1. Healthcare

2015 Plan Year
The School Board of Okaloosa County
Open Enrollment
Benefits Guide
RETIREES
HEALTH
DENTAL
VISION
LIFE
IMPORTANT!
READ CAREFULLY BEFORE
MAKING ENROLLMENT ELECTION.
Keep this booklet for your records.
TABLE OF CONTENTS
PAGE
DO YOU NEED TO ENROLL? .................................................................................................................................. 1
BENEFITS GUIDE HIGHLIGHTS ............................................................................................................................... 2
MEDICAL INSURANCE ........................................................................................................................................... 6
DENTAL INSURANCE ............................................................................................................................................. 10
LIFE INSURANCE .................................................................................................................................................... 11
VISION INSURANCE ............................................................................................................................................... 12
NOTIFICATION – FLORIDA BLUE CREDITABLE COVERAGE NOTICE....................................................................... 13
INSURANCE MEETING SCHEDULE & CONTACT INFORMATION ........................................................................... 15
Do you need to Enroll?
Use the checklist below to help you determine if there are
changes you need to make for the 2015 Plan Year. Remember,
everyone’s needs are different. Carefully consider the needs of
you and your family before making any benefit changes.
What you should think about:
Do you want to make a change to a
plan option?
Do you want to make a change to your
life insurance amount?
Do you want to delete dependents?
YES
NO
If you answered yes you should consider:
Changes must be marked on your
enrollment form.
You can choose to decrease the amount of
optional life insurance you have on the
enrollment form.
Indicate changes to dependents on your
enrollment form.
.
Two FRS authorization forms have been enclosed. One should be
returned to the Risk Management Department whether you make
an insurance change or not. The second FRS authorization form is
for your records. An envelope has been provided for your
convenience.
1
School Board of Okaloosa County
Benefits Guide Highlights
Calendar Year 2015
Open Enrollment Forms must be
returned to Risk Management no
later than November 7, 2014.
Open Enrollment is your one-time opportunity to review your current benefit elections and make any changes that
may be needed for you and your family. Please take the time to familiarize yourself with the guide’s contents.
We hope that after you review this guide you will have a clear understanding of the changes that will be effective
January 1, 2015, and how they may impact you and your covered dependents.
We also recommend that you attend an Open Enrollment meeting. A schedule of meetings may be found on
page 18. Please be sure to bring this enrollment guide and any questions you may have when attending your
meeting.
When is the deadline?
The deadline for all elections is November 7, 2014. If you are using the courier, please allow at least three (3) days
for delivery.
What happens if you don’t enroll by the deadline?
The benefit elections you currently have in place will rollover automatically. Your deductions will reflect the 2015
premium amounts.
What do I do if I want to make changes?
If you wish to make a plan change, you must complete, sign, and date one of the attached enrollment/benefit
authorization forms and return it to the Risk Management Department.
Use your legal name (name on retirement check) and the last four numbers of your social security number on all
correspondence sent to the Risk Management Department.
Please remember should you cancel or reduce any part of your insurance, you will not be able to reinstate that
portion of insurance in the future.
Any change you make to your insurance throughout the year must be in the Risk Management Department by the
first of the month prior to the month you need the change to take effect. For example, should you wish to cancel
your health insurance coverage after enrolling in Medicare beginning May 1st, your written cancelation request
should be forwarded to the Risk Management Department by April 1st.
2
Is your dependent a valid dependent?
If any of the dependents you currently cover are not your legal dependents or do not meet the eligibility
requirements, Open Enrollment is an opportunity to remove them from your coverage without question. The
School Board of Okaloosa County reserves the right to audit retiree benefits enrollment at any time.
What do I do with my FRS authorization form?
You must return one FRS authorization form to the Risk Management Department whether you make an
insurance change or not. The second FRS authorization form is for your records. An envelope has been provided
for your convenience.
How do I have insurance deducted from my retirement check?
Please note that the Okaloosa County School District only makes insurance deductions from your retirement
check for health, dental, vision and life policies. We do not make the deductions for your cancer and intensive
care policies. Please contact the company or your agent with questions about those deductions.
The enclosed Insurance Payroll Authorization Form will require your signature for authorization to deduct the
amount indicated from your retirement check. Please return one signed authorization form in the enclosed
envelope by Friday, November 7, 2014.
If you are making changes to any of your insurance policies, please note the change on your Insurance Payroll
Authorization form.
3
MEDICAL INSURANCE
Florida Blue (Blue Cross Blue Shield) will offer 4 health plans for 2015: Blue Options Base Plans, 3160 (Single) and
3161 (Family), and Blue Option Buy Up Plans, 3166 (Single) and 3167 (Family). If you elected medical coverage for
calendar year 2014, you will be automatically enrolled in the same coverage for calendar year 2015. If you would
like to make changes for calendar year 2015, you must complete an enrollment/benefit authorization form. To
find a physician or to check on your deductible or claims, visit www.bcbsfl.com.

The Blue Options Buy Up Plan 3166 (Single)
o Calendar Year Deductible – $1,500 In-Network; $3,000 Out-of-Network
o Coinsurance (After Deductible Met) – Employee Pays 0% In-Network; 20% Out-of-Network
o Prescription (After Deductible Met) – Employee Pays 0% In-Network; 50% Out-of-Network
o Max Out-of-Pocket – $1,500 In-Network; $6,000 Out-of-Network

The Blue Options Buy Up Plan 3167 (Family)
o Calendar Year Deductible – $3,000 In-Network; $6,000 Out-of-Network
o Coinsurance (After Deductible Met) – Employee Pays 0% In-Network; 20% Out-of-Network
o Prescription (After Deductible Met) – Employee Pays 0% In-Network; 50% Out-of-Network
o Max Out-of-Pocket – $3,000 In-Network; $12,000 Out-of-Network
The Blue Options Base Plan 3160 (Single)
o Calendar Year Deductible – $1,250 In-Network; $2,500 Out-of-Network
o Coinsurance (After Deductible Met) – Employee Pays 20% In-Network; 40% Out-of-Network
o Prescription (After Deductible Met) – Employee Pays 20%/30%/50% In-Network;
50%/50%/50% Out-of-Network
o Max Out-of-Pocket – $5,000 In-Network; $10,000 Out-of-Network


The Blue Options Base Plan 3161 (Family)
o Calendar Year Deductible – $2,500 In-Network; $5,000 Out-of-Network
o Coinsurance (After Deductible Met) – Employee Pays 20% In-Network; 40% Out-of-Network
o Prescription (After Deductible Met) – Employee Pays 20%/30%/50% In-Network;
50%/50%/50% Out-of-Network
o Max Out-of-Pocket – $5,000 In-Network; $10,000 Out-of-Network
The Healthcare Reimbursement Account (HRA) will fund $750.00 for single coverage and $1,500.00 for family
coverage for all medical plans. You may continue to file for reimbursement for dental and vision expenditures
with the HRA for 2015. Do not discard your current HRA/Take Care card until you have verified its expiration date.
These cards are good for three years. If your card is set to expire on 12/2014 then you will automatically receive a
replacement card by mail at your home address during the month of December. Make sure your address is up-todate. To check your account balance, visit www.myflexonline.com.
If you cancel your health insurance with the Okaloosa County School District, you will have 90 days to file claims
under the HRA plan. Expenses must have been incurred prior to the policy termination date. After 90 days, any
remaining account balance will be forfeited.
4
DENTAL INSURANCE
Delta Dental will continue as our dental provider for 2015. If you elected dental coverage for calendar year 2014,
you will be automatically enrolled in the same coverage for calendar year 2015. If you would like to make
changes for 2015, you must complete an enrollment/benefit authorization form. For a list of providers, visit
www.deltadentalins.com.
Retirees who are not currently enrolled in the District’s dental insurance may not re-enroll.
LIFE INSURANCE
Sun Life will continue as our life insurance provider for 2015. The District offers basic life insurance to all retirees
at a reduced rate. If you had optional life insurance coverage as an active employee, you may continue it as a
retiree. Optional life insurance must be elected at retirement. If you refuse it upon retirement it may not be
added later. While you may elect to reduce the amount of your optional life insurance coverage, it cannot be
increased after retirement. Optional life insurance coverage is rated based on the age banded rates listed in the
life insurance section of this booklet.
VISION INSURANCE
EyeMed will continue as our vision provider for 2015. EyeMed will offer two (2) plans for retirees that are
currently enrolled in vision. If you elected vision coverage for calendar year 2014, you will be automatically
enrolled in the same coverage for calendar year 2015. If you would like to make changes for calendar year 2015
you must complete an enrollment/benefit authorization form.
THE PRIVACY RULE
Congress passed the Health Insurance Portability and Accountability Act (HIPPA), in1996. The privacy component
of this law, also known as the Privacy Rule, was effective April 14, 2003. It is imperative you understand the
Privacy Rule prohibits anyone, not even your spouse or other family members, from getting information in regard
to you or a claims issue with any of your insurance unless you have signed an authorization form naming the
specific persons to be given this information. Authorization forms can be obtained by calling the Customer
Service phone number on your ID card and requesting the form. The signed authorization form will allow the
insurance company to then release health and/or dental information to family members and/or district
personnel.
5
6
OKALOOSA COUNTY SCHOOL DISTRICT
January 1, 2015 Renewal Plans
COST SHARING
Maximums shown are Per Benefit Period (BPM) unless
noted
Deductible (DED) (Per Person/Family Agg)
In-Network
Out-of-Network
Coinsurance (Member Responsibility)
In-Network
Out-of-Network
Out of Pocket Maximum (Per Person/Family Agg)
In-Network
Out-of-Network
Lifetime Maximum
PROFESSIONAL PROVIDER SERVICES
Allergy Injections
In-Network Family Physician
In-Network Specialist
Out-of-Network
E-Office Visit Services
In-Network Family Physician
In-Network Specialist
Out-of-Network
Office Services
In-Network Family Physician
In-Network Specialist
Out-of-Network
Provider Services at Hospital and ER
In-Network Family Physician
In-Network Specialist
Out-of-Network
Provider Services at Other Locations
In-Network Family Physician
In-Network Specialist
Out-of-Network
Radiology, Pathology and Anesthesiology Provider
Services at Hospital or Ambulatory Surgical Center
In-Network Specialist
Out-of-Network
PREVENTIVE CARE
Adult Wellness Office Services
In-Network Family Physician
In-Network Specialist
Out-of-Network
Colonoscopies (Routine)
Covered at 100% of Allowed Amt
In-Network
BlueOptions
HSA-Compatible 3166
BlueOptions
HSA-Compatible 3167
BlueOptions
HSA Compatible 3160
BlueOptions
HSA Compatible 3161
(Single Coverage)
(Family Coverage)
(Single Coverage)
(Family Coverage)
$1,500 / Not Applicable
$3,000 / Not Applicable
$3,000 / $3,000
$6,000 / $6,000
$1,250 / Not Applicable
$2,500 / Not Applicable
$2,500 / $2,500
$5,000 / $5,000
0%
20%
Includes DED & Coins
$1,500 / Not Applicable
$6,000 / Not Applicable
No Maximum
0%
20%
Includes DED & Coins
$3,000 / $3,000
$12,000 / $12,000
No Maximum
20%
40%
Includes DED & Coins
$5,000 / Not Applicable
$10,000 / Not Applicable
No Maximum
20%
40%
Includes DED & Coins
$5,000 / $5,000
$10,000 / $10,000
No Maximum
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED
In-Ntwk DED (No Coins)
DED
DED
In-Ntwk DED (No Coins)
DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
In-Ntwk DED (No Coins)
DED
In-Ntwk DED (No Coins)
DED + 20%
In-Ntwk DED + 20%
DED + 20%
In-Ntwk DED + 20%
$0
$0
20% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
$0
$0
20% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
20% (No DED)
20% (No DED)
40% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
20% (No DED)
20% (No DED)
40% (No DED)
Age 50+ then Frequency
Schedule Applies
$0
7
COST SHARING
Maximums shown are Per Benefit Period (BPM) unless
noted
Out-of-Network
Mammograms (Routine and Dx)
In-Network
Out-of-Network
Well Child Office Visits (No BPM)
In-Network Family Physician
In-Network Specialist
Out-of-Network
EMERGENCY/URGENT/CONVENIENT CARE
Ambulance
In-Network
Out-of-Network
Convenient Care Centers (CCC)
In-Network
Out-of-Network
Emergency Room Facility Services
(also see Professional Provider Services)
In-Network
Out-of-Network
Urgent Care Centers (UCC)
In-Network
Out-of-Network
FACILITY SERVICES - HOSP/SURG/ICL/IDTF
Unless otherwise noted, physician services are in addition to
facility services. See Professional Provider Services.
Ambulatory Surgical Center
In-Network
Out-of-Network
Independent Clinical Lab
In-Network
Out-of-Network
Independent Diagnostic Testing Facility Xrays and AIS (Includes Physician Services)
In-Network - Advanced Imaging Services (AIS)
Out-of-Network
Inpatient Hospital (per admit)
In-Network
Out-of-Network
Inpatient Rehab Maximum
Outpatient Hospital (per visit)
In-Network
Out-of-Network
Therapy at Outpatient Hospital
BlueOptions
HSA-Compatible 3166
BlueOptions
HSA-Compatible 3167
BlueOptions
HSA Compatible 3160
BlueOptions
HSA Compatible 3161
(Single Coverage)
(Family Coverage)
(Single Coverage)
(Family Coverage)
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
20% (No DED)
$0
$0
20% (No DED)
20% (No DED)
20% (No DED)
40% (No DED)
20% (No DED)
20% (No DED)
40% (No DED)
DED
In-Ntwk DED (No Coins)
DED
In-Ntwk DED (No Coins)
DED + 20%
In-Ntwk DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED
DED + 40%
DED
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
Option 1 - DED
Option 2 - DED
DED + 20%
30 Days
Option 1 - DED
Option 2 - DED
DED + 20%
30 Days
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
30 Days
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
30 Days
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
8
COST SHARING
Maximums shown are Per Benefit Period (BPM) unless
noted
In-Network
Out-of-Network
BlueOptions
HSA-Compatible 3166
BlueOptions
HSA-Compatible 3167
BlueOptions
HSA Compatible 3160
BlueOptions
HSA Compatible 3161
(Single Coverage)
(Family Coverage)
(Single Coverage)
(Family Coverage)
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED + 20%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED + 20%
Option 2 - DED + 20%
DED + 40%
Option 1 - DED + 20%
Option 2 - DED + 20%
DED + 40%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED
Option 2 - DED
DED + 20%
Option 1 - DED + 20%
Option 2 - DED + 20%
DED + 40%
Option 1 - DED + 20%
Option 2 - DED + 20%
DED + 40%
DED
In-Ntwk DED (No Coins)
DED
In-Ntwk DED (No Coins)
DED + 20%
In-Ntwk DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
In-Ntwk DED (No Coins)
DED
In-Ntwk DED (No Coins)
DED + 20%
In-Ntwk DED + 20%
DED + 20%
In-Ntwk DED + 20%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED
DED + 20%
DED
DED
DED + 20%
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 20%
DED + 40%
DED
DED + 20%
DED
DED + 20%
DED + 20%
DED + 40%
DED + 20%
DED + 40%
DED
DED + 20%
Enteral Formulas:$2,500 All
Other: No Maximum
DED
DED + 20%
20 Visits
DED
DED + 20%
No Maximum
DED
DED + 20%
Enteral Formulas:$2,500 All
Other: No Maximum
DED
DED + 20%
20 Visits
DED
DED + 20%
No Maximum
DED + 20%
DED + 40%
Enteral Formulas:$2,500 All
Other: No Maximum
DED + 20%
DED + 40%
20 Visits
DED + 20%
DED + 40%
No Maximum
DED + 20%
DED + 40%
Enteral Formulas:$2,500 All
Other: No Maximum
DED + 20%
DED + 40%
20 Visits
DED + 20%
DED + 40%
No Maximum
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient Hospitalization
In-Network
Out-of-Network
Outpatient Hospitalization (per visit)
In-Network
Out-of-Network
Provider Services at Hospital and ER
In-Network Family Physician or Specialist
Out-of-Network Provider
Physician Office Visit
In-Network Family Physician or Specialist
Out-of-Network Provider
Emergency Room Facility Services (per visit)
In-Network
Out-of-Network
Provider Services at Locations other than Hospital and ER
In-Network Family Physician
In-Network Specialist
Out-of-Network Provider
OTHER SPECIAL SERVICES AND LOCATIONS
Advanced Imaging Services in Physician's Office
In-Network Family Physician
In-Network Specialist
Out-of-Network
Birthing Center
In-Network
Out-of-Network
Diabetic Equipment and Supplies*
In-Network
Out-of-Network
Durable Medical Equipment, Prosthetics, Orthotics BPM
In-Network
Out-of-Network
Home Health Care BPM
In-Network
Out-of-Network
Hospice LTM
9
COST SHARING
Maximums shown are Per Benefit Period (BPM) unless
noted
In-Network
Out-of-Network
Outpatient Therapy and Spinal Manipulations BPM
Skilled Nursing Facility BPM
In-Network
Out-of-Network
BlueOptions
HSA-Compatible 3166
BlueOptions
HSA-Compatible 3167
BlueOptions
HSA Compatible 3160
BlueOptions
HSA Compatible 3161
(Single Coverage)
(Family Coverage)
(Single Coverage)
(Family Coverage)
DED
DED + 20%
35 Visits (Includes up to 26
Spinal Manipulations)
60 Days
DED
DED + 20%
DED
DED + 20%
35 Visits (Includes up to 26
Spinal Manipulations)
60 Days
DED
DED + 20%
DED + 20%
DED + 40%
35 Visits (Includes up to 26
Spinal Manipulations)
60 Days
DED + 20%
DED + 40%
DED + 20%
DED + 40%
35 Visits (Includes up to 26
Spinal Manipulations)
60 Days
DED + 20%
DED + 40%
In-Network Health Plan DED
In-Network Health Plan DED
In-Network Health Plan DED
In-Network Health Plan DED
In-Ntwk DED then $0/$0/$0
In-Ntwk DED then $0/$0/$0
In-Ntwk DED + 20%/30%/50%
In-Ntwk DED + 20%/30%/50%
In-Ntwk DED then $0 / $0 / $0
In-Ntwk DED then $0 / $0 / $0
In-Ntwk DED + 20%/30%/50%
In-Ntwk DED + 20%/30%/50%
$861.65
2,003.78
$752.67
$1,803.35
PRESCRIPTION DRUGS
Deductible
In-Network
Retail (30 Days)
Generic/Preferred Brand/Non-Preferred
Out-of-Network
Retail (30 Days)
Generic/Preferred Brand/Non-Preferred
Rates
Retirees
This is not an insurance contract or Benefit Booklet. The above Benefit Summary is only a partial description of the many benefits and services covered by Blue Cross and Blue Shield of Florida, Inc., an
independent licensee of the Blue Cross and Blue Shield Association. For a complete description of benefits and exclusions, please see Blue Cross and Blue Shield of Florida’s Benefit Booklet and Schedule of
Benefits; their terms prevail.
Florida Blue is currently reviewing all health care reform legislation—the Patient Protection and Affordable Care Act and the Health Care and Education
Affordability Reconciliation Act—which includes numerous provisions to expand access to health insurance, improve the quality and comprehensiveness of
coverage, and make coverage more affordable for all Americans. Although some major elements of reform begin in 2010, others will be implemented over the next
several years. Therefore, the information in our enrollment materials is subject to change based on the final result of this legislation.
10
OKALOOSA COUNTY SCHOOL DISTRICT DENTAL INSURANCE PLAN – DELTA DENTAL
Eligibility
Primary enrollee, spouse and eligible dependent children to age 26.
Deductibles
$125 per person / $375 per family each calendar year
Deductibles waived for Diagnostic & Preventive Services (D & S) for
Participating Providers only
Maximum Benefit
$2,000 per person each calendar year
Diagnostic & Preventive Services (D & P) count towards maximum
Waiting Period(s) – Waived at
Initial Enrollment Only
Diagnostic &
Preventive
0 Months
Benefits and
Covered Services*
Diagnostic & Preventive Services (D & P)
Exams, cleanings, x-rays, sealants
Basic Services
Fillings, simple tooth extractions
Endodontists (Root Canals)
Covered Under Basic Services
Oral Surgery
Covered Under Basic Services
Non-Surgical Periodontics (Gum Treatment)
Covered Under Basic Services
Crowns, Inlays, Onlays & Cast Restorations
Covered Under Basic Services
Surgical Periodontics (Gum Treatment)
Covered Under Major Services
Major Services
Bridges, Dentures and Implants
Basic
6 Months
Major
12 Months
Orthodontics
N/A
(No Benefits)
Delta Dental Dentists**
Delta %/Employee %
Non-Delta Dental Dentists**
Delta %/Employee %
100%/0%
100%/0%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
80%/20%
50%/50%
50%/50%
50%/50%
50%/50%
Orthodontic Benefits
Not Covered
Premiums
Type of Employee
Retiree
Single
$33.23
Family
$93.91
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
** Reimbursement is based on PPO contracted fees for PPO dentists, Maximum Plan Allowance for Premier dentists and Maximum Plan
Allowance for non-Delta Dental dentists.
11
A list of dental providers can be found at www.deltadentalins.com by clicking the “Find a Dentist” option or
on the Risk Management page of the OCSD website under the Delta Dental tab.
Delta Dental Insurance Company
1130 Sanctuary Parkway, Suite 600
Alpharetta, GA 30009
Customer Service
800-521-2651
Claims Address
P.O. Box 1809
Alpharetta, GA 30023-1809
www.deltadentalins.com
Basic Restorative care includes the treatment of caries, commonly referred to as cavities and tooth decay. Your plan offers coverage for
anterior composite resin fillings and posterior amalgam fillings. But what does this mean?
Your mouth is comprised of two sections of teeth: anterior and posterior. Anterior teeth are the six upper and six lower front teeth. All
other teeth are considered posterior teeth. Your plan provides coverage for composite resin fillings (tooth colored fillings) on your anterior
teeth and amalgam coverage (silver colored fillings) on your posterior teeth.
However, this does not mean you cannot select a composite resin filling for a posterior tooth. If you choose a composite resin filling on a
posterior tooth, your plan will reimburse you at the amalgam level. You will be responsible for the difference between the dentist’s fees
for the composite filling vs. the amalgam filling.
OKALOOSA COUNTY SCHOOL DISTRICT LIFE INSURANCE PLAN – SUN LIFE FINANCIAL
As a retiree, you may either maintain the benefit you currently have or elect to reduce the benefit to the
amount of your choice. You may not purchase additional coverage.
Basic Life Insurance – Paid by Retiree - Under Age 70
Before reaching age 70, you may maintain a basic life insurance policy at a composite rate of $0.457/$1,000. The
maximum allowed for this policy is $25,000. Please note, that the amount of basic life insurance is limited to the
amount of basic life insurance coverage in force at the time of retirement.
Optional Life Insurance – Paid by Retiree - Under Age 70
Before reaching age 70, you may also retain any optional life insurance that was in force before retirement. The
premium will be based on the age banded rates shown below:
Retiree Age
< 50
50-54
55-59
60-64
65-69
Premium
$0.51/$1,000
$0.65/$1,000
$1.13/$1,000
$1.46/$1,000
$2.35/$1,000
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Basic Life Insurance – Paid by Retiree - Age 70 & Over
Upon turning 70, basic life insurance is reduced to $10,000. Risk Management will notify you of your options by
letter. You will have 30 days to notify Risk Management in writing that you would like to purchase the $10,000 at
a rate of $0.457/$1,000. If you elect not to enroll within the 30 days, you may not enroll at a later date.
Optional Life Insurance – Paid by Retiree - Age 70 & Over
Upon turning 70, all optional life insurance is dropped. However, as a retiree, you may choose to purchase
$10,000 in optional life insurance based on the age bands shown below:
Retiree Age
70-74
75-79
80-84
85-89
90+
Premium
$ 4.36/$1,000
$ 6.79/$1,000
$10.06/$1,000
$18.39/$1,000
$46.44/$1,000
OKALOOSA COUNTY SCHOOL DISTRICT VISION INSURANCE PLAN
If you are currently enrolled in vision insurance, you will be automatically enrolled in calendar year 2015. If you
want to change coverage, you must complete an enrollment form. Once you enroll in vision insurance, you
cannot cancel coverage during the year.
The Board offers the following two vision plans:
Benefits and Covered Services
Deductible – Exam
Deductible – Eye Glass Lenses and/or Frames
Maximum – Frame
Maximum – Elective Contacts
Maximum – Medically Necessary Contacts
Type of Employee
Retiree
Single - Low
$5.34
Low Plan (Plan 3)
$10
$25
$120
$105
Paid in Full
Premiums
Family - Low
$14.80
High Plan (Plan 4)
$10
$25
$150
$150
Paid in Full
Single - High
$6.55
Family - High
$18.21
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Important Notice from
Blue Cross and Blue Shield of Florida D/B/A Florida Blue
and Health Options Inc. D/B/A Florida Blue HMO.
About Your Prescription Drug Coverage and Medicare
This notice applies ONLY to individuals who are over age 65 and on Medicare or approaching
age 65 and eligible for Medicare or receiving Medicare Disability benefits. Please disregard
this notice if you are not in one of these categories of individuals.
Please read this notice carefully and keep it where you can find it. This notice has information about your current
prescription drug coverage with Florida Blue and about your options under Medicare’s prescription drug coverage. This
information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you
should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the
plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make
decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if
you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers
prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some
plans may also offer more coverage for a higher monthly premium.
2. Florida Blue has determined that the prescription drug coverage offered by your health plan is, on average for all plan
participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore
considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and
not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to
December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be
eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Florida Blue coverage will be affected. You can keep this
coverage if you elect to join a Medicare drug plan and your Florida Blue health plan will coordinate your benefits with
Medicare for drug coverage. If you would like more information about the prescription drug plan provisions and options
that Medicare eligible individuals may have when they become eligible for Medicare prescription drug coverage, see pages
7-9 of the CMS Disclosure of Creditable Coverage to Medicare Part D Eligible Individuals Guidance located at
http://www.cms.hhs.gov/CreditableCoverage/.
If you do decide to join a Medicare drug plan and drop your current Florida Blue coverage, be aware that you and your
dependents will not be able to get this coverage back.
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When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Florida Blue and don’t join a Medicare drug
plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a
Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up
by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage.
For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19%
higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you
have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug
Coverage…
Contact us for further information at 1-800-FLA-BLUE (TTY: 711). NOTE: You’ll get this notice each year. You will
also get it before the next period you can join a Medicare drug plan, and if this coverage through Florida Blue changes.
You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug
Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by
Medicare drug plans. For more information about Medicare prescription drug coverage:



Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare &
You” handbook for their telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For
information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-7721213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the
Medicare drug plans, you may be required to provide a copy of this notice when you join
to show whether or not you have maintained creditable coverage and, therefore, whether
or not you are required to pay a higher premium (a penalty).
Date: 9/23/2014
Name of Entity: Florida Blue
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2014 Insurance Meeting Schedule
Schedule
Maintenance - South
Transportation - South
Destin Elementary
Day
Monday
Monday
Monday
Date
Oct. 6
Oct. 6
Oct. 6
Time
7:30 a.m.
9:30 a.m.
3:15 p.m.
Contact
Steve Bolton
Maggie Hattaway
Janet Stein
Location
Beck Building
Beck Building
Media Center
Phone
689-7193
833-3554
833-4360x1
Maintenance - Central
Transportation Central
Nutrition Center
Ft. Walton Beach
High School
Tuesday
Oct. 7
7:30 a.m.
Steve Bolton
Dining Facility
689-7193
Tuesday
Oct. 7
9:30 a.m.
Pam Jenks
Dining Facility
833-4161
Tuesday
Oct. 7
11:00a.m.
Valerie Wooten
Tuesday
Oct. 7
4:30 p.m.
Charlene Couvillon
Dining Facility
Media Center
Conference Room
301-3020
833-3300
x3x1
Maintenance - North
Wednesday
Oct. 8
7:30 a.m.
Steve Bolton
Transportation - North
Wednesday
Oct. 8
9:30 a.m.
Mary Stevens
Carver Hill - DJJ
Wednesday
Oct. 8
1:30 p.m.
Sherry Anglin
Shoal River Middle
School
Wednesday
Oct. 8
4:00 p.m.
Cheree Davis
Lunch Room
689-7229
x2x2
Teacher’s Credit Union
Thursday
Oct. 9
8:30 a.m.
Jerry Maughon
Credit Union-Crestview
682-2225
Lowery - Active
Lowery - Retirees
Nutrition Center Retirees
Ruckel Middle School
Monday
Monday
Oct. 13
Oct. 13
9:00 a.m.
11:00 a.m.
Russ Frakes
Russ Frakes
Main Board Room
Main Board Room
833-3190
833-3190
Monday
Oct. 13
2:30 p.m.
Valerie Wooten
Dining Facility
301-3020
Monday
Oct. 13
4:00 p.m.
Kim Piccorossi
Media Center
833-4142
Tuesday
Oct. 14
11:00 a.m.
Tommy Harvell
Auditorium
689-7177
Tuesday
Oct. 14
3:00 p.m.
Mike Martello
Auditorium
689-7279
Wednesday
Oct. 15
2:40 p.m.
Lee Martello
Media Center
652-4111
Wednesday
Oct. 15
5:00 p.m.
Tommy Harvell
Media Center
689-7177
Crestview High School Retirees
Baker School –
Employees & Retirees
Laurel Hill – Employees
& Retirees
Crestview High School Employees
Carver HillTraining Room
North TransportationBreak Room
Carver HillTraining Room
689-7193
689-7301
689-7117
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RISK MANAGEMENT DEPARTMENT CONTACT INFORMATION
Hours of Operation: 7:30 a.m. to 4:00 p.m.
Address: 120 Lowery Place, S.E., Building C, Fort Walton Beach, FL 32548
Telephone Number: 833-3190
Fax Number: 833-3195
For Blue Cross, Tricare, Life and Long Term Disability questions, please contact one of the following:
Michael J. Locht
Kevin H. Locht
Florida Financial Services, Inc.
Corporate Benefits of the Emerald Coast, Inc.
Phone (850)-837-3883
Phone (850) 244-0849
Fax (850) 837-9858
Fax (850) 244-0852
For Delta Dental questions, please contact:
Barnes Insurance and Financial Services
327 Racetrack Rd.
Fort Walton Beach, FL 32547
Phone (850) 586-7766
www.deltadentalins.com
For FSA/HRA Account questions, please contact:
Kenny Anderson
Lockard & Williams
(800) 530-7222
Fax (850) 479-2923
For Vision questions, please contact:
EyeMed
4000 Luxottica Place
Mason, OH 45040
(866) 800-5457
www.eyemed.com
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