Fisher Athletic Benefits Guide : simplebooklet.com

You must request a change to your benefitswithin 30 days of your life event (60 days forchanges involving Medicaid eligibility). Documentation may be required.Enroll nowYour benefit plans are in effect November 1 –October 31 each year. In general, there are threetimes you can make benefit selections:Making benefit selectionsGetting startedEligibility Enrolling in coverageFor youCovering your familyMedical, dental and vision: until age 26regardless of student or marital statusChild life insurance: until age 21, or 26 if afull-time studentYou are eligible for benefits as a full-time employeeworking at least 30 hours per week.Covering your familyYou may also cover your eligible dependents whenyou elect coverage for yourself.You may cover your legal spouse or domesticpartner.Dependent children are eligible:Your Spouse or PartnerYour ChildrenYour benefits begin on the next day following 90days of fulltime employment; this is your effectivedate. Be sure to submit your selections within yourfirst 30 days of benefits eligibility/within your first30 days of employment. Your benefit selections will be in effect throughOctober 31. When you're first eligible Open Enrollment is your one chance each year toreview your coverage options and make changes toyour benefits.Your choices are in effect from November 1–October 31 of the following year unless you have aqualifying life event. At Open Enrollmentmarriage or divorce, birth or adoption, death of a covered dependent, and a change in eligibility through Medicare,Medicaid, or a spouse or parent's coverage. Qualifying life events allow you to change yourcoverage during the year outside of OpenEnrollment. These include: If you have a qualifying life event

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Balance billingWhen you use an out-of-networkmedical or dental provider, theymay bill you the difference betweenwhat they charge and the amountyour insurance pays.Medical: balance billing is inaddition to – and does not counttowards – your out-of-pocketmaximum.CoinsuranceAfter you’ve met your deductible,you’re sometimes responsible for apercentage of the cost of themedical care, dental care, orprescription medication youreceived. This percentage iscoinsurance.CopayA flat fee you pay each time youreceive a copay-eligible medical,dental, or vision service orprescription medication. DeductibleThe amount you’re responsible forpaying in care expenses before themedical or dental plan starts payingdeductible-eligible expenses.In-networkIn-network care is always yourlowest-cost option. Networks aregroups of medical, dental, andvision providers, pharmacies, andfacilities that agree to discount thecost of their care or service.Out-of-pocket maximumThe most you’ll pay for covered in-network medical care in a year. Thisincludes your deductible, anycoinsurance or copays, andprescription drugs. The out-of-pocket maximum doesnot include your premium (theamount you pay for coverage), non-covered expenses, or out-of-network care that’s been balancebilled.Primary care physicianA primary care physician (PCP) isyour main medical doctor – usuallya general practitioner (GP), familydoctor, internist, OB/GYN, orpediatrician (for children).Referral/pre-authorizationSome specialty medical providersand services require a referral froma primary doctor. These may include- but are not limited to -cardiology, psychiatry, orthopedicsurgeons, rheumatology, surgery,and imaging (CT or MRI).Have questions? Your advocate is here to help youwith all things benefits. See theircontact information on the nextpage.How to handle medicalbills (4:46)Annual NoticesWe’re required to tell you about certainrights and responsibilities you have as anemployee of Fisher Athletic. You can request a paper copy at nocharge from:Fisher Athletic(704)636-5713Download nowHelpful terms & resourcesGetting startedWe've removed as much jargon as possible.But you’ll probably still encounter some terms as you enroll in and use your benefits, and wewant you to be prepared!

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In-network carePPO planNetwork name:National PPOAnnual Deductible (DED)Out-of-pocket maximum$9,100 per person $18,200 family max$9,100 per person $18,200 family maxPre-tax account availabilityNonePreventive carePrimary care visitSpecialist visitVirtual visit100% coveredDED then you pay 0%DED then you pay 0%DED then you pay 0% (in Network only)Urgent careEmergency roomInpatient hospital careDED then you pay 0%DED then you pay 0%DED then you pay 0%Prescription drugsTier 1 DrugsTier 2 DrugsTier 3 DrugsTier 4 DrugsTier 5 Drugs(30 days )$10 copay$25 copay $40 copay $80 copay25% ($100/$200)Out-of-network careAnnual deductible Out-of-pocket maximum Balance billing applies$18,200/ $36,400$18,200/ $36,400Your cost for coverageEmployee onlyEmployee + SpouseEmployee + Child(ren)Employee + FamilyPer paycheck$$$$See plan detailsMedical insuranceMental health supportReminder:Fisher Athletic has added areimbursement benefit. This benefit will help payfor eligible healthcareexpenses to lower yourdeductible. See pages 7-8.The information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.what you pay for the plan, what you pay when you get care, how out-of-network care is covered, andyour annual maximum cost for care (out-of-pocket maximum).All plans cover in-network preventive care at 100%, prescription drugs, andinclude an annual limit on your expenses. The differences are: Select from three medical options through BCBCNC.For out-of-network benefits, refer to your plan documents.

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To start using Accredo, contact a patient care advocate at 1-833-599-0513.Blue Cross and Blue Shield of North Carolina (Blue Cross NC) remains committedto helping you get the specialty medications and support you need to manageyour health and well-being. That’s why we’re working with Accredo.Accredo has 15 Therapeutic Resource Centers® (TRCs), each focused on aspecific specialty condition. You’ll have direct access to counseling and educationon your health condition from specially trained pharmacists, nurses and otherclinicians. They’ll discuss how to reduce your disease progression, achieve your treatment goals, manage any side effects and find the most effective way to take your medicines. They’ll also monitor your progress and offer support with any financial or insurance concerns you may have. • Access to 99.9% of specialty medicines so you’re more likely to get all specialty medicines from one pharmacy• Simple communication, including refill reminders, through phone, email, text or web• A mobile app where you can refill and track prescriptions, make payments and set reminders to take your medicines*• 500 condition-specific pharmacists and 600+ nurses, all offering one-on-one counseling• Free standard delivery• 24/7 support• Asthma and allergies• Blood disorders• Cystic fibrosis treatments• Endocrine conditions• Fertility issues• Hepatology conditions• HIV treatments• Immune disorders• Oncology treatments• Neurology and multiple sclerosis treatments• Pulmonary arterial hypertension conditions• Rare diseases• Rheumatoid arthritis and inflammatory conditions• Select specialty conditions• Transplant treatmentsPersonalized, one-on-one supportA safe and convenient way to get your medicine. Accredo offers:Accredo TRCs IncludeAccredo® Safe and convenient specialty medicinesLearn moreBlueCrossNC. com*Not all medicines can be refilled on the mobile appAccredo is an independent company that is solely responsible for the services it is providing. Accredo does not offer Blue Cross or Blue Shield products or services.BLUE CROSS®, BLUE SHIELD®, and the Cross and Shield symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other trade names are the property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. U38373, 6/21

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To help control drug costs, your employer has chosen the NetResults performanceformulary for your prescription drug coverage. This program is administeredthrough our pharmacy benefits manager, Prime Therapeutics (Prime).The NetResults formulary helps manage rising drug costs by replacing high-cost drugs with their lower-cost alternatives.2 The NetResults drug list includes nearly all of the most-used generic drugs and 90% of the most-used brand-name drugs.3NetResults drug benefits are tiered, which means the amount you pay may vary. Tier 1drugs are typically the lowest cost option. If you have a medicine that is in a higher tieror requires a medical necessity prior authorization, you should talk with your doctor tosee if there is an available alternative.For added savings, the NetResults formulary can be paired with a network of pharmacies selected by your employer. There are two pharmacy networks: (1) Limited National (Rx E5) and (2) Broad Plus (Rx E3). Refer to your member ID card or confirm your network with your benefits administrator. See instructions below to search for participating pharmacies.Learn moreImportant termsFormulary – A list of prescription drugscovered by your health benefit plan. Alsocalled a drug list.Generic Drug – An FDA-approved drug with the same active ingredient, strength and dose as a brand-name drug. Generics provide the same health benefits.Tier – A way to group drugs within a formulary according to cost; Tier 1 being the lowest cost, Tier 5 being highest.To learn more about how your drugbenefits work, visit or contact your benefits administrator.BlueCrossNC.com/find-a-drug-or-pharmacy1 For self-funded employers with 100+ employees. 2 There are few exceptions where brand-name drugs with a low-cost alternative are covered and even preferred due to negotiated pricing.3 This estimate was derived from a 2020 internal Blue Cross and Blue Shield of North Carolina pharmacy department analysis.4 New-to-market drugs and variations of those drugs will not be added to this formulary until they have been evaluated and approved by Prime Therapeutics. Additional restrictions may apply. Blue Cross NC evaluates its prescription drug formularies periodically. The formularies and the copayments for certain prescription drugs are subject to change at any time.5 If your medication is not listed in a specific tier, it will be part of the highest cost tier.NetResults is a trademark of Prime Therapeutics. Prime Therapeutics is an independent company. It is the pharmacy benefit manager for Blue Cross NC and does not offer Blue Cross or Blue Shield products or services.BLUE CROSS®, BLUE SHIELD®, and the Cross and Shield symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and trade names are the property of their respective owners. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. U13198b, 6/22What tier is my medication? Is my pharmacy in-network?Members:JANESAMSubscriber Name:JOHN DOESubscriber ID:01Group No: 123456789RxBin/Group: 123456Date Issued: 00/00/00In-Network Member Responsibility:02Primary $2503Specialist $50Urgent Care $50ER $200Prescription Drug $8/$35/$50/25%Preventive Care No CopayYPPW123456789Rx E5 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) provides free aids to service people with disabilities aswell as free language services for people whose primary language is not English. Please contact the Customer Servicenumber on the back of your ID card for assistance.Blue Cross and Blue Shield of North Carolina (Blue Cross NC) proporciona asistencia gratuita a las personas condiscapacidades, así como servicios lingüísticos gratuitos para las personas cuyo idioma principal no es el inglés.Comuníquese con el número para servicio al cliente que aparece en el reverso de su tarjeta del seguro para obtener ayuda.YOUR NETRESULTSTM DRUG FORMULARY1 A performance formulary with tiered Rx benefitsYour plan and formulary type are printed on the front of your member ID card. Yourformulary type is shownin the bottom-right corner. Look for the Rx symboland a letter/number combination, as shown on the member ID card to the right. This will indicate theNetResults formulary with either the Limited Nationalor Broad Plus network. Here’s howto see if your drug and pharmacy are available:4If you are moving to NetResults and do not have a new Blue Cross and Blue Shield ofNorth Carolina (Blue Cross NC) member ID card, contact your benefits administrator toget your Rx letter code.

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Hybrid Plan - EmployeeThe most you could pay out of your pocket is $3,240 for medical costs, aslong as you use in-network providers, plus any prescription copays. Youcannot use your Benefit Card for Prescription copays.$9,100 BCBS Employee Only$9,100 Out of Pocket MaximumThe information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.The first $1,000 of the BCBS $9,100 deductible is paid by Fisher AthleticEquipment, Inc. Active employees will be provided with a Benefits Card to directlyaccess the $1,000 and to pay providers the BCBS discounted amount. COBRAparticipants will need to submit their BCBS Explanation of Benefits (EOB) toreceive their reimbursement$1,000/$2,000 100% Fisher Athletic Equipment, Inc.Of the remaining $8,100 of the BCBS deductible Fisher Athletic Equipment, Inc.will reimburse the employee for 60% ($4,860) and the employee is responsible for40% ($3,240). This will be a check reimbursement – sent to the employee. Theemployee will use this money to pay their providers $3,240 40% Employee$4,860 60% Fisher Athletic Equipment, Inc.$8,10021The BCBSNC deductible is shared between the employee andcompany.$1,000$8,100

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Hybrid Plan - Employee/FamilyThe most you could pay out of your pocket is $3,240/$6,480 for medical costs,as long as you use in-network providers, plus any prescription copays. You cannot use your Benefit Card for Prescription copays. $9,100/$18,200 BCBS Employee/Family Deductible$9,100/$18,200 Out of Pocket MaximumThe information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.The first $1,000 of each of two (2) possible $9,100 deductibles can be paid by usingyour Employer Sponsored Benefits Card. Active employees will be provided aBenefits Card with direct access to $1,000. Active dependents will be providedwith their own Benefit Cards linked to a shared $1,000.$1,000/$2,000 100% Fisher Athletic Equipment, Inc.Of the remaining $8,100 of each or two (2) possible BCBS deductible. FisherAthletic Equipment, Inc will reimburse the employee for 60% ($4,860) of each oftwo (2) possible deductibles and the employee is responsible for 40% ($3,240) ofeach of the two (2) possible deductibles. This will be a check reimbursement – sentto the employee. The employee will use this money to pay their providers$3,240 40% Employee$4,860 60% Fisher Athletic Equipment, Inc.$8,100/$6,480 40% Employee/Dep(s)/$9,720 60% Fisher Athletic Equipment, Inc. $16,20021The BCBSNC deductible is shared between the employee andcompany.$1,000/$2,000$8,100/$1,400

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SELECT “NEW USER”ENTER YOUR BENEFIT CARDNUMBER (NOSPACES/DASHES)EMPLOYEE ID IS YOUR SOCIALSECURITY NUMBER (NODASHES)CREATE USER ID ANDPASSWORDVisit our website at : www.mywealthcareonline.com/ieb to log-in to your account and checkthe balance on your card. WEBSITE ADDRESS:www.mywealthcareonline.com/iebPASSWORD MUST INCLUDE ATLEAST ONE LETTER AND ONENUMBEREEmployee Only Coverage· If you’ve used the $1,000 on your card, no need to wait until youpay your provider, send your EOBs to IEB.· Be sure to always present your BCBS ID card so you’ll get the BCBSdiscount, and the charge will be applied to your BCBS $9,100deductible.· Once you’ve met $1,000+ of your BCBS $9,100 deductible, IEB willreimburse you 60% of the final $8,100 of your BCBS deductible bycheck. Use this money to pay your provider.Family Coverage (Employee +Spouse), (Employee +Child(ren)), Family· You will receive 2 Benefit Cards with a $1,000 on each.· If you’ve used the $1,000 on either/both cards, no need to waituntil you pay your provider, send your EOBs to IEB.· Be sure to always present your BCBS ID card so you’ll get the BCBSdiscount, and the charge will be applied to your two BCBS $9,100deductibles.· Once you’ve met $1,000+ of each BCBS $9,100 deductible, IEB willreimburse you 60% of the final $8,100 of each BCBS deductible bycheck. Use this money to pay your provider.Innovative Employee Benefits, Inc. The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlyingplan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlyinginsurance documents will govern in all cases.Reimbursement PlanIEB PLAN YEAR: 11/1/2022 – 10/31/2023• Present your BCBS ID card at the provider’s office/hospital.• In the Specialists’ office, you will normally not pay at the time of service unlessthe specialists’ office knows the BCBS discounted amount to charge you. Generally speaking, most specialists’ offices have to wait on the BCBSexplanation of benefit (EOB) to get that information.• If the provider’s office insists on payment at the time of service, make a “downpayment” of $50 using your Benefits Card. • Provider will file your claim with BCBS.• BCBS will send Explanation of Benefit (EOB) to provider, and to your home.• Provider will send you a bill. If you made a $50 down payment while you werethere, they’ll bill you only for the additional amount.• Call your provider and pay using your Benefits card, if you have moneyremaining on your card. • When you pay your provider you’ll receive an email/letter from IEB requestinga copy of your EOB. Send your EOB to Innovative Employee Benefits (IEB) only when you receive thisrequest. You can fax, mail, or scan and email. Be sure to keep a copy if you mail your EOB.Don’t toss your Benefits Card when/if you use all the money on the card. The sameBenefits Card will be reloaded next year.You cannot swipe your card for more than the balance on your card. If you do, the entiretransaction will be declined. For example, if you have $100 on your card and you swipeit for $105, the transaction will be declined.If you don’t send IEB your EOBs when requested, your Benefits Card will be deactivated,and you will lose the convenience of having direct access to the money your employer isprovided as first dollar coverage.Plan year: 11/1/2022 – 10/31/2023As of 11/1/2023, do NOT use your Benefits Card to pay for services incurredprior to 11/1/23. You will need to send your BCBS EOB to IEB and you’llreceive a check reimbursement.You have 60 days after 11/1/2023 to submit your EOBs for reimbursement. Use this 60 days to make sure you have an EOB for every service you andyour covered family members incurred, and that you’ve receivedan invoice from the provider, and you’ve paid the provider.

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Additional questions you may have?• Why is my benefit card not working at the pharmacy?Prescriptions are not eligible for reimbursement. • Am I able to use my debit card to pay for dental expenses,routine eye exams, glasses/contacts or over-the-countermedicines?No, these items are not eligible for reimbursement. • Why is my benefit card not working?If your benefit card is denied, Contact IEB by phone at 704-341-5981or by email at cs@better-benefits.com. • What do I do if I need copies of my Explanation of Benefits(EOB)?Contact IEB by phone at 704-341-5981 or by email at cs@better-benefits.com. • Where do I send copies of my Explanation of Benefits (EOB)?Scan and email to cs@better-benefits.com (preferred). You can alsofax to 704-341-5984 or mail to PO Box 410811, Charlotte, NC 28241• How do I check my account balance?Create an online account at wealthcareadmin.com where you cancheck your account balance 24/7/365. You can also call us at 704-341-5981 or email us at cs@better-benefits.com for assistance.• Do I need to activate my Benefits Card?No activation of card is needed. You Benefits Card will be active11/1/2022.• What if I lose my Benefits Card?Contact IEB by phone at 704-341-5981 or by email at cs@better-benefits.com.What do I do when I seek medical care?PLAN YEAR: 11/1/2022-10/31/2023 • Present your BCBS ID card at the provider’s office, urgent cares,hospital and pharmacies. • Provider will file your claim with BCBS.• BCBS will send Explanation of Benefit (EOB) to provider, and toyour home.• When you pay your provider you’ll receive an email/letter fromIEB requesting a copy of your EOB. Send your EOB to InnovativeEmployee Benefits (IEB) when you receive this request. You can fax,mail, or scan and email. Be sure to keep a copy if you mail your EOB. An extra benefits card is available for your covered spouse andcovered child not living in your household. Contact Information: Phone: 704-341-5981Email: cs@better-business.comInnovative Employee Benefits, Inc.

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Additional perksThe information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.There's more to love with these extra benefits. Perk nameThis is where we add in perks and other benefits thatmay come with the medical plan. See plan detailsPerk nameThis is where we add in perks and other benefits thatmay come with the medical plan. See plan detailsMy Pregnancy app®Get answers to your pregnancy questions Find resources, tools and support Enjoy fun features like the kick counter andrelaxation toolsWhether this is your first child or your fourth, you’regoing to need help. With our My Pregnancy mobileapp, you can:Use the free, confidential app wherever and wheneveryou want.7Download the AppSee plan detailsBlue365®Apparel and footwear Fitness and healthy eating servicesHearing and vision supplies Travel and more! Our members-only discount program6 helps you getexclusive deals on: Sign up for email alerts and weekly discounts. See plan detailsBlue ConnectOnline Member portalSee plan details

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In-network careNetwork name:EquitableAnnual Deductible (DED)$50 per person $150 family maxAnnual maximum benefit$1,500 per person Preventive care100% coveredBasic careDED then you pay 20%Major careDED then you pay 50%Orthodontic careCoverageLifetime maximum benefitNot coveredN/AYour cost for coverageEmployee onlyEmployee + SpouseEmployee + Child(ren)Employee + FamilyPer paycheck$$$$See plan detailsDental insuranceThe information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.Stay in-network to avoid balance billing (the difference between what an out-of-network provider charges and the amount your insurance pays). what you pay for the plan, what you pay when you get care, the maximum amount Equitable will pay each year for dental care (annualmaximum benefit), andwhether orthodontic care is covered.All plans cover in-network preventive care at 100%. The differences are: Select from three dental options through Equitable.

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In-network careIn NetworkOut of NetworkNetwork name:EquitableAnnual eye exam (every 12 months)$10 copayUp to $45Materials copay(lenses & frames)$25 copayLenses (every 12 months)Included in materials copayFrames(every 24 months)$150 allowance Included in Prescription Eyeglasses CopayUp to $70Contact lenses (every 12 months)Single VisionLined BifocalLined TrifocalLenticularCovered in FullUp to $30Up to $50Up to $65Up to $100Your cost for coverageEmployee onlyEmployee + SpouseEmployee + Child(ren)Employee + FamilyPer paycheck$$$$Vision insuranceYour vision plan covers either glasses (lenses and frames) or contact lenses each year. If you receive contact lenses, they will be instead of your glasses benefit.what you pay for the plan, what you pay when you get care, andthe materials allowance (how much the plan will pay) for frames or contactlenses.All plans cover annual exams, lenses and frames, or contacts in lieu of glasses.The differences are:Select from three vision options through Equitable.The information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.

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Basic lifeBasic AD&DABC Company provides$30,000$30,000See plan detailsFor youFor your spouseFor your child(ren)Coverageincrements$10,000 to $300,000in $10,000 increments$5,000 to $100,000 in increments of $5,000Live birth to less than15 days $50015 days to 26 years$1,000 to $10,000 in$1,000 incrementsCoveragemaximum5x your annualearnings Not to exceed 50% ofEmployee amount$10,000Medicalquestion limit$100,000$30,000Does not applyYou may also purchase additional coverage for you, your spouse, and youreligible child(ren). Additional life and AD&D insuranceSee plan detailsLife insurance pays a benefit if you pass away while you're covered. AccidentalDeath and Dismemberment (AD&D) insurance offers additional support if youpass away or are seriously injured due to an accident.Financial peace of mind through Equitable.Life and AD&D insuranceyour beneficiary if you passaway due to an accidentyou a partial benefit if youlose specified bodily functions(sight, limbs, etc.)What's AD&D?Accidental death anddismemberment (AD&D)insurance may pay:Make sure to designate a beneficiary for your life insurance coverage to ensureyour family is cared for according to your wishes.Medical question limitWhen you’re first eligible (a newhire), you can purchaseadditional life insurance up tothis limit without any medicalquestions required. Medical questions and approvalwill be required for all futureincrease and purchase requests.The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlyingplan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlyinginsurance documents will govern in all cases.Basic life and AD&D insuranceABC Company provides life and AD&D insurance at no cost to you.

Fisher Athletic Benefits Guide

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