
benefit.
• Late entrant provisions, age limitations
and waiting periods may apply.
10City of Hollywood | Retiree Benefit Highlights | 2018
Vision Insurance
Vision Service Plan Option 1
The City offers vision insurance through Vision Service Plan (VSP) to benefit- Out-of-Network Benefits
eligible retirees. For more detailed information about the vision plans, please
Retiree and covered dependent(s) may also choose to receive services from
refer to the separate rate sheet for Vision Service Plan Option 1, Option 2 and
vision providers who do not participate in the VSP Choice Network. When going
Option 3 Plan costs for your specific retiree classification.
out of network, the provider will require payment at the time of appointment.
In-Network Benefits VSP will then reimburse based on the plan’s out-of-network reimbursement
schedule upon receipt of proof of services rendered.
The vision plan offers retiree and covered dependent(s) coverage for routine
eye care, including eye exams, eyeglasses (lenses and frames) or contact Calendar Year Deductible
lenses. To schedule an appointment, covered retiree and dependent(s) can
There is no plan year deductible.
select any network provider who participates in the VSP Choice network. At
the time of service, routine vision examinations and basic optical needs will Calendar Year Out-of-Pocket Maximum
be covered as shown on the plan’s schedule of benefits. Cosmetic services and
upgrades will be additional if chosen at the time of the appointment. There is no out-of-pocket maximum. However, there are benefit reimbursement
maximums for certain services.
VSP | Customer Service: (800) 877-7195 | www.vsp.com
11City of Hollywood | Retiree Benefit Highlights | 2018
VSP – Vision Plan Option 1 At-A-Glance
Network VSP Choice
Services In-Network Out-of-Network
Eye Exam $10 Copay Up to $45 Reimbursement
Reimbursement Based on Locate a Provider
Materials $25 Copay
Type of Service
To search for a participating provider,
Frequency of Services contact VSP's customer service or visit
www.vsp.com. When completing the
Examination 12 Months necessary search criteria, select VSP
Choice network.
Lenses 12 Months
Frames 24 Months
Contact Lenses 12 Months
Lenses
Single Up to $30 Reimbursement Plan References
Covered at 100% *Contact lenses are in lieu of spectacle
Bifocal Up to $50 Reimbursement
After $25 Materials Copay lenses and a frame
Trifocal Up to $65 Reimbursement
Frames
$100 Allowance on Any Frame or
$120 if Part of the "Collection"
Allowance Up to $70 Reimbursement
Frame Options. 20% Discount on
Any Amount Over the Allowance. Important Notes
• Member options, such as LASIK, UV
Contact Lenses* coating, progressive lenses, etc. are not
Non-Elective (Medically Necessary) Covered at 100% Up to $210 Reimbursement covered in full, but may be available at
a discount.
$100 Allowance with a $60
Elective (Fitting, Follow-up & Lenses) Maximum Copay for the Up to $105 Reimbursement
Contact Lense Exam.
12City of Hollywood | Retiree Benefit Highlights | 2018
Vision Insurance
Vision Service Plan Option 2
The City offers vision insurance through Vision Service Plan (VSP) to benefit- Out-of-Network Benefits
eligible retirees. For more detailed information about the vision plans, please
Retirees and covered dependent(s) may also choose to receive services from
refer to the separate rate sheet for Vision Service Plan Option 1, Option 2 and
vision providers who do not participate in the VSP Choice Network. When going
Option 3 Plan costs for your specific retiree classification.
out of network, the provider will require payment at the time of appointment.
In-Network Benefits VSP will then reimburse based on the plan’s out-of-network reimbursement
schedule upon receipt of proof of services rendered.
The vision plan offers retiree and covered dependent(s) coverage for routine
eye care, including eye exams, eyeglasses (lenses and frames) or contact Calendar Year Deductible
lenses. To schedule an appointment, covered retiree and dependent(s) can
There is no plan year deductible.
select any network provider who participates in the VSP Choice network. At
the time of service, routine vision examinations and basic optical needs will Calendar Year Out-of-Pocket Maximum
be covered as shown on the plan’s schedule of benefits. Cosmetic services and
upgrades will be additional if chosen at the time of the appointment. There is no out-of-pocket maximum. However, there are benefit reimbursement
maximums for certain services.
VSP | Customer Service: (800) 877-7195 | www.vsp.com
13City of Hollywood | Retiree Benefit Highlights | 2018
VSP – Vision Plan Option 2 At-A-Glance
Network VSP Choice
Services In-Network Out-of-Network
Eye Exam $10 Copay Up to $45 Reimbursement
Reimbursement Based on Locate a Provider
Materials $20 Copay
Type of Service
To search for a participating provider,
Frequency of Services contact VSP's customer service or visit
www.vsp.com. When completing the
Examination 12 Months necessary search criteria, select VSP
Choice network.
Lenses 12 Months
Frames 24 Months
Contact Lenses 12 Months
Lenses
Single Up to $30 Reimbursement Plan References
Covered at 100% *Contact lenses are in lieu of spectacle
Bifocal Up to $50 Reimbursement
After $20 Materials Copay lenses and a frame
Trifocal Up to $65 Reimbursement
Frames
$130 Allowance on Any Frame
or $150 Allowance if Part of the
Allowance "Collection" Frame Option. 20% Up to $70 Reimbursement
Discount for Any Amount Over the Important Notes
Allowance.
• Member options, such as LASIK, UV
coating, progressive lenses, etc. are not
Contact Lenses* covered in full, but may be available at
Non-Elective (Medically Necessary) Covered at 100% Up to $210 Reimbursement a discount.
$130 Allowance with a $20
Elective (Fitting, Follow-up & Lenses) Maximum Copay for the Up to $105 Reimbursement
Contact Lense Exam.
14City of Hollywood | Retiree Benefit Highlights | 2018
Vision Insurance
Vision Service Plan Option 3
The City offers vision insurance through Vision Service Plan (VSP) to benefit- Out-of-Network Benefits
eligible retirees. For more detailed information about the vision plans, please
Retiree and covered dependent(s) may also choose to receive services from
refer to the separate rate sheet for Vision Service Plan Option 1, Option 2 and
vision providers who do not participate in the VSP Choice Network. When going
Option 3 Plan costs for your specific retiree classification.
out of network, the provider will require payment at the time of appointment.
In-Network Benefits VSP will then reimburse based on the plan’s out-of-network reimbursement
schedule upon receipt of proof of services rendered.
The vision plan offers retiree and covered dependent(s) coverage for routine
eye care, including eye exams, eyeglasses (lenses and frames) or contact Calendar Year Deductible
lenses. To schedule an appointment, covered retiree and dependent(s) can
There is no plan year deductible.
select any network provider who participates in the VSP Choice network. At
the time of service, routine vision examinations and basic optical needs will Calendar Year Out-of-Pocket Maximum
be covered as shown on the plan’s schedule of benefits. Cosmetic services and
upgrades will be additional if chosen at the time of the appointment. There is no out-of-pocket maximum. However, there are benefit reimbursement
maximums for certain services.
VSP | Customer Service: (800) 877-7195 | www.vsp.com
15City of Hollywood | Retiree Benefit Highlights | 2018
VSP – Vision Plan Option 3 At-A-Glance
Network VSP Choice
Services In-Network Out-of-Network
Eye Exam $10 Copay Up to $45 Reimbursement
Reimbursement Based on Locate a Provider
Materials $10 Copay
Type of Service
To search for a participating provider,
Frequency of Services contact VSP's customer service or visit
www.vsp.com. When completing the
Examination 12 Months necessary search criteria, select VSP
Choice network.
Lenses 12 Months
Frames 24 Months
Contact Lenses 12 Months
Lenses
Single Up to $30 Reimbursement Plan References
Covered at 100% *Contact lenses are in lieu of spectacle
Bifocal Up to $50 Reimbursement
After $10 Materials Copay lenses and a frame
Trifocal Up to $65 Reimbursement
Frames
$150 Allowance on Any Frame
or $170 Allowance if Part of the
Allowance "Collection" Frame Option. 20% Up to $70 Reimbursement
Discount for Any Amount Over the Important Notes
Allowance.
• Member options, such as LASIK, UV
coating, progressive lenses, etc. are not
Contact Lenses* covered in full, but may be available at
Non-Elective (Medically Necessary) Covered at 100% Up to $210 Reimbursement a discount.
$150 Allowance with a $10
Elective (Fitting, Follow-up & Lenses) Maximum Copay for the Up to $105 Reimbursement
Contact Lense Exam.
16City of Hollywood | Retiree Benefit Highlights | 2018
Retiree Basic Life Notes
The City offers Basic Term Life Insurance to eligible retirees who elected life Use this section to make notes regarding personal benefit plans or to keep track
insurance at the time of retirement through Symetra. The retiree Basic Term of important information such as doctor’s names and addresses or prescription
Life Insurance amount is a set benefit of $5,000. Cost for coverage is $3.00 per medications.
$1,000.
Retiree Life
$5,000 X $3.00 / $1,000 = $15.00
Volume Rate Monthly Cost
Always remember to keep beneficiary forms updated. Retiree
may update beneficiary information at anytime through the
Human Resources Department or by logging onto BenTek at
www.mybentek.com/hollywood.
Symetra | Customer Service: (800) 796-3872 | www.symetra.com
17City of Hollywood | Retiree Benefit Highlights | 2018
Notes
Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctor’s names and addresses or prescription medications.
18City of Hollywood | Retiree Benefit Highlights | 2018 Notes Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctor’s names and addresses or prescription medications. 19
City of Hollywood | Retiree Benefit Highlights | 2018
Notes
Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctor’s names and addresses or prescription medications.
204200 Northcorp Parkway, Suite 185
Palm Beach Gardens, Florida 33410
Toll Free: (800) 244-3696 | Fax: (561) 626-6970
FINAL
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