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Health & Welfare: Group Medical Preferred Provider Organization (PPO)

Note: New Hire Automatic Enrollment

Employees who do not make an enrollment election during their initial enrollment period will be automatically enrolled in the Group Medical PPO Plan HRA Option — Option 3E. The automatic enrollment will only cover the employee. Employees wanting to waive coverage or make changes must make those changes through the My State Farm Benefits Resource website within 31 days of hire.

General Information

Choosing the right health care plan is essential to meeting your needs and the needs of your family. The State Farm Group Medical Preferred Provider Organization (PPO) Plan provides comprehensive medical and outpatient prescription drug coverage for accidents and illnesses, and offers freedom of choice. You may choose your own medical providers and hospitals without having to obtain a referral from a primary care physician. You also have the freedom to seek treatment anywhere in the nation. As a PPO Plan, choosing to use in-network or PPO Providers offers the lowest out-of-pocket expenses than using out-of-network or Non-PPO Providers. The charts below illustrate the differences.

Blue Cross Blue Shield of Illinois is the Claim Administrator for major medical services and CVS Caremark is the Pharmacy Benefit Manager for outpatient prescription drug coverage. Enrolled members will receive an ID card from both Blue Cross Blue Shield and CVS Caremark.

The Group Medical PPO Plan provides one option to active employees. The Health Reimbursement Arrangement (HRA) Option 3E features a Company-funded HRA account. The following are some of the highlights of the PPO Plan:

  • State Farm contributes up to $1000 for a single employee with no covered dependents and up to $2000 for an employee with dependent coverage annually to the HRA. The maximum contribution per year is $2000.
  • The HRA automatically covers eligible expenses, such as the deductibles, as they are incurred up to the HRA balance. HRA remaining balances at year end automatically roll over to the next year and are added to the annual amount. The maximum roll over balances are $10,000 for single and $20,000 for employee plus dependents.
  • Individual and family deductibles represent the amount members pay before the Plan pays benefits. As noted above, HRA funds can help cover deductibles on a first dollar basis. Deductibles apply to major medical services and not to outpatient prescription drug expenses.
  • Once the deductible is satisfied, eligible medical charges are shared by you and the Plan which is the coinsurance percentage. As illustrated in the charts, the coinsurance percentage depends on whether PPO Providers or Non-PPO Providers are used for treatment.
  • Coinsurance amounts continue to apply to eligible expenses until the maximum out-of-pocket limit has been reached. Once the out-of-pocket expense limit has been reached, the Plan will then cover 100 percent of eligible expenses not subject to any Plan restrictions or limitations. Out-of-pocket expense limits include deductibles and coinsurance amounts.
  • Dedicated Health Assistant – all members will have access to a dedicated Health Assistant through Accolade. The Health Assistant is your first point of contact for all your Group Medical PPO Plan benefit related issues such as resolving claim billing issues, selecting in-network providers, help manage a chronic health condition and more.

Please note – if an employee changes from the HRA Option 3E to an HMO or other insured medical option, or waives coverage – any remaining HRA balance is forfeited.

Annual Medical Deductibles

    Individual Family
Annual Medical Deductibles Option 3E $2,500* $5,000*

*The deductible can be reduced by the available HRA.

Out-of-Pocket Expense Limit (Medical and Prescription Drug)

Includes calendar year deductible and coinsurance.

  PPO Providers Non PPO Providers
Individual Family Individual Family
Medical Out-of-Pocket Expense Limit (Includes calendar year deductible and coinsurance.) Option 3E $5,000* $10,000* $7,500* $15,000*
  Combined for all pharmacies
Individual Family
Outpatient Prescription Drug Out-of-Pocket Expense Limit $1,600* $3,200*

*The out-of-pocket expense limit can be reduced by the available HRA.

Coinsurance for Major Medical Services

  PPO Providers Non-PPO Providers
Coinsurance Percentages
(after satisfaction of the annual deductible)
All services:
Associate pays 10% Plan pays 90%
All services, except those noted below:
Associate pays 40% Plan pays 60%
Emergency services and services performed outside the United States: Associate pays 10% Plan pays 90%
Other Miscellaneous Services performed by Non-Solicited Providers: Associate pays 10% Plan pays 90%
Usual & Customary charges apply.
Preventive Care (includes coverage for Well-Child care for regularly scheduled checkups, immunizations, laboratory tests, and other associated screening or diagnostic services through age 19) Associate pays 0%
Plan pays 100%
Associate pays 40% Plan pays 60%
40% Coinsurance not applied to Out-of-Pocket Expense Limits
Usual & Customary charges apply.

Prescription Drug Coverage

You may obtain prescriptions through several different delivery methods as referenced below:

  • Visit any retail network pharmacy for short-term medicines, up to a 30-day supply, or
  • CVS Caremark Mail Order Service Pharmacy or any retail CVS/pharmacy for long-term maintenance medications up to a 90-day supply.

Your coinsurance depends on whether you choose generic, preferred brand name, or non-preferred brand name prescription drugs, and whether you buy them at a participating retail pharmacy or through mail order.

Tier Description Retail (30-Day Supply) Mail Order or retail CVS/pharmacy (90-Day Supply)
1st Generic - least expensive. Be sure to check out the Value Generic Program for best savings. 20% coinsurance
$10 minimum
$25 maximum
20% coinsurance
$20 minimum
$50 maximum
2nd Preferred Brand Names - When a generic is not available, choosing a Preferred Brand can save you money. View www.caremark.com . 30% coinsurance
$10 minimum
$75 maximum
30% coinsurance
$20 minimum
$150 maximum
3rd Non-Preferred Brand Names - Most expensive Brand drugs due to availability of alternate lower cost Preferred Brand drugs and/or generics. 50% coinsurance
$10 minimum
$100 maximum
50% coinsurance
$20 minimum
$200 maximum

The minimums and maximums apply to the coinsurance amounts. For example,

  • If a generic medication costs $8.00 for a 30-day supply, you pay only $8.00 since the total cost of the medication is less than $10.00.
  • If a preferred brand costs $70, you will pay $21 which is equal to 30% of $70.

It's important you understand that if you decide to waive or cancel medical coverage, you must wait until the next Annual Enrollment Period to enroll. Your coverage will be effective the following January 1. If you have a qualified Health Insurance Portability and Accountability Act (HIPAA) special enrollment event (e.g., loss of coverage, obtaining a new dependent due to marriage, a birth, an adoption, or placement for adoption), you may be eligible to enroll in medical coverage mid-year. You must notify the State Farm Benefits Center within 31 days of an event in order to be eligible for coverage.

State Farm encourages you to review your benefit options carefully and make informed decisions. The information presented here is only a brief summary. Please review the Group Medical PPO Plan Summary Plan Description (SPD) for more details on the benefits provided by the Plan.

Disclaimer

This brief overview of the State Farm Group Medical Preferred Provider Organization Plan is not intended to be a complete explanation of plan features. For more detailed information and state exceptions, please refer to the online Human Resources Policy Manual for U.S. employees.

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