Employee Benefits Guide October 1, 2021 - September 30, 2022
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Employee B enefits Guide O ctober 1, 2021 – Septe mber 30, 2022
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What’s Inside
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This guide provides
information for consideration 9
when newly enrolling,
changing your elections, or 10
reenrolling in our benefit 11
programs.
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Important Information
Weber School District
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Medical
Selecthealth
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Medical - SelectHealth
SelectHealth:Value Network HSA SelectHealth:Med Network HSA
Qualified Qualified
In-Network Out-of-Network
In-Network ONLY
Individual Family Individual Family
Deductible - Plan Year $3,000 Individual/ $6,000 Family $3,000 $6,000 $3,250 $6,500
Out Of Pocket Maximum $3,000 Individual/ $6,000 Family $3,000 $6,000 $4,500 $9,000
Office Visits
Preventative Covered 100% Covered 100% Not Covered
Primary Care Covered 100%AD Covered 100%AD Not Covered
=t
Specialist Covered 100%AD Covered 100%AD Not Covered
Urgent Care Covered 100%AD Covered 100%AD 40%AD
Hospital Visits
Outpatient 100%AD 100%AD 40%AD
Inpatient 100%AD 100%AD 40%AD --
Emergency Room 100%AD 100%AD See In-Network
Mental Health
Office Visit 100%AD 100%AD 40%AD
Outpatient 100%AD 100%AD 40%AD
Inpatient 100%AD 100%AD 40%AD
Prescription
Deductible Medical Deductible Applies Medical Deductible Applies
Tier1 100% Retail AMD 100% Retail AMD
100% Mail Order AMD 100% Mail Order AMD
Tier2 100% Retail AMD 100% Retail AMD I
100% Mail Order AMD 100% Mail Order AMD
Tier3 100% Retail AMD 100% Retail AMD
100% Mail Order AMD 100% Mail Order AMD
Tier4 100% Retail AMD 100% Retail AMD
Some Maintenance Medications are not Some Maintenance Medications are not
Maintenance subject to deductible, see page14 or subject to deductible, see page14 or visit
Medications visit selecthealth.org for a list of selecthealth.org for a list of qualified
qualified medications medications.
*Yearly Deductible - Embedded: All individual deductible amounts will count towards meeting the family deductible,
but an individual will not have to pay more than the individual deductible amount.
*Out-of-Pocket Maximum - Embedded: All individual out-of-pocket limit amounts will count towards meeting the
family out-of-pocket limit, but an individual will not have to pay more than the individual out-of-pocket limit
amount. Copayments, Coinsurance and Deductibles accumulate towards the Out-of-Pocket Maximum.
10WEBER SCHOOL DISTRICT OPTION 2 10/01/2021
MEMBER PAYMENT SUMMARY
IN-NETWORK
When using In-Network Providers, you are responsible to pay the amounts in this column.
VALUE NETWORK / HSA QUALIFIED Services from Out-of-Network Providers are not covered (except emergencies).
CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person None
Pre-Existing Conditions (PEC) None
Benefit Accumulator Period plan Year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET 5,6 IN-NETWORK
Self Only Coverage, 1 person enrolled - per plan Year
Deductible $3,000
Out-of-Pocket Maximum $3,000
Family Coverage, 2 or more enrolled - per plan Year
Deductible - per person/family $3000/$6000
Out-of-Pocket Maximum - per person/family $3000/$6000
(Medical and Pharmacy Included in the Out-of-Pocket Maximum)
INPATIENT SERVICES IN-NETWORK
4
Medical, Surgical and Hospice Covered 100% after Deductible
4
Skilled Nursing Facility - Up to 60 days per plan Year Covered 100% after Deductible
4
Inpatient Rehab Therapy: Physical, Speech, Occupational Covered 100% after Deductible
Up to 40 days per plan Year for all therapy types combined
PROFESSIONAL SERVICES IN-NETWORK
Office Visits & Minor Office Surgeries
1
Primary Care Provider (PCP) Covered 100% after Deductible
1
Secondary Care Provider (SCP) Covered 100% after Deductible
Allergy Tests See Office Visits Above
Allergy Treatment and Serum Covered 100% after Deductible
Major Surgery Covered 100% after Deductible
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) Covered 100% after Deductible
PREVENTIVE SERVICES AS OUTLINED BY THE ACA 2,3 IN-NETWORK
1
Primary Care Provider (PCP) Covered 100%
1
Secondary Care Provider (SCP) Covered 100%
Adult and Pediatric Immunizations Covered 100%
Elective Immunizations - herpes zoster (shingles), rotavirus Covered 100%
Diagnostic Tests: Minor Covered 100%
Other Preventive Services Covered 100%
VISION SERVICES IN-NETWORK
Preventive Eye Exams Covered 100%
All Other Eye Exams Covered 100% after Deductible
OUTPATIENT SERVICES4 IN-NETWORK
Outpatient Facility and Ambulatory Surgical Covered 100% after Deductible
Ambulance (Air or Ground) - Emergencies Only Covered 100% after Deductible
Emergency Room - (In-Network facility) Covered 100% after Deductible
Emergency Room - (Out-of-Network facility) Covered 100% after Deductible
®
Intermountain InstaCare Facilities, Urgent Care Facilities Covered 100% after Deductible
®
Intermountain KidsCare Facilities Covered 100% after Deductible
®
Intermountain Connect Care Covered 100%
Chemotherapy, Radiation and Dialysis Covered 100% after Deductible
2
Diagnostic Tests: Minor Covered 100% after Deductible
2
Diagnostic Tests: Major Covered 100% after Deductible
Home Health, Hospice, Outpatient Private Nurse Covered 100% after Deductible
Outpatient Cardiac Rehab Covered 100% after Deductible
Outpatient Rehab/Habilitative Therapy: Physical, Speech, Occupational Covered 100% after Deductible
MPS-HMO HDHP 01/01/21 See other side for additional benefits
11WEBER SCHOOL DISTRICT OPTION 2 10/01/2021
MEMBER PAYMENT SUMMARY
IN-NETWORK
VALUE NETWORK / HSA QUALIFIED
MISCELLANEOUS SERVICES IN-NETWORK
4
Durable Medical Equipment (DME) Covered 100% after Deductible
3
Miscellaneous Medical Supplies (MMS) Covered 100% after Deductible
Autism Spectrum Disorder See Professional, Inpatient, Outpatient, or
Mental Health and Chemical Dependency Services
4,7
Maternity and Adoption See Professional, Inpatient or Outpatient
4
Cochlear Implants See Professional, Inpatient or Outpatient
Infertility - Selected Services Covered 100% after Deductible
4
Donor Fees for Covered Organ Transplants Covered 100% after Deductible
TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime See Professional, Inpatient or Outpatient
OPTIONAL BENEFITS IN-NETWORK
4
Mental Health and Chemical Dependency
Office Visits Covered 100% after Deductible
Inpatient Covered 100% after Deductible
Outpatient Covered 100% after Deductible
2
Residential Treatment Covered 100% after Deductible
4
Injectable Drugs and Specialty Medications Covered 100% after Deductible
4
Bariatric Surgery (Up to one surgery/lifetime) See Professional, Inpatient or Outpatient
PRESCRIPTION DRUGS
Prescription Drug List (formulary) RxSelect ®
4
Prescription Drugs - Up to 30 Day Supply of Covered Medications
Tier 1 Covered 100% after Deductible
Tier 2 Covered 100% after Deductible
Tier 3 Covered 100% after Deductible
Tier 4 Covered 100% after Deductible
4
Maintenance Drugs - 90 Day Supply (Mail-Order, Retail90 ® )-selected drugs
Tier 1 Covered 100% after Deductible
Tier 2 Covered 100% after Deductible
Tier 3 Covered 100% after Deductible
Deductible Waiver Certain prescription drugs are not subject to the Deductible
Generic Substitution Required Generic required or must pay Copay plus cost
difference between name brand and generic
1 Refer to selecthealth.org/findadoctor to identify whether a Provider is a primary or secondary care Provider.
2 Refer to your Certificate of Coverage for more information.
3 Frequency and/or quantity limitations apply to some Preventive care and MMS Services.
4 Preauthorization is required for certain Services. Benefits may be reduced or denied if you do not preauthorize certain Services with Out-of-Network Providers. Please refer to
Section 11--" Healthcare Management", in your Certificate of Coverage, for details.
5 All Deductible/Copay/Coinsurance amounts are based on the allowed amounts and not on the Providers billed charges. Out-of-Network Providers or Facilities have not
agreed to accept the Allowed Amount for Covered Services. When this occurs, you are responsible to pay for any charges that exceed the amount that SelectHealth pays for
Covered Services. These fees are called Excess Charges, and they do not apply to your Out-of-Pocket Maximum.
6 Certain Services as noted on this document and in your Certificate of Coverage are not subject to the Deductible.
7 SelectHealth provides a $4000 adoption indemnity as outlined by the state of Utah. Medical Deductible, Copay, or Coinsurance listed under the benefit applies and may exhaust
the benefits prior to any plan payments.
To contact Member Services, call 800-538-5038 weekdays, from 7:00 a.m. to 8:00 p.m., Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users should call 711.
Benefits are administered and underwritten by SelectHealth, Inc. SM (domiciled in Utah).
selecthealth.org
12WEBER SCHOOL DISTRICT OPTION 2 10/01/2021
MEMBER PAYMENT SUMMARY
IN-NETWORK OUT-OF-NETWORK
When using In-Network Providers, you are responsible When using Out-of-Network Providers, you are
MED NETWORK / HSA QUALIFIED to pay the amounts in this column. responsible to pay the amounts in this column.
CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment - Per Person None
Pre-Existing Conditions (PEC) None
Benefit Accumulator Period plan Year
Maximum Annual Out-of-Network Payment - (per plan Year) None None
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET5,6 IN-NETWORK OUT-OF-NETWORK
Self Only Coverage, 1 person enrolled - per plan Year
Deductible $3,000 $3,250
Out-of-Pocket Maximum $3,000 $4,500
Family Coverage, 2 or more enrolled - per plan Year
Deductible - per person/family $3000/$6000 $3250/$6500
Out-of-Pocket Maximum - per person/family $3000/$6000 $4500/$9000
(Medical and Pharmacy Included in the Out-of-Pocket Maximum)
INPATIENT SERVICES IN-NETWORK OUT-OF-NETWORK
4
Medical, Surgical and Hospice Covered 100% after Deductible 40% after Deductible
4
Skilled Nursing Facility - Up to 60 days per plan Year Covered 100% after Deductible 40% after Deductible
4
Inpatient Rehab Therapy: Physical, Speech, Occupational Covered 100% after Deductible 40% after Deductible
Up to 40 days per plan Year for all therapy types combined
PROFESSIONAL SERVICES IN-NETWORK OUT-OF-NETWORK
Office Visits & Minor Office Surgeries
1
Primary Care Provider (PCP) Covered 100% after Deductible 40% after Deductible
1
Secondary Care Provider (SCP) Covered 100% after Deductible 40% after Deductible
Allergy Tests See Office Visits Above Not Covered
Allergy Treatment and Serum Covered 100% after Deductible Not Covered
Major Surgery Covered 100% after Deductible 40% after Deductible
Physician's Fees - (Medical, Surgical, Maternity, Anesthesia) Covered 100% after Deductible 40% after Deductible
PREVENTIVE SERVICES AS OUTLINED BY THE ACA2,3 IN-NETWORK OUT-OF-NETWORK
1
Primary Care Provider (PCP) Covered 100% Not Covered
1
Secondary Care Provider (SCP) Covered 100% Not Covered
Adult and Pediatric Immunizations Covered 100% Not Covered
Elective Immunizations - herpes zoster (shingles), rotavirus Covered 100% Not Covered
Diagnostic Tests: Minor Covered 100% Not Covered
Other Preventive Services Covered 100% Not Covered
VISION SERVICES IN-NETWORK OUT-OF-NETWORK
Preventive Eye Exams Covered 100% Not Covered
All Other Eye Exams Covered 100% after Deductible 40% after Deductible
OUTPATIENT SERVICES4 IN-NETWORK OUT-OF-NETWORK
Outpatient Facility and Ambulatory Surgical Covered 100% after Deductible 40% after Deductible
Ambulance (Air or Ground) - Emergencies Only Covered 100% after Deductible See In-Network Benefit
Emergency Room - (In-Network facility) Covered 100% after Deductible See In-Network Benefit
Emergency Room - (Out-of-Network facility) Covered 100% after Deductible See In-Network Benefit
®
Intermountain InstaCare Facilities, Urgent Care Facilities Covered 100% after Deductible 40% after Deductible
®
Intermountain KidsCare Facilities Covered 100% after Deductible Not Available
®
Intermountain Connect Care Covered 100% Not Available
Chemotherapy, Radiation and Dialysis Covered 100% after Deductible 40% after Deductible
2
Diagnostic Tests: Minor Covered 100% after Deductible 40% after Deductible
2
Diagnostic Tests: Major Covered 100% after Deductible 40% after Deductible
Home Health, Hospice, Outpatient Private Nurse Covered 100% after Deductible 40% after Deductible
Outpatient Cardiac Rehab Covered 100% after Deductible 40% after Deductible
Outpatient Rehab/Habilitative Therapy: Physical, Speech, Occupational Covered 100% after Deductible 40% after Deductible
See other side for additional benefits
13WEBER SCHOOL DISTRICT OPTION 2 10/01/2021
MEMBER PAYMENT SUMMARY
IN-NETWORK OUT-OF-NETWORK
MED NETWORK / HSA QUALIFIED
MISCELLANEOUS SERVICES IN-NETWORK OUT-OF-NETWORK
4
Durable Medical Equipment (DME) Covered 100% after Deductible 40% after Deductible
3
Miscellaneous Medical Supplies (MMS) Covered 100% after Deductible 40% after Deductible
Autism Spectrum Disorder See Professional, Inpatient, Outpatient, or See Professional, Inpatient, Outpatient, or
Mental Health and Chemical Dependency Mental Health and Chemical Dependency
Services Services
4,7
Maternity and Adoption See Professional, Inpatient or Outpatient 40% after Deductible
4
Cochlear Implants See Professional, Inpatient or Outpatient Not Covered
Infertility - Select Services Covered 100% after Deductible Not Covered
4
Donor Fees for Covered Organ Transplants Covered 100% after Deductible Not Covered
TMJ (Temporomandibular Joint) Services - Up to $2,000 lifetime See Professional, Inpatient or Outpatient Not Covered
OPTIONAL BENEFITS IN-NETWORK OUT-OF-NETWORK
4
Mental Health and Chemical Dependency
Office Visits Covered 100% after Deductible 40% after Deductible
Inpatient Covered 100% after Deductible 40% after Deductible
Outpatient Covered 100% after Deductible 40% after Deductible
2
Residential Treatment Covered 100% after Deductible 40% after Deductible
4
Injectable Drugs and Specialty Medications Covered 100% after Deductible 40% after Deductible
4
Bariatric Surgery (Up to one surgery/lifetime) See Professional, Inpatient or Outpatient Not Covered
PRESCRIPTION DRUGS
Prescription Drug List (formulary) RxSelect ®
4
Prescription Drugs-Up to 30 Day Supply of Covered Medications
Tier 1 Covered 100% after In-Network Deductible
Tier 2 Covered 100% after In-Network Deductible
Tier 3 Covered 100% after In-Network Deductible
Tier 4 Covered 100% after In-Network Deductible
4
Maintenance Drugs-90 Day Supply (Mail-Order,Retail90 ® )-selected drugs
Tier 1 Covered 100% after In-Network Deductible
Tier 2 Covered 100% after In-Network Deductible
Tier 3 Covered 100% after In-Network Deductible
Deductible Waiver Certain prescription drugs are not subject to the Deductible
Generic Substitution Required Generic required or must pay Copay plus cost
difference between name brand and generic
1 Refer to selecthealth.org/findadoctor to identify whether a Provider is a primary or secondary care Provider.
2 Refer to your Certificate of Coverage for more information.
3 Frequency and/or quantity limitations apply to some Preventive care and MMS Services.
4 Preauthorization is required for certain Services. Benefits may be reduced or denied if you do not preauthorize certain Services with Out-of-Network Providers. Please refer to
Section 11--" Healthcare Management", in your Certificate of Coverage, for details.
5 All Deductible/Copay/Coinsurance amounts are based on the allowed amounts and not on the Providers billed charges. Out-of-Network Providers or Facilities have not
agreed to accept the Allowed Amount for Covered Services. When this occurs, you are responsible to pay for any charges that exceed the amount that SelectHealth pays for
Covered Services. These fees are called Excess Charges, and they do not apply to your Out-of-Pocket Maximum.
6 Certain Services as noted on this document and in your Certificate of Coverage are not subject to the Deductible.
7 SelectHealth provides a $4000 adoption indemnity as outlined by the state of Utah. Medical Deductible, Copay, or Coinsurance listed under the benefit applies and may exhaust the
benefits prior to any plan payments.
All Covered Services obtained outside the United States, except for routine, Urgent, or Emergency conditions require preauthorization.
To contact Member Services, call 800-538-5038 weekdays, from 7:00 a.m. to 8:00 p.m., Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users should call 711.
Benefits are administered and underwritten by SelectHealth, Inc. SM (domiciled in Utah).
selecthealth.org
14Deductible Waived – Drugs, Devices, and Tests
Do you use medications, tests, or equipment in
Devices > Cande sa rta n / H CT Z > Novolin N
one of the categories below? We have good
> Blood Pressure > Cande sa rta n > Novolin R
news for you! Many of our plans provide Monito r > Carvedi l ol > Novol o g
coverage for drugs, equipment, and tests in > Peak Flow Meter > Corlan o r > Novolo g Mix
these categories even before you meet your Asthma and COPD > Diltiaze m > Toujeo
> Albu te r ol / H F A > Eliquis
deductible (cost-sharing still applies). If you Diabetes –
> Anoro Ellipt a > Entres to Non-Insulin
aren't sure about your plan's benefit, contact > Arca p t a > Furose mi d e > Alogl i p ti n
our Member Services team. > Arnuit y Ellipta > Hydrochl o rot h ia zi d e > Farxig a
> Asman e x > Lisino p / H C T Z > Glimepi ri de
We’ve listed the most commonly prescribed > Atrove n t /H F A > Lisinop ri l > Glipiz i d e
> Budes o ni d e > Losarta n > Glucag e n
covered medications in these no-deductible
> Combiv e nt > Losarta n /H C TZ > Glucag o n
categories. If you don’t see the one you’re > Dalires p > Metopro lo l > Glyxam bi
looking for, you’ll find a more complete > Flovent > Multaq > Jardian ce
Prescription Drug List on selecthealth.org, or > Flutica so n e / > Olmesa rta n / > Jentadu e t o
Salmete rol Amlodi p i ne /H CT Z > Metformi n
log in to your SelectHealth member account > Ipratrop iu m > Olmesa rta n / H CT Z > Pioglita z o n e
and use our online drug search. > Levalbut e ro l > Olmesa rta n > Segluro m et
> Montel uk a st > Propra n ol o l > Steglat ro
> Provent il > Ranolaz i ne > Synjardy
NEED MORE INFORMATION? > Pulmico rt > Spiron ol a ct o ne > Tradjenta
> Qvar > Telmisartan / > Trulicit y
WEB > Sereven t Amlodi p i ne > Victo z a
> Telmisa rt a n /H CT Z
selecthealth.org/pharmacyresources > Spiriva
> Telmisarta n
> Xigd u o XR
> Stiolt o
Mental Health
> Trandol o p ril /
PHONE > Striverdi
Verapa m il > Citalop ra m
> Symbico rt
> Escital o p ra m
800-538-5038 > Terbut a li n e
> Triamt e re n e /H C TZ
> Valsarta n /H CTZ > Fluoxe ti n e
> Trelegy
> Valsarta n > Fluvoxa m i n e
> Ventol i n /H F A
> Warfari n > Paroxe ti n e
> Wixela Inhub
> Xarelto > Sertral i ne
Cardiovascular
Cholesterol Osteoporosis
Antiadrenergics
> Atorva st at i n > Alendro n a te
> Clonid i ne
> Choles ty ra mi n e > Fosama x
> Minipre ss
> Prazosi n > Colesti p o l Tests
> Fenofib rat e > Hemogl o b i n A1c
Cardiovascular Testing
> Livalo
> Alda ct o n e > Intern at i o na l
> Pravast at i n
> Amlodi p i ne / Normal iz e d Ratio
Olmesa rta n > Rosuvas ta t i n (INR) Testing
> Amlo d i pi n e > Simvast at i n > Low-de n si ty
Lipopro t ei n (LDL)
> Aten ol o l Diabetes – Insulin Testing
> Bysto li c > Lantus > Retinopa t hy
> Byvalso n > Novolin Screen i n g
SelectHealth refers to many of the drugs in this list by their respective
trademarks, but SelectHealth does not own those trademarks; the manufacturer
or supplier of each drug owns the drug's trademark. By listing these drugs,
SelectHealth does not endorse or sponsor any drug, manufacture r, or supplier.
And these manufacturers and suppliers do not endorse or sponsor any
SelectHealth service or plan and are not affiliated with SelectHealth.
*This list is not a complete list of all covered drugs and may be subject to change.
Other limitations may apply.
15
© 2020 SelectHealth. All rights reserved. 1079765 08/20Stretching Your Rx Dollar
GoodRx Comparison Tool
Stop paying too much for your prescriptions! With the GoodRx Comparison Tool, you can
compare drug prices at over 70,000 pharmacies, and discover free coupons and savings tips.
Isn’t health insurance all I need?
Your health insurance provides valuable prescription and other health benefits, but a smart
consumer can save much more, especially for drugs that are not covered by health insurance
(weight-loss medications, some antihistamines, etc.), drugs that have limited quantities, drugs
that can be found for less than your copay, or drugs with a lower priced generic.
How can I find these savings?
The GoodRx Comparison Tool provides you with instant access to current prices on more than
6,000 drugs at virtually every pharmacy in America.
› On the Web: https://www.goodrx.com/
Instantly look up current drug prices at CVS, Walgreens, Walmart, Costco, and other local
pharmacies.
Please Note:
• Prescription drug pricing displayed on the GoodRx Comparison Tool may be more or less than
your insurance drug card.
• Please be sure to compare all discount pricing options before you purchase.
• Check your insurance carrier’s pharmacy benefit before purchasing a 90 day supply.
› On Your Phone
Available on the app store or with Android on Google play. Or, just go to m.goodrx.com from
any mobile phone.
Generic Prescriptions
$4 30-Day Supply or a $10 90-Day Supply
These programs may assist you in paying a reduced amount for generic medications, as well as,
reducing utilization of the medical prescription benefits.
Did You Know?
Even if the generic substitute for one of your prescription drugs is not on one of the $4 lists,
generic drugs are often 80% less expensive than brand name drugs, so switching to a generic will
have a large impact on your pocketbook whether you switch pharmacies or not. To see if you
would benefit from a switch to a generic drug, do some comparison shopping. One of the better
places to do this is at www.crbestbuydrugs.org, a Consumer Reports site.
Tips
• When you receive a prescription from your doctor, ask if a generic equivalent is available.
• The member must present the written prescription to the pharmacist and request the $4-
Generic price.
• The member should not present the medical ID card. The pharmacy will not submit a claim to
the insurance carrier.
How can I find out if my prescription is on the $4-Generic Drug List?
Most of the generic programs offer approximately 150 to 300 generic drugs at a discounted price.
The generic drugs offered cover most diseases and most chronic conditions such as arthritis,
heart disease, high blood pressure, depression and diabetes.
You may search for the generic medication on the pharmacy’s website or contact the pharmacy to
inquire if the generic medication the provider prescribed is on the pharmacy’s $4-Generic Drug
List.
16Health Savings Account
Health Equity
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19Dental
Dental Select
20Summary of Benefits for:
Weber County School District
Co-Pay Plan
Gold Network
Contracted Dentist Non-Contracted Dentist
Preventive
Routine exams, cleanings (2 per 100% No Benefit
year), topical fluoride, x-rays
Basic
Fillings, extractions, oral surgery Fixed Co-Pays No Benefit
Refer to Co-Pay Schedule
Major
Crowns, bridges, dentures, Fixed Co-Pays No Benefit
endodontics, periodontics Refer to Co-Pay Schedule
Orthodontics
All Members: Discounts May Apply; See Plan Notes No Benefit
Lifetime Maximum: No Maximum
Waiting Period: No Waiting Period
Maximum Benefit
Applies to Benefit Period is: No Maximum
Preventive,
Basic and Per Calendar
Major Services Year
Deductible
Applies to Per Year: No Deductible
Basic and
Major Services
21
7/8/20212:48 PMUT GOLD 1-2 IN SUM CP (Member CoPay) PCP.9000332 H:4
This summary includes a list of the most common procedures.
GENERAL DENTIST
ADA CODE PROCEDURE DESCRIPTION
MEMBER COPAY IN-NETWORK
PREVENTIVE
D0120 PERIODIC ORAL EXAMINATION 0
D0150 COMPREHENSIVE ORAL EXAMINATION 0
D0210 X-RAYS, COMPLETE SET 0
D0220 X-RAYS, PERIAPICAL, 1ST FILM 0
D0272 X-RAYS, BITEWING, 2 FILMS 0
D0274 X-RAYS, BITEWING, 4 FILMS 0
D0330 X-RAYS, PANORAMIC FILM 0
D1110 CLEANING - ADULT 0
BASIC
D0140 LIMITED ORAL EXAMINATION 0
D1351 SEALANT - PER TOOTH (AGE 15 & UNDER) 13
AMALGAM (SILVER) FILLINGS
D2140 AMALGAM - 1 SURFACE 18
D2150 AMALGAM - 2 SURFACE 25
D2160 AMALGAM - 3 SURFACE 31
D2161 AMALGAM - 4+ SURFACES 40
ANTERIOR COMPOSITE (WHITE) FILLINGS
D2330 COMPOSITE - 1 SURFACE ANTERIOR 37
D2331 COMPOSITE - 2 SURFACE ANTERIOR 41
D2332 COMPOSITE - 3 SURFACE ANTERIOR 48
D2335 COMPOSITE - 4+ SURFACES ANTERIOR 53
POSTERIOR COMPOSITE (WHITE) FILLINGS
D2391 COMPOSITE - 1 SURFACE POSTERIOR 36
D2392 COMPOSITE - 2 SURFACE POSTERIOR 54
D2393 COMPOSITE - 3 SURFACE POSTERIOR 66
D2394 COMPOSITE - 4+ SURFACES POSTERIOR 71
CROWNS
D2750 CROWN - PORCELAIN, HIGH NOBLE METAL 313
D2751 CROWN - PORCELAIN, PREDOMINANTLY BASE METAL 313
D2752 CROWN - PORCELAIN, NOBLE METAL 313
ENDODONTICS (ROOT CANALS)
D3310 PULP CAP - DIRECT, EXCLUDING FINAL RESTORATION 200
D3320 ROOT CANAL - BICUSPID, EXCLUDING FINAL RESTORATION 241
D3330 ROOT CANAL - MOLAR, EXCLUDING FINAL RESTORATION 332
PERIODONTICS
D4341 PERIODONTAL ROOT PLANING, 4+ PER QUAD 85
D4910 PERIODONTAL MAINTENANCE PROCEDURE 59
PROSTHODONTICS (DENTURES)
D5110 COMPLETE DENTURE - UPPER 404
D5120 COMPLETE DENTURE - LOWER 404
ORAL SURGERY
D7210 SURGICAL EXTRACTION 69
D7220 SURGICAL EXTRACTION, IMPACTED 91
D7230 SURGICAL EXTRACTION, PARTIAL BONY 122
D7240 SURGICAL EXTRACTION, COMPLETELY BONY 150
MISCELLANEOUS
D9440 OFFICE VISIT FOR OBSERVATION - AFTER HOURS 37
* Discount only. This program provides discounts only from a specific network of dental providers. The member is responsible to pay for all services but will receive a discount from dental providers who
are contracted on Dental Select's Silver network. This sample is not a complete list of covered procedures.
Region 1 includes: Davis, Salt Lake, Tooele, Weber, and Utah counties.
For a full schedule of copayments, please see Employee Navigator
22Summary of Benefits for:
Weber County School District
EPO Classic In Network Only
Platinum Network
Contracted Dentist Non-Contracted Dentist
Preventive
Routine exams, cleanings (2 per 100% No Benefit
year), topical fluoride, x-rays
Basic
Composite fillings, extractions, 60% No Benefit
oral surgery, space maintainers,
sealants
No Waiting Period
Major
Crowns, bridges, dentures, 40% No Benefit
endodontics, periodontics
12 Month Waiting Period
Orthodontics
All Members: 0% (Discounts May Apply; See Plan Notes) 0% (No Benefit)
Maximum Benefit
Applies to Benefit Period is: $1,000.00
Preventive,
Basic and Per CRQWUDFW
Major Services Year
Deductible
Applies to Per Benefit Period
Basic and
Major Services Per Person: $50.00 $50.00
Family Maximum: $150.00 $150.00
23Summary of Benefits for:
Weber County School District
PPO MAC Classic
Platinum Network
Contracted Dentist Non-Contracted Dentist
Preventive
Routine exams, cleanings (2 per 100% 60% of Fee Schedule
year), topical fluoride, x-rays
Basic
Composite fillings, extractions, 80% 60% of Fee Schedule
endodontics, periodontics, oral
surgery, space maintainers,
sealants
No Waiting Period
Major
Crowns, bridges, dentures 50% 30% of Fee Schedule
12 Month Waiting Period
Orthodontics
Children under 19 50% 30%
Waiting Periods 12 Month Waiting Period
Lifetime Maximum $1,000
All Members: Discounts May Apply; See Plan Notes No Benefit
Maximum Benefit
Applies to Benefit Period is: $1,500.00
Preventive,
Basic and Per CRQWUDFW
Major Services Year
Deductible
Applies to Per Benefit Period
Basic and
Major Services Per Person: $0.00 $0.00
Family Maximum: $0.00 $0.00
24Dental Notes for:
Weber County School District
Dental Plan Notes
Co-Pay Plans (Available in Texas and Utah only)
● Contracted: All payments made to contracted General Dentists
are based on the contracted dental fee schedule for co-pay plans.
Contracted General Dentists accept a combination of fixed co-
payments and insurance plan payments as payment in full. Dental
procedures not covered under your plan may also be subject to a
discounted fee in accordance with a participating provider's
contract and subject to state law*.
● Non-Contracted: All payments made to non-contracted General
Dentists are based on the contracted dental fee schedule for co-
pay plans. The member is responsible for paying the difference
Co-Insurance MAC Plans
between the plan payment and the General Dentist’s usual
● Contracted: All payments made to contracted General Dentists charges.
and Specialists are based on the contracted dental fee schedule
and are accepted as payment in full after the required deductible
amount, as shown. Dental procedures not covered under your
plan may also be subject to a discounted fee in accordance with a
participating provider's contract and subject to state law.*
● Non-Contracted: Dental Select will allow up to the contracted
dental fee schedule amount for dental procedures and services
after the required deductible amount, as shown. Charges above
the plan payment are the patient's responsibility.
MAC refers to the Maximum Allowable Charge in Utah and Texas. Contracted Dentist refers to a network dentist in UT and TX.
MAB refers to the Maximum Allowable Benefit in all other states. Participating Provider refers to a network dentist in all other
states.
Non-Contracted Dentist refers to a non-network dentist in UT and
TX.
Non-Participating Provider refers to a non-network dentist in all
other states.
* Please contact Dental Select's Customer Care at 800-999-9789 or consult your provider to confirm availability.
This summary of benefits is current as of 07/08/2021. To verify up to date benefits, please contact Dental Select Customer Care at 800-999-9789.
25Voluntary Vision
Dental Select
26Summary of Benefits for:
Weber County School District
Vision 13
EyeMed Insight Network
In-Network (Member Cost) Out-of-Network (Reimbursement)
Exam with Dilation as Necessary $10 Up to $35
Retinal Imaging Benefit Up to $39 N/A
Contact Lens Options
Standard fit & follow-up Up to $55 Not covered
Premium fit & follow-up 10% off retail price Not covered
Frames
Any frame at provider location $0 copay, $100 allowance; 20% off balance over Up to $50
$100
Standard Plastic Lenses
Single Vision $10 Up to $25
Bifocal $10 Up to $40
Trifocal $10 Up to $55
Lenticular 20% off Retail Price N/A
Standard progressive $75 Up to $40
Premium Progressive
Tier 1 $75
Tier 2 $105 Up to $40
Tier 3 $120
Tier 4 $75, 80% of Retail less than $120
Lens Options
UV Coating $10 Not covered
Tint (Solid and Gradient) $15 Not covered
Standard Scratch-Resistance $10 Not covered
Standard Polycarbonate- Adults $40 Not covered
Standard Polycarbonate- Kids under 19 $40 Not covered
Standard Anti-Reflective $45 Not covered
Premium Anti-Reflective Coating
Tier 1 $57
Tier 2 $68
Tier 3 20% off retail Price Not Covered
Polarized 20% off retail Price Not Covered
Plastic Photocromatic/Transition $75 Not Covered
Other Add-ons and Services 20% off retail price Not covered
Contact Lenses -- Declining Balance Allowance --
Conventional $0 copay: $115 allowance; 15% off balance over Up to $100
$115
Disposables $0 copay: $115 allowance; member responsible Up to $100
for balance over $115
Medically Necessary $0 copay: paid in full Up to $200
Laser Correction (US Laser Network)
Lasik or PRK 15% off retail price -or- 5% off promotional price Not covered
Additional Pairs Benefit: Members also receive a 40% discount off complete pair Not covered
eyeglass purchases and a 15% discount off conventional
contact lenses once the funded benefit has been used.
Frequency
Examination Once every 12 months Once every 12 months
Frames Once every 12 months Once every 12 months
Lenses or Contact Lenses Once every 12 months Once every 12 months
27Summary of Benefits for:
Weber County School District
Vision 14
EyeMed Insight Network
In-Network (Member Cost) Out-of-Network (Reimbursement)
Exam with Dilation as Necessary $10 Up to $35
Retinal Imaging Benefit Up to $39 N/A
Contact Lens Options
Standard fit & follow-up Up to $40 Not covered
Premium fit & follow-up 10% off retail price Not covered
Frames
Any frame at provider location $0 copay, $120 allowance; 20% off balance over Up to $80
$100
Standard Plastic Lenses
Single Vision $10 Up to $25
Bifocal $10 Up to $40
Trifocal $10 Up to $55
Lenticular 20% off Retail Price N/A
Standard progressive $75 Up to $40
Premium Progressive
Tier 1 $75
Tier 2 $105 Up to $40
Tier 3 $120
Tier 4 $75, 80% of Retail less than $120
Lens Options
UV Coating $10 Not covered
Tint (Solid and Gradient) $15 Not covered
Standard Polycarbonate- Adults $40 Not covered
Standard Polycarbonate- Kids under 19 $40 Not covered
Standard Anti-Reflective $45 Not covered
Premium Anti-Reflective Coating
Tier 1 $57
Tier 2 $68
Tier 3 20% off retail Price Not Covered
Polarized 20% off retail Price Not Covered
Plastic Photocromatic/Transition $75 Not Covered
Polarized 20% off retail price Not covered
Other Add-ons and Services 20% off retail price Not covered
Contact Lenses -- Declining Balance Allowance --
Conventional $0 copay: $120 allowance; 15% off balance over Up to $80
$120
Disposables $0 copay: $120 allowance; member responsible Up to $80
for balance over $120
Medically Necessary $0 copay: paid in full Up to $200
Laser Correction (US Laser Network)
Lasik or PRK 15% off retail price -or- 5% off promotional price Not covered
Additional Pairs Benefit: Members also receive a 40% discount off complete pair Not covered
eyeglass purchases and a 15% discount off conventional
contact lenses once the funded benefit has been used.
Frequency
Examination Once every 12 months Once every 12 months
Frames Once every 12 months Once every 12 months
Lenses AND Contact Lenses Once every 12 months Once every 12 months
28Dental Notes for:
Weber County School District
Vision Plan Notes
Discounts
● Members will receive a 20% discount on items not covered by the plan when using contracted Lasik & PRK
providers. Since Lasik or PRK vision correction is an elective procedure, performed by specially trained providers,
this discount may not always be available from a provider in your immediate location. For a location near
● This discount may not be combined with any other discounts or promotional offers and does not
you and the discount authorization, please call 1-877-5LASER6
apply to EyeMed Provider's professional services or contact lenses.
Allowances
● Retail prices may vary by location. Allowances are one-time use benefits; no remaining balance except for contact lens materials, when
applicable. Lost or broken materials are not covered.
● Discounts do not apply to benefits provided by other group benefit plans.
● When enrolled on the vision plans, Members receive a 40% discount off complete eyeglass Member Co-Pay in Utah and Texas, deductible in all other states
purchases and a 15% discount off conventional contact lenses at unlimited frequency after the
initial benefit has been used. After initial purchase, replacement contact lenses may be obtained
via the internet at substantial savings and mailed directly to the member. Details are available at
www.eyemedvisioncare.com. The contact lens benefit allowance is not applicable to this
service.
● Based on applicable laws, reduced costs may vary by doctor location.
Discounts on products and Services are not insured benefits and not underwritten by
Ameritas Life Insurance Corp.
Vision Plan Exclusions
Limitations and Exclusions may vary by state. Refer to your Policy or contact Us.
(1 Orthoptic or vision training, subnormal vision aids and any associated supplemental testing. (9) Charges in excess of the Reasonable and Customary charge for the Service or Materials.
(2 Plano lenses. (10) Charges incurred after: (a) the Policy ends; or (b) the Insured’s coverage under the Policy ends,
except as stated in the Policy.
(3 Two pair of glasses, in lieu of bifocals or trifocals.
(4 Medical or surgical treatment of the eye, eyes or supporting structures. (11) Experimental or non-conventional treatment or devices.
(5 Any eye examination, or any corrective eyewear, safety eyewear required by an employer as a (12) Lost or broken Materials, except when replaced at normal intervals when Services are available.
condition of employment, unless specifically covered under the Plan.
(6 Services provided as a result of any Workers’ Compensation law, or similar legislation, or (13) Photorefractive Keratectomy (PRK) surgery or Laser-assisted in Situ Keratomileusis (LASIK)
required by any governmental agency or program whether federal, state or subdivisions thereof. surgery.
(14) Aniseikonic lenses.
(7 Sub-normal vision aids or non-prescription lenses. (15) Non-prescription sunglasses. - Certain name brand Vision Materials for which the manufacturer
maintains a no-discount practice.
(8) Services rendered or Materials purchased outside the U.S. or Canada, unless: (a) the Insured
resides in the U.S. or Canada; and (b) the charges are incurred while on a business or pleasure (16) Services or Materials provided by any other group benefit providing for Vision care.
trip.
(17) Care or treatment rendered by You, Your insured Dependent, or a member of Your Immediate
Family or household.
This summary of benefits is current as of 07/08/2021. To verify up to date benefits, please contact Dental Select Customer Care at 800-999-9789.
The EyeMed Network offers access to thousands of independent vision care providers and top optical retailers nationwide,
including:
luding:
This is not a certificate of insurance or guarantee of coverage. Plan designs may not be available in all areas and are subject to individual state regulations. Group dental and vision products
are issued by Ameritas Life Insurance Corp. Ameritas, the bison design, “fulfilling life” and product names designated with SM or ® are service marks or registered service marks of Ameritas
Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. © 2020 Ameritas Mutual Holding Company.
2930
OPTICARE PLAN:
70B Weber School District
Products/Services In-Network Out-Of-Network
Standard Plastic Lenses
$70 Allowance for lenses, options, and
Single Vision $20 Co-pay
coatings
$70 Allowance for lenses, options, and
Bifocal (FT 28) $20 Co-pay
coatings
$70 Allowance for lenses, options, and
Trifocal (FT 7x28) $20 Co-pay
coatings
Lens Options
Progressive (Standard plastic no-line) $75 Co-pay
Premium Progressive Options $125 Co-pay
Ultra-Premium Progressive Options Up to 20% Discount
Polycarbonate 25% Discount
High Index 25% Discount
Coatings
Scratch Resistant Coating $10 Co-pay
Ultra Violet protection $10 Co-pay
Other Options Up to 25% Discount
A/R, edge polish, tints, mirrors, etc.
Frames
Allowance Based on Retail Pricing $70 Allowance $50 Allowance
Additional Eyewear
Additional Pairs of Glasses Throughout the Year Up to 50% Off Retail
Contacts
Contact benefits is in lieu of lens and frame benefit. $70 Allowance $50 Allowance
Additional contact purchases:
Conventional Up to 20% Discount
Disposables Up to 10% Discount
Frequency
Exams, Lenses, Frames, Contacts Every 12 months Every 12 months
Refractive Surgery
LASIK 20% off Retail Not Covered
31
Phone: 800-363-0950 www.opticarevisionservices.comDISCOUNTS
Any item listed as a discount is a merchandise discount only and not an insured benefit. Discounts vary by providers, see
provider for details
Up to 20% Discount off balance above Frame Allowance
50% discount varies by provider, ask provider for details.
Must purchase full year supply to receive discounts on select brands. See provider for details.
LASIK (Refractive surgery) Standard Optical Locations ONLY.
LASIK services are not an insured benefit – this is a discount only.
All pre & post-operative care is provided by Standard Optical only and is based on Standard Optical retail fees.
Out of Network – Out of Network benefit may not be combined with promotional items. Online purchases at approved
providers only.
32
Phone: 800-363-0950 www.opticarevisionservices.comOPTICARE PLAN:
120B Weber School District
Products/Services In-Network Out-Of-Network
Standard Plastic Lenses
$85 Allowance for lenses, options, and
Single Vision $10 Co-pay
coatings
$85 Allowance for lenses, options, and
Bifocal (FT 28) $10 Co-pay
coatings
$85 Allowance for lenses, options, and
Trifocal (FT 7x28) $10 Co-pay
coatings
Lens Options
Progressive (Standard plastic no-line) $50 Co-pay
Premium Progressive Options $100 Co-pay
Ultra-Premium Progressive Options Up to 20% Discount
Polycarbonate 25% Discount
High Index 25% Discount
Coatings
Scratch Resistant Coating $10 Co-pay
Ultra Violet protection $10 Co-pay
Other Options Up to 25% Discount
A/R, edge polish, tints, mirrors, etc.
Frames
Allowance Based on Retail Pricing $120 Allowance $80 Allowance
Additional Eyewear
Additional Pairs of Glasses Throughout the Year Up to 50% Off Retail
Contacts
Contact benefits is in lieu of lens and frame benefit. $120 Allowance $80 Allowance
Additional contact purchases:
Conventional Up to 20% Discount
Disposables Up to 10% Discount
Frequency
Exams, Lenses, Frames, Contacts Every 12 months Every 12 months
Refractive Surgery
LASIK $250 Off Per Eye Not Covered
33
Phone: 800-363-0950 www.opticarevisionservices.comDISCOUNTS
Any item listed as a discount is a merchandise discount only and not an insured benefit. Discounts vary by providers, see
provider for details
Up to 20% Discount off balance above Frame Allowance
50% discount varies by provider, ask provider for details.
Must purchase full year supply to receive discounts on select brands. See provider for details.
LASIK (Refractive surgery) Standard Optical Locations ONLY.
LASIK services are not an insured benefit – this is a discount only.
All pre & post-operative care is provided by Standard Optical only and is based on Standard Optical retail fees.
Out of Network – Out of Network benefit may not be combined with promotional items. Online purchases at approved
providers only.
34
Phone: 800-363-0950 www.opticarevisionservices.comFlexible Spending Account
National Benefit Services
35FLEXIBLE BENEFITS PLAN
Weber School District
Employer ID NBS759236
PLAN HIGHLIGHTS
Login at: my.nbsbenefits.com
Congratulations! Weber School District has established a "Flexible Benefits Plan" to help you pay for your out-of-pocket medical expenses.
One of the most important features of the Plan is that the benefits being offered are paid for with a portion of your pay before Federal income
or Social Security taxes are withheld. This means that you will pay less tax and have more money to spend and save. However, if you receive
a reimbursement for an expense under the Plan, you cannot claim a Federal income tax credit or deduction on your return.
DETERMINING CONTRIBUTIONS
Before each Plan Year begins, you will select the benefits you WHAT TYPE OF BENEFITS ARE AVAILABLE
want and how much of the contributions should go toward each Under our Plan, you can choose the following benefits. Each
benefit. It is very important that you make these choices carefully benefit allows you to save taxes at the same time because the
based on what you expect to spend on each covered benefit or amount you elect is set aside on a pre-tax basis.
expense during the Plan Year.
Health Flexible Spending Account:
Generally, you cannot change the elections you have made after The Health Flexible Spending Account (FSA) enables you to pay
the beginning of the Plan Year. However, there are certain limited for expenses allowed under Section 105 and 213(d) of the
situations when you can change your elections if you have a Internal Revenue Code which are not covered by our insured
“change in status”. Please refer to your Summary Plan medical plan. The most that you can contribute to your Health
Description for a change in status listing. FSA each Plan Year is set by the IRS. This amount can be
adjusted for increases in cost-of-living in accordance with Code
GENERAL PLAN INFORMATION Section 125(i)(2). Please note: If you participate in a Health
Savings Account (HSA) benefit you cannot participate in the Full
Plan Year End:…………………………………..…September 30th Health Flexible Spending Account benefit, but you can participate
Run-out Period:…………………………………..……....…90 Days in the Limited Health Flexible Spending Account Benefit.
Maximum Medical Limit…………..…...…Current IRS limit $2,750 Health Savings Account:
…See Code Section 125(i)(2) or current enrollment information A Health Savings Account allows participants insured by a
Qualified High Deductible Insurance Plan to save for deductibles
Maximum Dependent Care Limit:……..……………..……..$5,000 and other expenses not covered under the Plan. If you participate
in this benefit you cannot participate in the Health Flexible
Health FSA Grace Period…………………….....………….75 days Spending Account benefit, only a Limited FSA.
Dependent Care Grace Period:………………..……...…...75 days
Limited Health Flexible Spending Account:
WHEN AM I ELIGIBLE TO PARTICIPATE If you participate in a Limited Health Flexible Spending Account,
You will be eligible to join the Plan as of your date employment. you can only be reimbursed for out-of-pocket dental and/or vision
Teachers will be eligible to participate if they work 20 hours or expenses incurred by you and your dependents. However, once
more per week. Classified Employee hired before July 1, 2013 you satisfy the statutory deductible you may be reimbursed for
will be eligible to participate if they work at least 20 hours per medical expenses that are allowed under Section 105 and 213(d)
week. Classified Employees hired on or after July 1, 2013 are of the Internal Revenue Code which are not covered by our
eligible to participate if they work at least 30 hours per week. insured medical Plan. Please refer to your SPD for the current
statutory amount. You may not, however, be reimbursed for the
You will enter the Plan on the first day of the month following the cost of other health care coverage maintained outside of the Plan,
day in which you meet the above eligibility requirements. or for long-term care expenses.
36Dependent Care Flexible Spending Account: Orthodontic expenses that are paid fully up-front at the time of
The Dependent Care Flexible Spending Account (DCAP) enables banding are reimbursable in full after the initial service has been
you to pay for out-of-pocket, work-related dependent day-care performed and payment has been made. Ongoing orthodontia
cost. Please see the Summary Plan Description for the definition payments are reimbursable only as they are paid.
of eligible dependent. The law places limits on the amount of
money that can be paid to you in a calendar year. Generally, your WHO ARE HIGHLY COMPENSATED & KEY EMPLOYEES
reimbursement may not exceed the lesser of: (a) $5,000 (if you Under the Internal Revenue Code, "highly compensated
are married filing a joint return or you are head of a household) or employees" and "key employees" generally are Participants who
$2,500 (if you are married filing separate returns; (b) your taxable are officers, shareholders or highly paid.
compensation; (c) your spouse’s actual or deemed earned
income. Also, in order to have the reimbursements made to you If you are within these categories, the amount of contributions and
and be excluded from your income, you must provide a statement benefits for you may be limited so that the Plan as a whole does
from the service provider including the name, address, and in not unfairly favor those who are highly paid, their spouses or their
most cases, the taxpayer identification number of the service dependents. Please refer to your Summary Plan Description for
provider, as well as the amount of such expense and proof that more information. You will be notified of these limitations if you
the expense has been incurred. are affected.
Premium Expense Plan:
A Premium Expense portion of the Plan allows you to use pre-tax
dollars to pay for specific premiums under various insurance
programs that we offer you.
Updated: 1/16/2020
Please note: Policies other than company sponsored policies (i.e.
spouse's or dependents' individual policies etc.) may not be paid
through the Flexible Benefits Plan. Furthermore, qualified long-
term care insurance plans may not be paid through the Flexible
Benefits Plan.
HOW DO I RECEIVE REIMBURSEMENTS
During the course of the Plan Year, you may submit requests for
reimbursement of expenses you have incurred. Expenses are
considered “incurred” when the service is performed, not
necessarily when it is paid for. You can get a claim form at
www.NBSbenefits.com.
Claim forms must be submitted no later than 90 days after the
end of the Plan Year for the Health Flexible Spending Account
and the Dependent Care Flexible Spending Account. However,
if you have unused contributions in your Flexible Spending
Accounts from the immediately preceding plan year, and you
incur qualified medical care and/or dependent care expenses
during the grace period; you may be reimbursed for those
expenses as if the expenses had been incurred in the prior plan
year. Any monies left from the previous plan year will be forfeited
following the grace and run-out period.
NBS Flexcard – FSA Pre-paid MasterCard
Your employer may sponsor the use of the NBS Flexcard, making
access to your flex dollars easier than ever. You may use the
card to pay merchants or service providers that accept credit
cards, so there is no need to pay cash up front then wait for
reimbursement.
37Kannact 38
Human Driven
Digital Health
Introducing a Special
Health Benefit
for Eligible Weber County
School District Employees
& Covered Dependents
➢Better Health
➢Free Supplies
➢No Cost to You
A lot of things can get in the way of improving
your health. We get it.
Testimonials
That’s why your employer is making it easier
with our proven program to support your “Kannact helps me stay
health between doctor visits.
With Kannact, you’ll get your own health coach
accountable to my goals.”
and access to our nurses and pharmacists to
answer your questions. You’ll get free testing "Kannact gives me a safe
supplies shipped to your door. And you’ll get
digital tools to use with your phone or laptop. place and the support I need
It’s easy and free – the cost is covered fully for to address my health."
eligible employees and family members.
The result? You’ll feel better and be on the path "I like the App and find it easy
to better health.
to use."
Learn more about this powerful benefit.
If you have any of these conditions, Kannact can help
Diabetes Cardiovascular Hypertension
Disease
39
Visit our Weber County School District website at www.kannact.com/wsd/Your Road to Better Health
➢Free Diabetes Testing Supplies
➢Free automated devices –
glucometer, blood pressure
cuff, etc.
➢Flexible coaching – By phone
or messaging
Let's Connect
We are available to answer your questions and help you take the
first steps to a better, healthier you.
• Find answers to common questions about
how our program works.
• Enroll in just minutes.
Visit our Weber County School District website at www.kannact.com/wsd/
4041
42
Employee Assistance Program
Blomquist Hale
43WHEN LIFE GETS CHALLENGING
WE CAN HELP
The Blomquist Hale Solutions Program provides direct, face-to-face guidance to address virtually
any stressful life situation or problem. Not to mention there is absolutely no cost to you. Meeting
with our team is simple. Call to schedule an appointment today. (800) 926-9619
Count On: WE CAN HELP WITH
a 24/7 Crisis Service Marital & Family Counseling
a 100% Confidential
Stress, Anxiety or Depression
a Professional, Friendly Team
Personal & Emotional Challenges
Grief or Loss
a Convenient Locations
Financial or Legal Problems
a Extended Hours
Substance Abuse or Addictions
a No Co-pay Required
Senior Care Planning
To register for our no cost online webinars, please go to:
https://blomquisthale.com/Work-Shops.html
44Life can get complicated.
Weber School District - Mental Health Solutions Program
Weber School District would like to remind you of a free service provided for the
employees. This service is called Mental Health Solutions and is administered
through Blomquist Hale Solutions.
Blomquist Hale Solutions is a resource to help address a broad range of personal
difficulties that may be causing distress. Receive brief, face-to-face
counseling to help resolve such concerns as:
• Marital Difficulties • Drug/Alcohol Addictions
• Family Problems • Legal or Financial Issues
• Stress & Anxiety • Grief & Depression
• Elderly or Child Care • Any Distressing Life Issue
These counseling services are free, with no copay. They are completely
confidential and good for you and your eligible dependents. Visits to the
EAP service do not count against your mental health benefit.
Most problems are addressed in just a few sessions over a couple of months.
However, some types of problems are not appropriately treated by short-term
counseling and may require a referral to outside mental health providers. Patients
who wish may still go directly to the traditional Mental Health Benefit as offered by
their medical plan.
Most services are available by appointment. Assistance is available for life
threatening emergencies 24 hours per day, 7 days per week. To receive assistance,
simply call 1-800-926-9619 to make an appointment.
Prevention is always the best medicine. If you or your eligible family members are
distressed by any type of life problem, please utilize the expertise made available by
this valuable service today.
Please see the link below a video that explains your benefit with Blomquist Hale.
Blomquist Hale Benefits Video
Warm Regards,
Weber School District
800.926.9619
We are glad to be here for you.
45Basic Life and AD&D/
Voluntary Life
LifeMap
46This summary is provided for your convenience only and is not intended to be inclusive of all
policy provisions. Please see your certificate for complete details. If there is any discrepancy
between this document and the master policy, master policy provisions will prevail.
Weber School District
Active Certified and Classified Employees Eligible for the Medical Plan
Life and Accidental Death & Dismemberment (AD&D)
Employer Paid
Basic Life Insurance $30,000
Basic AD&D Insurance $30,000
Age Reduction If you are still working the required number of hours to be eligible for this insurance at age 65, your
benefits will reduce according to the following scale.
Benefits reduce to: At age:
65% 65
50% 70
AD&D Schedule If due to an accident you die, lose a limb, sight of an eye or become paralyzed, the following benefits
are available.
100% of the Basic AD&D 75% of the Basic AD&D 50% of the Basic AD&D
Life Paraplegia One hand
Both hands Triplegia One foot
Both feet Sight of one eye
Sight of both eyes 25% of the Basic AD&D Speech
One hand and one foot Thumb and Index finger Hemiplegia
One hand and sight of one eye Uniplegia Hearing
One foot and sight of one eye
Quadriplegia
Seat Belt Benefit If you die in an automobile accident and were wearing your seat belt, your beneficiary (ies) will collect
an amount equal to the AD&D benefit to a maximum of $ 10,000 in addition to the Basic Life and Basic
AD&D benefits described above.
Accelerated Benefit You may collect part of your Basic Life insurance prior to death if you are diagnosed as terminally ill
and have a life expectancy of less than 12 months. You may apply for up to 80% of the Basic Life
insurance in force, to a $24,000 maximum. The remaining benefit you do not elect is payable to your
beneficiary upon your death.
Total Disability If you become totally disabled (as defined by the policy) prior to age 60 and are disabled for at least 6
consecutive months, your Basic Life insurance may be continued until you reach age 65 without further
premium payment by either your employer or you. At age 65 coverage terminates, however you may
continue coverage by applying for a conversion policy at that time.
Additional Benefits Included Adaptive Home/Vehicle, AirBag, Child Education, Coma, Day Care, Exposure and Disappearance,
Felonious Assault, Rehabilitation, Repatriation, Spouse Education.
Basic Life Insurance Exclusions None
AD&D Insurance Exclusions Benefits are not payable for losses due to suicide or attempted suicide, riot, war or act of war, military
service, felony, voluntary use of a controlled substance.
Conversion You may convert your Basic Life insurance to an individual policy if your coverage is terminated due to
termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date
your employment terminates or other loss of eligibility to apply for the Conversion policy.
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