Professional Documents
Culture Documents
(Crew)
Employee Benefits Enrollment Guide
Plan Year: 2015-2016
Fishermens Finest, Inc. is pleased to continue offering Crew Health, Voluntary
Dental, and Voluntary Vision. Elections made during open enrollment will become
effective March 1, 2015
North Pacific Fishing, Inc. offers you and your eligible family members a
comprehensive benefits program, which fulfills all of the Individual Affordable Care
Act mandates. We encourage you to take the time to educate yourself about your
options and choose the best coverage for you and your family.
Group Benefits for 2015-2016 Plan Year:
Crew Medical
Voluntary Dental
Voluntary Vision
Who is Eligible?
Employee is eligible when they return for their second contract.
How to Enroll?
The first step is to review your current benefit elections. Verify your personal
information and make any changes, if necessary. Make your benefit elections. Once
you have made your elections, you will not be able to change them until the next
open enrollment period unless you have a qualified change in status.
When to Enroll?
All enrollment forms need to be submitted to Courtney Banks by February 20,
2015. The benefits you elect during open enrollment will be effective from March 1,
2015 until February 28, 2016.
How to Make Changes?
Unless you have a qualified change in status, you cannot make changes to the
benefits you elect until the next open enrollment period. Qualified changes in status
include: marriage, divorce, legal separation, birth or adoption of a child, change in
childs dependent status, death of spouse, child or other qualified dependent,
change in residence due to an employment transfer for you or your spouse,
commencement or termination of adoption proceedings, or change in spouses
benefits or employment status.
Page: 1
Deductible
Outside the
U.S.
$250 Individual
$625 Family
$250 Individual
$625 Family
$500 Individual
$1,250 Family
100% of
Usual & Customary
Fee
80% of
Negotiated Rate
Covered
60% of
Usual & Customary Fee
Coinsurance Maximum
Surgical Care
Emergency Care
Prescriptions
Outside the US
1. Prescription Drugs
2. Injectables
Prescriptions
Inside the US
1. Generic
2. Brand name
3. Injectables
Page: 2
In Network
Out of Network
Deductible
Basic Services
Major Services
Preventive Services
Orthodontics
TMJ
Waiting Periods
Annual Maximum
Principals Network
You may choose any dentist. However, using dentists participating in the
network should lower your out-of-pocket expenses.
www.principal.com
Out of Network
No Charge
Up to $50
Prescription Glasses
$20 copay
Lenses
Single Vision
Bifocal
Trifocal
Lenticular
100% covered
Once every 12
months
Once every 12
months
Up to $50
100% covered
Up to $75
100% covered
100% covered
Up to $100
Up to $125
Frames
$130 allowance
Up to $70
Once every 24
months
$130 allowance
Up to $105
Once every 12
months
Once every 12
months
Page: 3
You have (30) days from a change in family status to make changes to
your current coverage.
Page: 4
Position
Courtney Banks
Phone: 206-283-1137
Email: cbanks@fishermensfinest.com
Rick Bagnall
Phone: 860-399-3634
Email: rickb@gowrie.com
Barbie Murray
Phone: barbiem@gowrie.com
Email: 860-399-3630
Account Executive
Account Manager
Contact
Position
Geo Blue
Phone: 855-282-3517
Customer Service
Medical Benefits
Principal
Phone: 800-843-1371
Customer Service
Dental Benefits
VSP
Phone: 800-852-7600
Member Services
Vision Benefits
The information in this Enrollment Guide is presented for illustrative purposes and is
based on information provided by the employer. The text contained in this Guide
was taken from various summary plan descriptions and benefit information. While
every effort was taken to accurately report your benefits, discrepancies, or errors are
always possible. In case of discrepancy between the Guide and the actual plan
documents the actual plan documents will prevail. All information is confidential,
pursuant to the Health Insurance Portability and Accountability Act of 1996. If you
have any questions about your Guide, contact Human Resources.
Page: 5
: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.geo-blue.com or by calling 1-855-282-3517 (+1.610.254.5304 from outside the U.S.).
Important Questions
Answers
You must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. Check your policy or
plan document to see when the deductible starts over (usually, at the
end of the Coverage Period). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
No.
You dont have to meet deductible for specific services, but see
amount before this plan begins to pay for these services.
Is there an outof
pocket limit on my
expenses?
The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.
Even though you pay these expenses, they dont count toward the outof-pocket limit.
No.
The chart starting on page 2 describes any limits on what the plan will
pay for specific covered services, such as office visits.
Do I need a referral to
see a specialist?
You can see the specialist you choose without permission from this
plan.
Yes.
Some of the services this plan doesnt cover are listed on page 5. See
your policy or plan document for additional information about
excluded services.
Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.
1 of 8
: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you havent met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical
Event
If you visit a
health care
providers
office or clinic
If you have a
test
Your Cost
Outside the
U.S.
No charge
Specialist visit
No charge
No charge
Preventive care/
screening/immunization
Diagnostic test (x-ray, blood
work)
Imaging (CT/PET scans,
MRIs)
No charge
No charge
No charge
none
none
none
none
none
Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.
2 of 8
: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical
Event
If you need
drugs to treat
your illness or
condition
Generic drugs
$10 copay/
prescription
$10 copay/
prescription
$10 copay/
prescription
Brand drugs
$10 copay/
prescription
$25 copay/
prescription
$25 copay/
prescription
Injectables
30%
coinsurance
30%
coinsurance
30%
coinsurance
No charge
Physician/surgeon fees
No charge
20%
coinsurance
20%
coinsurance
40%
coinsurance
40%
coinsurance
No charge
20%
coinsurance
40%
coinsurance
Emergency medical
transportation
No charge
20%
coinsurance
40%
coinsurance
Urgent care
No charge
No charge
Physician/surgeon fee
No charge
20%
coinsurance
20%
coinsurance
20%
coinsurance
40%
coinsurance
40%
coinsurance
40%
coinsurance
More
information
about
prescription
drug coverage
is available at
www.geoblue.com
If you have
outpatient
surgery
If you need
immediate
medical
attention
If you have a
hospital stay
Your Cost
Outside the
U.S.
none
none
If an Insured Person requires emergency treatment
of an Injury or Sickness and incurs covered
expenses at a non-Preferred Provider, Covered
Medical Expenses for the Emergency Medical
Care rendered during the course of the emergency
will be treated as if they had been incurred at a
Preferred Provider.
none
none
none
Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.
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: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical
Event
If you have
mental health,
behavioral
health, or
substance
abuse needs
Mental/Behavioral health
outpatient services
Mental/Behavioral health
inpatient services
Substance use disorder
outpatient services
Substance use disorder
inpatient services
If you are
pregnant
If you need
help
recovering or
have other
special health
needs
If your child
needs dental
or eye care
Your Cost
Outside the
U.S.
No charge
No charge
No charge
No charge
No charge
No charge
No charge
Rehabilitation services
No charge
Habilitation services
No charge
No charge
No charge
Hospice service
No charge
Eye exam
Glasses
Dental check-up
Not covered
Not covered
Not covered
none
none
none
none
none
none
Limited to 120 visits per Policy Year
Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.
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: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Cosmetic surgery
Long-term care
Private-duty nursing
Infertility treatment
Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Bariatric surgery
Chiropractic care
Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.
5 of 8
: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.
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: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
This is
not a cost
estimator.
Dont use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
(routine maintenance of
a well-controlled condition)
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$250
$20
$1,400
$150
$1,820
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$250
$400
$440
$80
$1,170
Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.
7 of 8
: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.
8 of 8
GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association.
Made available in cooperation with Premera Blue Cross.
geo-blue.com
GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association.
Made available in cooperation with Premera Blue Cross.
www.geo-blue.com
Global Wellness*
Set your baseline by taking the Health Assessment and then
work to improve your wellness via a one-on-one telephone
relationship with a Wellness Coach or by using one of the online
programs from the Mayo Clinic to address issues related to
fitness, weight, smoking and stress. Check out the smart, timely
advice on the best ways to manage diet and exercise around the
world at Travel Well (www.geo-blue.com).
To contact a Wellness Coach:
Inside the U.S.: 1.877.249.4752
Outside the U.S.: +44.208.987.6229
contactacoach@wellness-assist.com.
*Services are provided by WorkPlace Options, an independent company that is not affiliated with GeoBlue and does not provide Blue Cross or Blue Shield products or services.
WorkPlace Options is solely responsible for referring participants for counseling, coaching and work-life services by providers who are appropriately licensed by local authorities.
The evaluation and efficacy of any service delivered by a provider lies solely with the employee, spouse, dependent or other authorized party who inquires on behalf of the
participant. GeoBlue shall have no responsibility or liability whatsoever for any aspect of the provider counseling or the counselor/participant relationship.
Translate medications
Find country-specific equivalents for prescriptions and
over-the-counter medications.
*Available on geo-blue.com only.
GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association.
Made available in cooperation with Premera Blue Cross.
www.geo-blue.com
Submitting a Claim
If you are seeking reimbursement for covered services, you can quickly and conveniently submit claims electronically,
using the GeoBlue app or the Filing eClaims link on the Member Hub at www.geo-blue.com. Scanned paper
documents are delivered directly to our Claims Department, and your eClaims are saved in your Member Profile.
If you prefer to submit a claim via email, fax or postal mail, a printable claim form is available in the Member Hub on www.geo-blue.com.
Email: claims@geo-blue.com
Fax: +1.610.482.9623
Postal Mail: GeoBlue, Attn: Claims, One Radnor Corporate Center, Suite 100, Radnor, PA 19087
If a physician, ambulance company or other provider sends their bill directly to you, or you pay the medical provider at the time of service,
you will need to complete and submit a Claim Form. The Claim Form was developed for you to notify us of any covered health services for
which we have not already been billed.
Please read the following instructions about how to report health care services. Following these instructions will expedite
the payment of your claim.
1. Complete the claim form. Answer all questions, even if the answer is none or N/A. Be certain that the name on the bill you are
submitting is the same as that which is indicated on your ID card. If not, please enclose a short note of explanation. A signature is required
on all claim forms.
2. Attach the provider bill/documentation to the claim form and follow the instructions on the back of the form for submission to GeoBlue.
Bills must be itemized: Canceled checks, cash register receipts and non-itemized balance due statements cannot be processed.
Each itemized bill must include: name and address of provider (doctor, hospital, laboratory, ambulance service, etc.), name of
patient, date(s) of service, amount charged for each service, total charge, diagnosis or reason for treatment.
Outpatient Prescription Drugs: duplicate pharmacy generated receipts (not register tape) must include Rx number; date filled,
medication name, form, strength and quantity. (NOTE: All prescription drug charges will be reimbursed to the insured person only.)
3. Additional Information
If submitting expenses for more than one family member, please use a SEPARATE claim form for each person.
All claims should be filed with our office within the six (6) month period from the date of the incurred expense.
If you have questions regarding the completion of this claim form, please contact Customer Service.
To check your claim status, visit Claims in the Member Hub on www.geo-blue.com.
Contact Information
For questions about your medical plan:
Toll free within the U.S.: 1.855.282.3517
Outside the U.S.: +1.610.254.5304
customerservice@geo-blue.com
2014 GeoBlue
Benefits Payable
Network
In-Network
Non-Network
In-Network
Non-Network
Unit 1 Preventive
$0
$0
100%
80%
Unit 2 Basic
$50
$50
80%
70%
Unit 3 Major
$50
$50
50%
40%
Combined Deductible
In-network deductibles for basic and major procedures are combined. Non-network
deductibles for basic and major procedures are combined.
Combined Maximums
Maximums for preventive, basic, and major procedures are combined. In-network Calendar
year maximums are $1,500 per person. Non-network Calendar year maximums are $1,500 per
person.
Maximum Accumulation
This allows for a portion of unused maximum benefit to carry over to next year's maximum
benefit amount. To qualify, you must have had a dental service performed within the
Calendar year and used less than the maximum threshold. The threshold is equal to the lesser
of 50% of the maximum benefit or $1000. If qualification is met, 50% of the threshold is
carried over to next year's maximum benefit. You can accumulate no more than four times the
carry over amount.
Additional Benefits
Lifetime Deductible
Unit 4 - Orthodontia
Child
In-Network
Non-Network
In-Network
Non-Network
$0
$0
50%
50%
Lifetime Maximum:
In-Network: $1,000
Non-Network: $1,000
01131510388 - 3
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VOLUNTARY DENTAL
Unit 1
Preventive
Procedures
Unit 2
Basic
Procedures
Unit 3
Major
Procedures
Unit 4 - Orthodontic
Procedures
There is Coordination of Benefits, which is a procedure for limiting benefits from two or more carriers to 100% of
the claimant's covered expenses.
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VOLUNTARY DENTAL
You must be enrolled for dental coverage before it can be offered to your dependents. Eligible dependents
include your spouse, qualified domestic partner and children, including those of your qualified domestic partner.
Additional eligibility requirements may apply.
An annual enrollment applies. Members can enroll for dental coverage during the annual enrollment period and
not be subject to the late entrant waiting period. Certain restrictions apply.
Use the Provider Directory on www.principal.com to locate nearby dentists or see if your dentist participates in
your network.
1
Visit www.principal.com.
Under the Quick Links heading on the left-hand side, click Provider Directory.
In the left-hand navigation under Providers/Networks, click Search For A Dental Provider.
Begin your search by picking the state where you would like to find a provider. Next, specify a network. Depending
on the network chosen, you may be transferred to a partner site.
Enter the name of the provider you are looking for (if known). If you are looking for a nearby dentist, enter the city
and state and/or ZIP code. Be sure to indicate how far you are willing to travel.
Select the desired specialty or use the No Specialty Preference default. Click Continue.
You may nominate your dentist for inclusion in our network. Please submit the dentist's name, address, phone
and specialty by calling 1-800-832-4450, or submit through www.principal.com.
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VOLUNTARY DENTAL
Those members enrolling more than 31 days after becoming eligible will be effective on the
policy anniversary.
Missing Tooth
Benefits for the initial placement of bridges, partials and dentures are not covered if those
teeth were missing prior to becoming insured under the Principal Life policy. When the policy
replaces coverage under a prior plan, continuous coverage under the prior plan may be
applied to the missing tooth provision requirement.
Orthodontia
If there is orthodontia (ortho) treatment in progress on the coverage effective date and you
are covered under any prior group coverage for ortho, there will be immediate coverage for
treatment if proof is submitted that shows:
1) The lifetime maximum under any prior group coverage has not been exceeded,
2) Ortho treatment was started and bands or appliances were inserted while insured under
any prior group coverage, and
3) Ortho treatment has been continued while insured under this policy.
Principal Life will credit payments made by the prior carrier toward the Principal Life lifetime
ortho payment limit.
You will not be covered if ortho treatment is in progress prior to the effective date with
Principal Life and you are not covered under any prior group coverage for ortho.
Prevailing Charge
When using non-network providers, you pay any amount over the allowable charge.
Other Limitations
There are additional limitations to your coverage. A complete list is included in your booklet.
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