Benefits Wise 2020 - 2021 Plan Year April 1, 2020 - March 31, 2021 - Florida Institute of Technology
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Benefits Wise 2020 - 2021 Plan Year April 1, 2020 - March 31, 2021
Contents Welcome To Your
Eligibility and Special Enrollment 3
Employee Benefit
Enrolling with ICUBABenefits.org 4 Program!
Have you Asked Emma? 4
We appreciate your commitment to our success. We’re equally
Quick Reference: Medical Plan Perks and
Additional Details 5-6 committed to providing you with competitive, affordable, health
and wellbeing benefits to help you take care of yourself and
ICUBA Medical Plan Option –
Preferred PPO Plan 7 your family.
ICUBA Medical Plan Option –
Premier Copay Plan (PPO) 8 Please read this guide carefully as it includes a summary of your
plan options and helpful tips for getting the most value from
ICUBA Medical Plan Option –
$4,000/$8,000 Deductible PPO Plan 9 your benefits plans. We understand that you may have questions
ICUBA Prescription Plan 10
about your annual enrollment, and we’ll do our best to help you
understand your options and guide you through
ICUBAcares Pharmacist Advocate Program 11
the process.
TELADOC 12
BlueRewards Powered by Rally 13 This guide is not your only resource. Anytime you have questions
about benefits or the enrollment process, you can contact your
SurgeryPlus 14
human resources representative or visit http://ICUBAbenefits.org.
Employee Assistance Program (EAP) 15 Although this guide contains an overview of benefits, for complete
Spending Accounts 16 information about the plans available to you, please see the
Understanding Health Care Accounts 17 summary plan description (SPD).
Dental Benefit Options 18
Vision Benefit Options 19
New Hire Open Enrollment
Income Protection Benefit Options
from Symetra 20 This is the time to enroll for coverage for you or any eligible family
Voluntary Benefits 21 members. If you do not enroll an eligible dependent now because
they have coverage through another employer, you may only
AFLAC Group Plans 21
add that person on our plan during next year’s Open Enrollment
Additional Benefits 23
Period, unless you experience a qualified family status change.
Contacts 24 Please refer to the Special Enrollment section.
Once you’re enrolled in benefits, you aren’t allowed to make
changes until the next annual Open Enrollment. Open Enrollment
is your one chance each year to review your coverage and make
changes to your benefits. It’s also your chance to enroll if you
declined coverage when you first became eligible.
2
2020 - 2021
ICUBA Benefits Guide
Eligibility Requirements
EMPLOYEE Full-time employees of your institution.
Your eligible dependents include: your legally recognized spouse or qualified domestic partner
and your legal child dependent(s) including natural child, legally adopted child, stepchild, child
DEPENDENTS required to be covered pursuant to a Qualifed Medical Child Support Order, child with proof of
legal guardianship who resides with you, or a foster child. Dependent children may remain on
the ICUBA plan until the end of the calendar year in which age 26 is attained.
WAITING PERIOD 1st of the month following or coinciding with the date of hire.
Special Enrollment
The Health Insurance Portability and Accountability Act 1996 (HIPAA), allows a Special Enrollment
period in addition to the regular Open Enrollment period. Only the following individuals may make
changes outside the Open Enrollment period:
Individuals who previously waived coverage under this program because they had other
coverage and then involuntarily lost the other coverage.
New dependents due to marriage, birth, adoption or placement for adoption. The eligible
employee and other dependents who previously did not elect to be covered under the
employer’s healthcare plan may also enroll at the time the new dependent is enrolled.
Enrollment must occur within 30 days of date of marriage, or 30 days of a birth, adoption or
placement for adoption;
Gain of other coverage + Enrollment time frame is 30 days.
Enrollment must occur within 30 days of the loss of other coverage.
A court has ordered coverage be provided for a spouse or minor child under this plan and
request for enrollment is made within 30 days after issuance of such court order;
If employee and/or dependent(s) become ineligible for Medicaid or the Children’s Health
Insurance Program and request coverage under our plan within 30 days of termination.
For further information on eligible qualifying events, please refer to the Plan Document
or contact your Human Resources Department.
3
Enrolling with ICUBABenefits.org
How to Enroll
Your enrollment can be completed online at http://ICUBAbenefits.org. Be sure to review your benefits, confirm
and submit.
1 5
Understand your choices Enroll in your benefit selections. When you are in an active
enrollment period, click the Start Your Enrollment button located
This Guide contains very useful reference material to help you on your home page.
prepare for your enrollment. Keep it handy so you can refer to it
throughout the year. First you will be asked to confirm your personal information.
Next, you have the option to enroll or waive coverage for the
2 various benefits offered to you.
Review your options with your family
Please make your way through each benefit category shown
Make sure you include any other individuals who will be affected below until the plan image shows green and says completed! You
by your elections in the decision-making process. may “View Plan Options” to find out more about each plan and
your other available options (if applicable). Once completed,
3 select the orange continue button on the right panel to review
Go to http://ICUBAbenefits.org. From the log on screen, enter your selections and complete your enrollment.
your username & password. If this is your first time logging on
we’ve set your default login information as follows: 6
Review all your benefit selections. Complete your benefit
USERNAME: Your user name is the First Initial of your enrollment by checking the “I agree and I’m finished with my
First Name + Last Name + Last Four Digits of SSN (e.g. enrollment” box and click the submit button.
JSmith6789)
Finally, be sure to Save your new benefit elections.
PASSWORD: Your Date of Birth (mmddyyyy). You’ll be directed to your final confirmation statement. You have
Please note: You will be asked to change your password after the option of emailing, printing or viewing a confirmation of your
your initial login. elections. This will submit your elections to Human Resources
for approval.
If you do not remember your password, select Forgot Password
and answer your security questions. After three failed login
attempts, your account will be locked and you will need to
contact Human Resources or bswift at 866-524-5063.
4 Have you Asked
Emma?
Upon logging in, you will be able to access your benefits
information, work through enrollments and access our Single
Sign-On section under My Carrier Accounts. From the top task
bar or side panel you can:
Verify your personal information. If you need to make any If you’re thinking, which plan is best for me — Ask
updates or changes, you may do so by contacting the Human
Emma! If you have questions while you are enrolling
Resources office.
Update contact information. Please make sure your phone for benefits, we encourage you to use our Ask Emma
number and email address are up to date. This is how we can decision support tool.
contact you about exciting benefits updates and wellbeing
communication opportunities.
If applicable, confirm dependent eligibility based on the plan Emma can help you make smart, cost-effective
document rules. benefits decisions to fit your individual needs by
Access ICUBA’s insurance carrier sites through our Single Sign-
estimating your annual costs, using real-life scenarios
On section. Approximately 48 hours after you’ve successfully
elected your ICUBA benefits, you will gain access to the from your personal experiences. She will ask you a few
insurance carrier portals. Upon your first connection attempt questions for a personalized “walk through” to guide
you’ll register with the carriers, however, each subsequent visit
you in the right direction.
will make the connection automatically without needing to
4 remember a ton of different usernames and passwords.
2020 - 2021
ICUBA Benefits Guide
Quick Reference: Medical Plan Perks
and Additional Details
SurgeryPlus
This is a surgical concierge benefit which focuses on medically necessary, non-emergent surgical cases including but not
limited to knee, hip, shoulder, foot & ankle, spine, wrist & elbow, general surgery, GI, GYN, bariatric, cardiac and ENT.
We know the surgery process can be very overwhelming and stressful. With the help of SurgeryPlus, your dedicated Care
Advocate will manage the entire procedure including helping you select the right surgeon, coordinating travel, scheduling
appointments and managing medical expenses. SurgeryPlus takes care of it all with a distinct group of High Quality
Surgeons of Excellence.
Procedures coordinated through SurgeryPlus will benefit from lower cost because the deductible and coinsurance
will be waived, eliminating all out-of-pocket costs including consultation and surgical procedure. To learn more about
SurgeryPlus, please call 855-200-2119 or register online at https://ICUBA.SurgeryPlus.com, access code: surgery plus.
(Remember, this benefit is effective 04/01/2019!)
Deductibles Only Apply to Major Services!
Please familiarize yourself with what our plan covers. Many services are free and not subject to the deductible. ICUBA
Medical Plan Deductibles only apply to Major Services!
No Member Cost Share for: Annual Wellness Visits, ALL Immunizations, Allergy Injections, Venipuncture/Conveyance
fees, Quest Diagnostic Labs, Primary Care Visits to a Blue Distinction Total Care Provider, Electrocardiograms,
Echocardiograms, Bone Mineral Density Tests, Colonoscopies, Sigmoidoscopies, Mammograms and Ultrasounds of the
Breast.
Deductible DOES NOT Apply to: Physician, Specialist & Therapy visits; Convenient Care & Urgent Care; Emergency Room
& Emergency Transportation, Prescription Drugs, and Advanced Imaging (precertification required for advanced
imaging).
Health Management and Care Consultants
We are calling because we care! Health management and care consultant services are available to ICUBA medical plan
members at no additional cost. These trained health advisors and registered nurses provide tools, education and
advocacy to help you manage chronic health conditions. They can assist with goal setting, help you better understand
your doctor’s treatment plan and support you with referrals, transition of care and assistance addressing gaps in care.
ICUBA Members with specific health challenges may receive a call from one of our Care Consultants from BCBS, Optum,
ICUBAcares or Aetna. We highly recommend you take advantage of this valuable service if a health advisor calls you!
Working together with an advisor to manage your health will help you live life to the fullest.
In-Network Outpatient Hospital Labs
In-Network Outpatient Hospital Labs are not subject to deductible. These laboratory tests (which are recommended
through Quest Diagnostics) can be performed during an evaluation and management visit to an in-network outpatient
hospital/office in places like Moffitt Cancer Center or the Mayo Clinic. Employees will only be responsible for the
coinsurance.
Advanced Imaging
Advanced imaging (such as an MRI or CT scan) is not subject to the deductible. ICUBA Members are only responsible for
the allowable charges up to $500. If your imaging is less than $500, you are only responsible for the cost of the image.
Please note: Prior Authorization is still required for all advanced imaging services.
Engaged Rally ICUBA Private Sweepstakes Winners
ICUBA is giving away $50 Amazon Gift Cards every 14 days for participation in City Walks. When you complete a cross
city challenge milestone, not only will you earn coins as you sync your tracking device, but you will be entered EVERY.
SINGLE. TIME. a milestone is reached! There is no limit on entries or winners – and we did have a DOUBLE winner in 2018 -
2019! Keep moving! In addition to the Amazon winners within Rally, ICUBA also draws winners monthly for participation
in all the challenges, missions and survey completions through your engagement in Rally. Learn more about the
BlueRewards powered by Rally program on page 13.
5
Quick Reference: Medical Plan Perks
and Additional Details (continued)
Teladoc rave reviews for $5!
Talk to a Doctor anytime! Teladoc gives you 24/7/365 access to a U.S.-based board-certified doctor through the
convenience of a phone or video chat consultations. It’s an affordable alternative to costly urgent care and ER visits when
you need care now. You can find additional information about Teladoc on page 12.
Blue Distinction Total Care (BDTC)
Doctors with the Blue Distinction Total Care (BDTC) recognition are dedicated to improving the quality of care for their
patients. By selecting one of the BDTC providers, your cost is $0 for all medically necessary services with a family practice,
internal medicine, and/or pediatric physician. These physicians specialize in care for people with chronic conditions, like
diabetes, asthma, COPD and heart problems, to ensure each person receives preventive screenings and follow-up care.
BDTC designation does not necessarily mean they provide a higher standard of care than other doctors. It means these
doctors take part in a quality improvement program recognized by BCBS of Florida.
Use the online Doctor and Hospital finder to locate these preferred physicians by filtering for BDTC designations. Simply
log in to your member account through the single sign-on section at ICUBAbenefits.org. (If applicable: Dependents can
visit the BCBS website directly at www.MyHealthToolKitFL.com.)
BlueCross BlueShield of Florida Member Website
ICUBA health insurance members can access the BlueCross BlueShield of Florida member website through the single
sign-on section in the center of your http://ICUBAbenefits.org home page. By using this website, you can view your claim
information, access your Rally wellbeing tools, look up doctors in your network and so much more. Spouses will need to
visit the BCBS site directly by visiting at http://MyHealthToolkitFL.com and enter his/her own name, DOB and ID number
to create an account.
Download the BCBS of Florida Mobile App
Now you can enjoy the making-your-life-easier utility of the MyHealthToolkit in an app! With the app you can use your
digital medical ID card from your phone and smart wallet feature, check the status of your claims, view benefits and what’s
covered by your medical plan and find local providers quickly! Available for Apple and Android devices.
Free Generic Statin Prescription Drugs
If you meet certain criteria as outlined by the Affordable Care Act (ACA), you may be eligible for Free Generic Statin
prescription drugs. Talk to your doctor or call the ICUBAcares Pharmacist Advocate Program to find out more!
ICUBAcares Pharmacist Advocate Program
Now you can speak with a pharmacist directly and have your personal questions answered over the telephone. Our
pharmacists are ready to answer medication management questions, assist with prior authorization, or troubleshoot your
personal side effects. They’ll even coordinate with your doctor and the insurance company to advocate on your behalf!
Learn more on page 11.
Aetna Behavioral Health and Substance Abuse
Behavioral health and substance abuse benefits through Aetna supplement the Medical benefits provided by BCBS. A few
examples of Behavioral Health services include psychologists, therapists, psychiatrists, substance abuse treatments and
much more! Inpatient and outpatient services are available through this valuable benefit.
6
2020 - 2021
ICUBA Benefits Guide
ICUBA Medical Plan Option –
Preferred PPO Plan
Preferred PPO
In-Network Out-of-Network
EMPLOYEE PAYS
Deductible (Individual/Family) $2,500/$5,000 $4,000/$10,750
Coinsurance 20% 40%
Out-of-Pocket Maximum
(Individual/Family)
$4,000/$8,000 $7,500/$15,000
Includes all medical copays,
deductibles & coinsurance
Physician Office Visits 20% 40% after deductible
Blue Distinction Total Care
(Family Practice, Internal Medicine, $0 Not Applicable
Pediatrics)
Specialist Office Visits 20% 40% after deductible
Convenient Care Clinics $10 Copay N/A
Independent Clinical Labs*
0%* 40% after deductible
(free standing facilities & office visits)
Preventive Care 0% Not covered
Teladoc Visit $5 Copay Not covered
Urgent Care Center $30 Copay
Emergency Room Services 0% after $300 Copay (waived if admitted)
Ambulance $250 Copay
Hospital Inpatient 20% after deductible 40% after deductible
*Quest Diagnostic Labs is the In-Network Lab for BlueCross BlueShield of Florida.
Monthly Employee Premium Amount
Employer HRA Contribution Employer Cost Employee Premium
Employee $120.00 $558.21 $101.79
Employee & Spouse $240.00 $1053.77 $351.23
Employee & Child(ren) $260.00 $891.85 $297.16
Family $260.00 $1388.27 $462.73
7
ICUBA Medical Plan Option –
Premier Copay Plan (PPO)
Premier Copay Plan
In-Network Out-of-Network
EMPLOYEE PAYS
Deductible (Individual/Family) $2,500/$5,000 $4,000/$10,750
Coinsurance 20% 40%
Out-of-Pocket Maximum
(Individual/Family)
$4,000/$8,000 $7,500/$15,000
Includes all medical copays,
deductibles & coinsurance
Physician Office Visits $25 Copay 40% after deductible
Blue Distinction Total Care
(Family Practice, Internal Medicine, $0 Not Applicable
Pediatrics)
Specialist Office Visits $50 Copay 40% after deductible
Convenient Care Clinics $10 Copay N/A
Independent Clinical Labs*
0%* 40% after deductible
(free standing facilities & office visits)
Preventive Care 0% Not covered
Teladoc Visit $5 Copay Not covered
Urgent Care Center $50 Copay
Emergency Room Services 0% after $300 Copay (waived if admitted)
Ambulance $250 Copay
Hospital Inpatient 20% after deductible 40% after deductible
*Quest Diagnostic Labs is the In-Network Lab for BlueCross BlueShield of Florida.
Monthly Employee Premium Amount
Employer HRA Contribution Employer Cost Employee Premium
Employee $120.00 $505.04 $207.96
Employee & Spouse $240.00 $1074.82 $442.18
Employee & Child(ren) $260.00 $910.49 $374.51
Family $260.00 $1416.23 $582.77
8
2020 - 2021
ICUBA Benefits Guide
ICUBA Medical Plan Option –
$4,000/$8,000 Deductible PPO Plan
$4,000/$8,000 Deductible Plan
In-Network Out-of-Network
EMPLOYEE PAYS
Deductible (Individual/Family) $4,000/$8,000 $8,000/$16,000
Coinsurance 30% 50%
Out-of-Pocket Maximum
(Individual/Family)
$5,350/$10,700 $10,700/$21,400
Includes all medical copays,
deductibles & coinsurance
Physician Office Visits $35 Copay 50% after deductible
Blue Distinction Total Care
(Family Practice, Internal Medicine, $0 Not Applicable
Pediatrics)
Specialist Office Visits $70 Copay 50% after deductible
Convenient Care Clinics $10 Copay N/A
Independent Clinical Labs*
0%* 50% after deductible
(free standing facilities & office visits)
Preventive Care 0% Not covered
Teladoc Visit $5 Copay Not covered
Urgent Care Center $70 Copay
Emergency Room Services 0% after $500 Copay (waived if admitted)
Ambulance $250 Copay
Hospital Inpatient 30% after deductible 50% after deductible
*Quest Diagnostic Labs is the In-Network Lab for BlueCross BlueShield of Florida.
Monthly Employee Premium Amount
Employer HRA Contribution Employer Cost Employee Premium
Employee $120.00 $553.21 $101.79
Employee & Spouse $240.00 $1048.57 $349.43
Employee & Child(ren) $260.00 $724.50 $241.50
Family $260.00 $1213.50 $404.50
9
ICUBA Prescription Plan
Included in Medical Plan Election
Copayments Prescription-FIll Methods*
90-day at Retail
Retail: Up to a Program Mail: Up to a
Tier
30-day supply Up to a 90-day 90-day supply
supply
Preferred generics at other network pharmacies $5 $10 $10
Non-Preferred generics $10 $20 $20
Preferred brands: brand-name medications on the
$40 $80 $80
Preferred Medication List (PML)
Non-Preferred brands: brand-name medications not on
$75* $150 $150
the Preferred Medication List
Preferred specialty at Briova Specialty Pharmacy $75 N/A N/A
Non-Preferred specialty at Briova Specialty Pharmacy $75 N/A N/A
*Preferred Specialty medications are eligible for copay card usage.
Pharmacy Out-of-Pocket Maximum
In-Network Rx copays will be applied toward an individual maximum out-of-pocket of $2,000/single and $4,000/
family. Once you reach your out-of-pocket maximum, your prescriptions will be paid for at 100% by the plan and no
cost to you ($0 copay).
If you have a question about your pharmacy benefit, call the OptumRx Customer Care Center, 24 hours a day, 7 days
a week. The toll-free number is 855-811-2213 and can be found on the back of your Optum ID card.
Tobacco Cessation Benefit
Tobacco cessation medications are covered—up to two cycles each year— $0 copay when you participate in coaching or
counseling options though local Area Health Education Centers, BCBS telephonic coaching or Resources for Living
counseling.
Free Over the Counter Items and Diabetic Supplies
With a prescription from your provider you can receive FREE prescribed diabetic supplies including meters, lancing
devices, lancets, test strips, control solution, needles, and syringes; prescribed aspirin for adults; prescribed generic
folic acid and generic prenatal vitamins for pregnancy. Simply take the prescription to the pharmacy counter and
your local pharmacist can assist you.
Getting Stuck?
Please be aware there are some prescriptions that require Prior Authorizations, have Quantity Limits or require
a Step Therapy Program. If you should have any issues with one of these programs, please contact ICUBAcares
Pharmacist Advocate Program at 1-877-286-3967 for assistance.
Definitions for your Reference
PA - Prior Authorization – Your doctor is required to provide additional information to determine coverage
QL - Quantity Limit – Medication may be limited to a certain quantity
SP - Specialty Medication – Medication is designated as specialty.
ST - Step Therapy – Trial of lower-cost
102020 - 2021
ICUBA Benefits Guide
ICUBAcares Pharmacist
Advocate Program
3 Real Pharmacists
3 Real Advocates
3 Real Solutions
The ICUBAcares team can review your prescriptions and answer questions. Call for a free
prescription check-up at 877-286-3967, Monday to Friday 9 a.m. – 5 p.m.!
Our ICUBAcares Pharmacist Team is ready to:
Serve as a liaison between your doctor, the pharmacy and the insurance company — taking the
burden off of you!
Answer questions on a medication you are taking or considering — providing useful information
on side effects and drug interactions.
Discuss preferred and non-preferred tier options to save you money.
Provide assistance for a prior authorization from your provider.
Our ICUBAcares Pharmacist Advocates will make outbound phone calls to members identified
for specific services and assistance. Our members can also call our Pharmacist Advocates
directly and speak to a real pharmacist if a questions arises.
ICUBAcares Rally Incentive: If you are a candidate for a qualified medication change, the
ICUBAcares team will assist with your transition to a medication less costly to the plan and
reward once complete. Call for a prescription check-up to find out more!
11TELADOC
Teladoc gives you 24/7/365 access to US board-certified doctors through the
convenience of phone or video consults. It’s an affordable alternative to costly
urgent care and ER visits when you need care now! With your consent,
Teladoc can provide information about your Teladoc consult to your primary
care physician. The Teladoc benefit is included with your election in an
ICUBA Medical Plan.
Talk to a doctor anytime for aWHEN
$5 copay!
CAN I USE TELADOC?
So many reasons When can I use• Teladoc?
• If your doctor is unavailable
When you need care now
to use Teladoc®! • If you’re considering the ER or
urgent care center for a non-
Teladoc does not replace your primary care
emergency issue
physician. It is a convenientonand
• On vacation, affordable
a business trip,
Teladoc gives you 24/7/365 access to a doctor or away from home
option for quality• For
care.short-term prescription
through the convenience of phone or video consults. refills
It's an affordable option for quality medical care.
When you need care now
If you’re considering the ER or urgent care for a non-
emergency issue GET THE CARE YOU NEED
On vacation, on a business trip, or away from home
Teladoc doctors can treat many
For short-term prescription refills
medical conditions, including:
• Cold & flu symptoms
Get the care you need
• Allergies
• Bronchitis
Talk to a doctor Receive quality Prompt treatment, • Skin problems
anytime, anywhere care via phone or Teladoc doctors •can
average call back in
treat infection
Respiratory many medical
• Sinus problems
you happen to be online video conditions, including:
16 min
• And more!
Cold & Flu symptoms
Allergies
Bronchitis SHARE WITH YOUR PCP
Urinary tract infection
With your consent, Teladoc is
Respiratory Infection
happy to provide information
A network of doctors Secure, personal and No limit on Problems about your Teladoc consult to
Sinus
that can treat children portable electronic consults, so your primary care physician.
of any age health record (EHR) And more!
take your time
Doctor Requirements
Talk to a doctor anytime forTeladoc
$45 isor less!
simply a new way to access qualified
doctors. All Teladoc doctors:
Teladoc.com Are practicing PCPs,
1-800-Teladoc pediatricians, and family medicine
(835-2362)
physicians
Facebook.com/Teladoc Teladoc.com/mobile
Average 15 years experience
Are US board certified and licensed in your state
Are credentialed every three years, meeting NCQA
standards
© 2015 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are trademarks of Teladoc, Inc. and may not be used without written permission.
Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available
in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc
Members must establish an account at www.teladoc.com prior to seeking treatment. 10E-103A
For
1014 first
physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, 7 days a week while video consultations are available during the
hours of 7am to 9pm, 7 days a week.
time registration with Teladoc there is a single sign-on feature through BCBS MyHealthToolkit or
dependents may visit www.teladoc.com directly. If you need further assistance, call 800-Teladoc,
12 and a customer representative can walk you through the account setup.2020 - 2021
ICUBA Benefits Guide
BlueRewards Powered
by Rally
Employee health and wellbeing is one of your institutions top priorities. We look at our programs
and incentives every year, making sure we are providing best-in-class tools and resources to assist
you and your family in achieving an optimal level of health. We want you to be the best you —
personally and professionally.
What is BlueRewards powered by Rally?
Rally is our digital health engagement experience that will help you stay engaged in improving
your health and wellbeing while incentivizing you for healthy activities along the way!
Who is Eligible?
Each employee and spouse enrolled in the ICUBA medical plan is eligible to participate in this
wellbeing incentive plan.
How do I access the Rally Wellness program Portal?
Visit http://ICUBAbenefits.org and utilize the single sign-on feature for BCBS MyHealthToolkit.
Activity Incentives
Rally Survey Gatekeeper required for Incentives 400 Coins &
ICUBA Private Sweepstakes
Biometric Screenings (ask about the Physician Results Form!) $40
Wellness Exams $60
Onsite/Campus Events $10 each (up to $70)
Qualified Preventive Screening (Colonoscopy, Mammogram, PSA) $50
Qualified Medication change with ICUBAcares $50
City Challenges Unlimited Coins & ICUBA Private Sweepstakes every
14 days!
Missions Unlimited Coins & ICUBA Sweepstakes
Teladoc Registration 400 Rally Coins
Tobacco Attestation 400 Rally Coins
Clinical Rewards for Chronic Conditions 500 Rally Coins per quarter = 2,000 Coins per year
Incentive Total $270
As you work toward your goals, you will earn Rally coins and ICUBA dollars that can be redeemed
through the Rally Marketplace. Coins can be used for a variety of discounts and ICUBA dollars can
be used for electronic gift cards.
Interested in Biometrics at your Primary Care Visit?
New for this plan year, you can get your biometric screenings with your regular blood work
through your annual wellness exam with a PCP. It’s easy! Covered employees and spouses can log
into your portal at My.QuestForHealth.com and download the Physician Results Form. Simply
download the form which contains a bar code unique to the employee or spouse and will include
Remember
specific valid date ranges for completion. Take the form with you to your doctor’s office when
you are reviewing the results of your blood work and have your doctor sign the Quest Physician to download
Results Form. Then, upload your completed form to the same Quest portal. *Pro Tip: If you have the Rally
an established relationship with your physician, ask if you can get your blood work ahead of your Health app!
annual wellness exam to save time and check this off your list with one visit.
13SurgeryPlus
PROVIDED TO YOU AS A MEMBER OF AN
ICUBA MEDICAL PLAN
SurgeryPlus is a comprehensive benefit at NO ADDITONAL COST included with medical that
SurgeryPlus surgeons
provides access to a premiere narrow network of high-performing is a comprehensive benefit at NO A
for non-emergent,
planned surgical procedures. provides access to a premier network of high-pe
non-emergent/planned surgical procedures.
No Enrollment Necessary!
If you are covered under ICUBA’s medical plan, youSurgeryPlus has identified
have been automatically the nation’s
enrolled in this extra
highest quality surgeons for the best possible
benefit at no additional cost. If you are planning a procedure, call SurgeryPlus at 1-855-200-2119
and you could save thousands of dollars. care in an elite network, setting them apart from
other under-performing surgeons.
Save Money!
If you choose to use the SurgeryPlus benefit, ICUBA will waive your deductible and coinsurance,
eliminating all out-of-pocket costs, including consultation, your surgical procedure and post-
procedure appointments for up to 90 days. Please keep in mind, pre-operative labs and testing will
be done at your PCP or Quest and will be submitted to your current medical plan through BCBS.
Additionally, follow-up care such as physical therapy, durable medical equipment and lab work will
still be covered by the BCBS medical plan and necessary prescription drugs will be covered under
OptumRx.
The Same Dedicated Care Advocate
Manages the Entire Pathway of Care For You
SurgeryPlus will recommend at least
Surgeon Selection: three of the best fitting surgeons for
You Canyour
Save Money
individualized needs
SurgeryPlus will waive your deductible and coinsurance, eliminating all
out-of-pocket costs, including consultation, your surgical procedure and
SurgeryPlus
post-procedure will book appointments,
appointments for up to 90 days.
Scheduling: transfer medical records and manage
logistics
You Do Not Need to Enroll in SurgeryPlus
Advocacy: If you are covered under
SurgeryPlus ICUBA’s
will listen andmedical plan, you have been
anticipate
automatically enrolled
your in this
surgery extraneeds
related benefit at no additional cost. If you
are planning a procedure, call SurgeryPlus as you could save
thousands of dollars.
Follow-up: SurgeryPlus will work to ensure your
complete satisfaction
To learn more about
SurgeryPlus, contac t 855.200.2119
To learn more about SurgeryPlus,
call 855-200-2119
Employer Direct Healthcare | 2100 Ross Avenue, Suite 550, Dallas, TX 75201 | Pho
142020 - 2021
ICUBA Benefits Guide
Employee Assistance Program (EAP)
Aetna’s Resources for Living EAP services are available to you, all members of
your household and your adult children up to the age of 26, regardless of your
medical insurance coverage. Services are confidential and are available 24
hours a day, 7 days a week. This resource includes six free counseling sessions
per issue per plan year.
To access services: 877-398-5816
www.resourcesforliving.com
Username: ICUBA
Password: 8773985816
Plan Year: April 1 through March 31
Emotional wellbeing support Daily life assistance
Support is available 24 hours a day for in-the- Competing day-to-day needs can make it tough
moment emotional wellbeing. You can also access to know where to start. Call RFL for personalized
up to 6 counseling sessions per issue each year. guidance. RFL will help you find resources for:
Visit with a counselor face to face, online Child care, parenting and adoption
with televideo or get in-the-moment support Summer programs for kids
by phone. Services are free and confidential. School and financial aid research
Resources For Living (RFL) is here to help with a Care for older adults
wide range of issues including: Caregiver support
Special needs
Relationship support
Pet care
Stress management
Home repair and improvement
Work/life balance
Household services and more
Family issues
Grief and loss RFL also offer carekits related to growing
Depression families, child care, caregiving and more.
Anxiety
Substance misuse and more
Self-esteem and personal development
Legal services Financial services
You can get a free 30-minute consultation with Simply call RFL for a free 30-minute consultation
a participating attorney for each new legal topic for each new financial topic related to:
related to:
Budgeting
General Retirement or other financial planning
Family Mortgages and refinancing
Criminal law Credit and debt issues
Elder law and estate planning College funding
Divorce Tax and IRS questions and preparation
Wills and other document preparation
Real estate transactions
Mediation services
Talkspace
Talkspace in an online therapy platform that makes mental health care more convenient
and accessible by connecting users with a network of 2,500+ licensed therapists. With
Talkspace, you can send unlimited multimedia messages to a therapist via web browser
or the Talkspace mobile app — anywhere, anytime. Talkspace is currently provided
to adults who are 18 or older. Register your account at www.talkspace.com/RFL then
download the app from your device’s app store. Enter your employer’s name when
prompted for Organization name. 15Spending Accounts
New Flexible Spending election required each year!
MORE of an FYI...
MANDATORY ELECTIONS EACH YEAR YOUR HRA IS PAIRED WITH YOUR
ICUBA MEDICAL PLAN
HCFSA DCFSA HRA
Health Care Dependent Care Health Reimbursement Account
Flexible Spending Account Flexible Spending Account Contributions funded by your employer
Funded by benefit eligible employees Funded by your employer and
(Please note: A medical insurance election is not required to enroll provided when you enroll in an ICUBA
in flex spending) Medical Plan
Deducted pre-tax throughout the year Deducted pre-tax throughout the year No deductions-EMPLOYER MONEY!!
Available for immediate use Available at the end of each month and
Deposited each pay period
04/01/2020 earns interest quarterly
Can be used for eligible healthcare
Can be used for healthcare expenses Can be used for the care of
expenses for participants enrolled in
for you & eligible dependents dependents under the age of 13
an ICUBA medical Plan
If enrolled in an ICUBA medical plan: Covered expenses include: Day Care, If you elect an HCFSA the Flex funds
HCFSA funds are used before HRA After Care, Gap Camps are used BEFORE the HRA funds
NEW! IRS annual individual limit: IRS calendar year household limit: Funds Rollover Every Year;
$2,750 $5,000 after 36 continuous months of
enrollment in an ICUBA medical plan
Use-it-or-lose-it, no annual carry over with IRA, you are considered vested
Please plan wisely! and the funds are yours to keep.
162020 - 2021
ICUBA Benefits Guide
Understanding Health Care Accounts
Health Care Reimbursement Account Health Care Flexible Spending
(HRA) Account (FSA)
Funded by employee pre-tax dollars.
The maximum amount you can
contribute to the Health Care
Spending Account is $2,750.
The maximum amount you can
Funding Contribution Funded by your employer.
contribute to the Dependent Care
Spending Account is $5,000
Flexible spending amounts are
subject to discrimination testing.
Highly compensated employees
may be asked to adjust flexible
spending dollars based on results.
Employee contributions are exempt
Tax Benefits for Employees from federal and FICA tax as
Reimbursements are tax-free.
well as most state and local tax.
Reimbursements are tax-free.
Have to spend funds by 6/15 and
Roll Over of Funds Funds roll over at the end of each
claim by 6/30 of the following plan
plan year indefinitely.
year (Use-it-or-lose-it).
Must be enrolled in ICUBA medical Enrollment in medical plan not
Medical Plan Enrollment plan to be eligible. required.
All qualified dependents are eligible,
Only if covered on medical plan.
Dependent Eligibility even if not enrolled in medical plan.
Annual election amount available
the 1st business day of the plan
year for Health Care Flex Spending
Can withdraw up to what has been Account; the amount available
Availability of Funds deposited. for the Dependent Care Spending
Account is the balance of the account
as it accumulates through payroll
deduction throughout the year.
Can continue after 36 months of
Available for remainder of plan year
Portability continuous participation in an ICUBA
through COBRA.
medical plan.
Remember: Each time you use your Health Reimbursement Account (HRA) or Flexible Spending
Account (FSA) debit card, you should keep your receipts. Each request for reimbursement must
be substantiated before it can be reimbursed.
17Dental Benefit Options
Benefits Summary
High Option PPO Preventive Plus DHMO Prepaid 250CS
Plan Year Maximum $2,000 $1,000 Unlimited
In- & Out-of-Network In- & Out-of-Network Network Providers/
Providers
Providers Providers Assignment Providers
Deductible $50 Individual/ $150 Family $50 Individual/ $150 Family Not Applicable
In-Network Out-of- Plan Pays Patient Pays Assigned
Network In- & Out-of-Network Network Provider
Benefit/Service EMPLOYEE PAYS
Preventive Services 0% 20% 0% You pay a pre-set copay
20% after 50% after
Basic Services 20% after deductible You pay a pre-set copay
deductible deductible
50% after 70% after Discount available for
Major Services You pay a pre-set copay
deductible deductible In-Network only*
Orthodontia (Adult and/or Discount available for
50% You pay a pre-set copay
Child) In-Network only*
Orthodontia Lifetime No Maximum, Member
$2,000 Not Covered
Maximum for each member pays pre-set copay
*Discount is subject to provider discretion and does not count toward the deductible or maximum out-of-pocket.
Monthly Employee Premium Amount
Higher Option PPO Preventive Plus DHMO 250CS
Employee Only $40.81 $19.67 $11.83
Employee + 1 $81.29 $45.72 $23.73
Employee & Family $136.71 $75.69 $36.85
182020 - 2021
ICUBA Benefits Guide
Vision Benefit Options
ICUBA offers two voluntary vision plans through EyeMed. The Base Vision Plan allows you and
your covered family members one routine exam every 12 months, plus lenses once every 12
months, and new frames every 24 months. The second option is the Buy-up Vision option that
works the same as the basic plan but allows for new frames every 12 months and has an increased
frame allowance of $130.
To view the entire provider network, please visit the EyeMed website at www.eyemed.com or
contact the Vison Service Center at 866-800-5457. Please review the complete summary of
benefits for full coverage details.
Base Plan
In-Network Out-of-Network Reimbursement
Exam
$5 copay up to $35
(Once every 12 months)
$0 copay;
Frames $100 allowance; 20% off balance over $100; up to $50
(Once every 24 mos.)
Single Vision Lenses
$15 copay up to $20
(Once every 12 months)
Contacts $0 copay;
up to $80
(Once every 12 months) $100 allowance; plus balance over $100
Monthly Employee Premium
Base Plan
Employee $3.91
Employee & Family $10.02
Download the EyeMed Members App
EyeMed gives you access to your benefit information on-the-
go. Check your benefit details for eye exams, eyeglass frames,
contacts, and lenses directly from your phone.
19Income Protection Benefit
Options from Symetra
Short-Term Disability Employee Voluntary
All benefit eligible employees are provided
Supplemental Life Insurance
Short-Term Disability coverage at no cost. and AD&D Plan
You will receive 66 2/3% of weekly earnings, to
You may purchase this coverage in $10,000
a maximum benefit of $2,000 per week. The
benefit units up to 5 times your annual salary
elimination period of this coverage is 14 calendar
not to exceed $500,000. Evidence of Insurability
days for disability due to an injury or sickness.
is required for amounts above $150,000 and
Short-Term Disability is provided for 11 weeks
must be approved by Symetra. All amounts are
before an employee converts to Long-Term
rounded to the next higher multiple of $10,000,
Disability.
if not already an exact multiple thereof. Age
reductions may apply.
Long-Term Disability
All benefit-eligible employees are provided Dependent Voluntary
salary continuance insurance. There are two Life Insurance
options to choose from:
In order to purchase life insurance for your
Option A: Base Level-This plan provides spouse and/or child, you must purchase
a benefit of 60% of weekly earnings, to Supplemental Life coverage for yourself. The
a maximum of $2,000 per month, and is spouse value can be purchased up to 50% of
provided by Florida Institute of Technology at employee amount in increments of $5,000, not
no cost to all benefit-eligible employees. to exceed $250,000. Evidence of Insurability is
Option B: Buy-Up Level - This plan provides a required for amounts above $50,000 and
benefit of 67% of weekly earnings, to requires approval by Symetra. Child life
a maximum of $14,000 per month. You and insurance can be purchased in increments of
Florida Institute of Technology share the cost $2,000 up to $10,000 if less than 50% of the
of this coverage. Benefit cost is based on your employee coverage amount. Age reductions
age and salary level. may apply.
Life Insurance and
AD&D Plan
Florida Institute of Technology provides group
life insurance at no cost to all active full-time,
benefit eligible employees. Employees receive
one times their annual earnings. All amounts are
rounded to the next higher multiple of $1,000,
if not already an exact multiple thereof. Age
reductions may apply.
This summary provides only a brief description of the coverage insured by Symetra Life Insurance Company. For a complete description,
20 including all definitions, exclusions, limitations, and reductions in coverage, as well as information on termination of benefits, please refer to
the Group Insurance Certificate you will receive when you become insured.2020 - 2021
ICUBA Benefits Guide
Voluntary Benefits
The ICUBA BlueCross BlueShield medical plans provide great coverage for you and your family’s
general health care needs. Still, everyone’s needs are slightly different. That’s where the Aflac
voluntary Accident, Critical Illness and Hospital Indemnity options come in! These benefits are
designed to protect your family’s finances in case of an unforeseen injury or illness.
AFLAC Group Plans
Accident Insurance
The Voluntary Accident Plan is designed to help cover the expenses associated with an accidental
injury such as a medical plan deductible. Accident pays direct cash benefits for emergency
treatment, hospitalizations, specific injury treatments, diagnostic exams and accidental death.
Benefit Highlights:
ACCIDENT BENEFITS
Plan Features
Emergency Room $175
Accident follow-up with $50 per treatment, 6 per
physician accident
X-ray $50
Dislocation and fractures Up to $6,000
Hospital Admission $1,000
Ground ambulance / Air $400 / $1,200
Concussion $500
Physical Therapy $50 per treatment, 10 per
accident
Wellness Benefit $50
21Critical Illness Insurance Hospital Indemnity Insurance
The Voluntary Critical Illness coverage is An unexpected or even planned stay in the
designed to pay cash in the event you or a hospital can be expensive as you meet your
covered family member is diagnosed with a deductible and out-of-pocket obligations under
critical illness such as cancer, heart attack, the medical plan. The Hospital Indemnity plan
stroke, kidney failure, benign brain tumor, loss is designed to provide financial protection by
of hearing or sight do to a severe medical paying you a direct benefit to meet out-of-
condition or Alzheimer’s. Critical illness helps pocket expenses and extra bills that can occur.
protect your income and personal assets when Lump sum benefits are paid directly to you
out of pocket expenses increase as a result of a based on the type of facility and number of days
specified critical illness. of confinement.
Benefit Highlights: Benefit Highlights:
$10,000 benefit for employees on a guarantee Guarantee issue (no medical questions)
issue basis (no health questions) No pre-existing condition limitation
No pre-existing condition limitation Portability is included
* Children are automatically covered at 50%
HOSPITAL INDEMNITY BENEFITS
The ability to collect 100% of enrolled benefit Plan Features Low High
amount for different diagnosed illnesses and Hospital Confinement / $500 per $1,000 per
Admission confinement confinement
recurrence of the same condition $100 per day up $100 per day
to 31 days up to 31 days
Pays a lump sum benefit tax free regardless of
Daily Confinement $100 per day, to a maximum of 31
any other insurance you may have days per calendar year
Hospital Intensive Care $100 or $200 per day up to 10
Eligibility is employee and spouse and Unit Confinement days
children up to the age of 26 Wellness Benefit $50
* Children are automatically covered at 50%
Coverage is available for you, your spouse and or child(ren). Your coverage is portable which means you can take the
policy with you if you leave the company.
222020 - 2021
ICUBA Benefits Guide
Additional Benefits
Post-Tax Benefits Available For Employee Purchase
These are portable individual policies that you pay for with after-tax dollars. If you leave the
University, you can take these policies with you. If you are interested in enrolling in these
plans, please use the web links below to complete an application/expression of interest.
Veterinary Pet Insurance: Affordable pet health care coverage. You can access ANY VET, for more
information: www.petinsurance.com/floridatech
Florida Institute of Technology offers four separate plans with LegalShield. Policy options include:
1. Legal Plan with Spouse or Domestic Partner
2. Identity Theft Plan (IDT) Stand Alone with Spouse or Domestic Partner
3. Identity Theft Plan (IDT) Stand Alone with SafeGuard for Minors (ages 1-17)
4. Combined Legal & IDT Plans plus Safeguard for Minors
Please visit www.fit.edu/hr/benefits/ for more information on these benefit options. Select
Pre-Paid Legal Services from the drop down menu.
Our Local LegalShield Agent would be happy to meet with you and answer all of your questions.
Yvette Mayo can be reached at 407-657-1940 or via email at mayogroupbenefits@msn.com.
Paycheck Calculator
Do you want to know what your benefits will cost each paycheck? Use this handy paycheck
calculator tool to help determine the exact amount. You can repeat this process for each monthly
benefit cost shown in this brochure!
Equation
[monthly amount] x 12 months = ——÷ [paychecks per year] = ——total cost per paycheck
20 Pay Employees
—— x 12 months = ——÷ 20 paychecks per year = ——total cost per paycheck (benefit amount)
26 Pay Employees
—— x 12 months = ——÷ 26 paychecks per year = ——total cost per paycheck (benefit amount)
23Contacts
Visit http://ICUBAbenefits.org for a
quick and easy Single Sign-On access
to many of the Brand Partner websites
listed below. After your initial set up, the
SSO links will take you directly into each
carrier with a connection!
BCBS Medical Insurance
Customer Service: 855-258-9029
24/7 Essential Advocate: 888-521-2583
Website http://myhealthtoolkitfl.com
Teladoc
Request a Consult: 800-TELADOC (835-2362)
Website www.teladoc.com
SurgeryPlus
Surgical Care Advocate: 855-200-2119
Aetna Behavioral Health & Resources for Living EAP
Customer Service: 877-398-5816
Option 1: Employee Assistance Program
Option 2: Behavioral Health
Website www.resourcesforliving.com
Username: ICUBA
Password: 8773985816
OptumRx Prescription Drugs
HealthCare Advisor: 855-811-2213
Website www.optumrx.com
ICUBAcares Pharmacist Advocate Program
Pharmacist Help Line: 877-286-3967
Humana Dental Insurance
Customer Service: DHMO: 800-979-4760
PPO: 800-233-4013
Website www.humanadental.com
EyeMed Vision Insurance
Customer Service: 866-800-5457
Website www.eyemed.com (network: Insight)
ICUBA Benefits MasterCard
Customer Service: 866-377-5102
Email: benefitsadministration@icuba.org
Website http://ICUBAbenefits.org
Symetra Life and Disability
(Always contact HR before Symetra!)
24
Customer Service: 877-377-6773
Website www.symetra.com2020 - 2021
ICUBA Benefits Guide
NOTES
25Visit our website http://ICUBAbenefits.org
to learn more about all of our benefits.
This summary of benefits does not create a contract between the
Institute and any employee. Details of these plans can be found
in official plan documents that govern the plans. In the event of
a discrepancy between the plan documents and this document,
the plan documents govern. While care has been taken to ensure
the accuracy of this information, the plan documents and your
employer policies will govern in all cases. Although it is our
intention to continue the plans, we reserve the right to modify,
amend or terminate the plans at any time. All rates are based on
current participation and are subject to change.
S:\Creative Services\Client Files\2019\ICUBA\Employee Benefits\2020-2021 Benefits GuideYou can also read
