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Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,UWHC Open Enrollment,Epic Benefits+,Resources

2018 EPIC Benefits+ Special Enrollment Brochure

2018 EPIC Benefits+ Special Enrollment Brochure - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWHC Open Enrollment, Epic Benefits+, Resources


2018 SPECIAL ENROLLMENT
WWW.EPICBENEFITS.COM
BENEFITS+
DENTAL
HOSPITAL/SURGERY
AD&D
VISION
Designed Exclusively for State of Wisconsin Members
Enrollment Period of October 2–October 27, 2017
Effective January 1, 2018
HOW TO ENROLL
Enrollment must occur within your eligibility period.
You must be eligible to enroll in a group health plan offered to state members
through the Group Insurance Board to be eligible for this coverage.
General outline of benefits does not serve as a legal document. For
complete list of benefits, limitations and exclusions please see contract.
Note: You will be required to remain enrolled for the calender year,
unless your eligibility changes.
2018 MONTHLY RATES
Without
Vision
With
Vision
Annuitants
without Vision
Annuitants
with Vision
Employee $21.38 $25.02 $28.74 $32.00
Employee + Spouse $42.76 $49.16 $57.36 $63.22
Employee + Child(ren) $42.76 $49.16 $66.58 $72.14
Family $64.14 $73.58 $79.16 $87.64

PROTECTION FOR UNPREDICTABLE, HIGH-COST DENTAL SERVICES
Dental expense benefit coverage lets you enjoy a wider range of dental protection by paying benefits for the following
services once you’ve paid the annual deductible.
* For eligible children under 19. All appliances must be in place before the eligible child’s 19th birthday. There is a 24-month waiting period from the dependent’s
effective date for benefits for orthodontic services and supplies.
Note: We’ll pay secondary after your other dental plan. | **Maximums and waiting period differ from new-hire benefit plans.
Questions? Call EPIC: 800-520-5750 | Delta Dental: 800-236-3712 | www.EpicBenefits.com
Annual Deductible $75 per member
Dental Services
• Extractions
• Therapeutic injections
• Periodontics
• Anesthesia services, as defined in the policy
• Endodontics
• Restorations, as defined in the policy
• Alveolectomy
• Prosthetics including dentures and bridges and their repair
• Crowns, as defined in the policy
• Inlays and onlays
• Oral surgery
• Dental implants
• Orthodontic services and supplies, as defined in the policy*
Deductible,
then 50% of covered
charges up to a calendar-year
maximum,
per member
Dental Maximums
• First year of coverage (2018)
• Second year of coverage (2019)
• Third year of coverage (2020 and later)
$750
$1,000
$1,500
Orthodontic Lifetime Maximum** $1,200 per member
Benefits+ Dental
Accidental Death & Dismemberment (AD&D)
HELP WHEN THE
UNEXPECTED HAPPENS
AD&D coverage is designed to help offset
some of the financial costs involved in coping
emotionally and financially, with accidental death
or specific life-altering injuries. AD&D pays a
lump sum benefit as outlined in the table.
* Beneficiary Designation forms may be downloaded from
the EPIC Specialty Benefits website. Please submit this
form to EPIC.
IN THE EVENT OF THE
ACCIDENTAL LOSS OF...
COVERAGE
ACTIVE
BENEFIT
ANNUITANT
BENEFIT
• Life
• Both feet
• Both hands
Member $15,000 $7,500
Spouse $7,500 $3,750
Child $3,000 $1,500
• One foot
• One hand
• Sight in one eye
Member $7,500 $3,750
Spouse $3,750 $1,875
Child $1,500 $750
Loss must occur within 90 days of injury to qualify

INPATIENT HOSPITAL STAY
A benefit of $200 for active members
per day will be paid, beginning on the
third day and continuing through the
365th day of a hospital confinement.
Confinement in a skilled nursing
facility does not qualify for this benefit.
OUTPATIENT SURGERY
A benefit of $200 for active members
per outpatient surgery will be paid
when performed in a hospital
outpatient department or freestanding
Ambulatory Surgical Center. Multiple
procedures occurring during a single
surgical session qualify for a single
$200 benefit. Surgery performed in
a physician’s office does not qualify
for the benefit.
Annuitant Up to Age 65
A benefit of $200 per day will be
paid, beginning on the third day and
continuing through the 365th day of a
hospital confinement.
Annuitant Age 65 and Over
A benefit of $150 per day will be
paid, beginning on the sixth day and
continuing through the 365th day of a
hospital confinement. Confinement in a
skilled nursing facility does not qualify
for this benefit.
A benefit of $200 ($150 for age 65
and over) per outpatient surgery will
be paid when performed in a hospital
outpatient department or freestanding
Ambulatory Surgical Center. Multiple
procedures occurring during a single
surgical session qualify for a single
$200 ($150 for age 65 and over)
benefit. Surgery performed in a
physician’s office does not qualify for
the benefit.

Hospital &
Surgery Benefit
These benefits are not subject
to any waiting periods, and
payments will be made directly
to the member, to be used in
any way they see fit.
Vision Benefit Option
(Davis Vision Network)
Complete an EPIC enrollment application to elect the EPIC Vision Plan for
a complete benefit package.
EPIC VISION PLAN
(DAVIS VISION NETWORK)
IN-NETWORK BENEFITS
(MEMBER PAYS COPAYMENT)
NON-NETWORK
BENEFITS
Copays
Routine Eye Exam Not applicable Not applicable
Lenses (spectacle or contact) $25 Not applicable
Frame Collection
Fashion Copay/Designer Copay $0 EPIC pays $30 allowance
Premier Copay $25 EPIC pays $30 allowance
Non-Collection
EPIC pays $130 & member
receives 20%
1
discount on charges
over $130 - No copay required
EPIC pays $30 allowance
Lens Allowance
Single, Bifocals, Trifocal,
Lenticular
Plastic lenses included
Copay not applicable
EPIC pays $25-$60
Contact Lenses (In Lieu of Eyeglasses)
Collection
• Evaluation, Fitting & Follow-up Included $75 allowance
• Materials
Includes Daily Wear, Planned
Replacement, and Disposable
$75 allowance
Non-Collection
• Standard Evaluation, Fitting &
Follow-up
Included $75 allowance
• Specialty Evaluation, Fitting &
Follow-up
$60 allowance, plus 15% discount
over allowance
$75 allowance
• Materials
$130 allowance, plus 15%
discount over allowance
$75 allowance
Medically Necessary
Materials, evaluation, fitting, and
follow-up included at no cost
EPIC pays $225
allowance
Lens Upgrade (Non-Insurance)
Glass, Oversize, Scratch
Resistant Coating
Included at no cost Not covered
Polycarbonate Lenses (children
& special)
Included at no cost Not covered
Fashion Tinting Plastic Lens $0 copay Not covered
Gradient Tinting Plastic Lens $0 copay Not covered
Blended Lenses (invisible),
Photochromic Glass Lenses
$20 copay Not covered
Polycarbonate Lenses (all other) $30 copay Not covered
Ultraviolet Coating $12 copay Not covered
Standard Anti-reflective Coating $35 copay Not covered
Premium Anti-reflective Coating $48 copay Not covered
Ultra Anti-reflective Coating $60 copay Not covered
Standard Progressive Lenses $50 copay Not covered
Premium Progressive Lenses $90 copay Not covered
Intermediate Vision Lenses $30 copay Not covered
High Index Lenses $55 copay Not covered
Polarized Lenses $75 copay Not covered
Photosensitive Plastic Lenses $65 copay Not covered
Scratch Protection Not covered
Single Vision $20 copay Not covered
Multifocal $40 copay Not covered
Benefit Frequency
Lenses 12 months 12 months
Frames 24 months 24 months
1
Members receive full allowance towards everyday low prices at Walmart and Sam’s Club.
Additional discounts do not apply.
Visit www.davisvision.com. You may contact Davis Vision at 1-877-923-2847.

Dental Exclusions - This plan does not cover: • dental services incurred
for the replacement of a full upper or a full lower denture regardless of
cause after we have included the charge for such denture(s) at least
once in considering benefits under this or a similar dental expense
benefit provision • dental services incurred for relining of dentures •
orthodontic treatment that begins after a covered dependent reaches
age 19 • dental services that are not medically necessary or not required
in accordance with accepted dental practices • diagnostic and preventive
dental services including, but not limited to, dental examinations, regular
and periodontal cleaning, fluoride, x-rays, sealants, and emergency
evaluations • orthodontic services and supplies incurred: (1) during the
first 12 calendar months following a new entrant’s effective date of
coverage under the policy; or (2) during the first 24 calendar months
following a late enrollee’s effective date of coverage under the policy
• dental services not specifically identified as being covered under the
policy • dental services and supplies for cosmetic treatment, unless
necessitated as a result of injuries sustained while the member is
covered under the policy • dental services and supplies provided in
connection with the treatment of the temporomandibular joint • dental
services furnished by the U.S. Veterans Administration, except for such
services for which under applicable federal law the policy is the primary
payor and the U.S. Veterans Administration is the secondary payor •
dental services, including oral surgical services, except as specifically
stated above.
Hospital and Surgery Benefit Exclusions - This plan does not cover:
hospital confinement that does not medically require the patient to
be hospitalized or surgery not medically necessary, as determined by
us • routine newborn care. Initial hospital and nursery care, per day,
for evaluation and management of normal newborn infant • hospital
confinement or surgery services connected with: obesity, weight
reduction, or dietetic control care, except for morbid obesity and disease
etiology • reconstructive surgery, except for such surgery required: (1)
to repair a significant defect caused by an injury; (2) to repair a defect
caused by congenital anomaly causing a functional impairment of a
dependent child; (3) incidental to a mastectomy; or (4) due to an illness
• eye refractive surgery • hospital confinement or surgery services in
connection with care for, or leading to, sexual transformation • reversal
of sterilization • hospital confinement or surgery services in connection
with artificial insemination or fertilization methods including, but not
limited to, in vivo and in vitro fertilization, embryo transfer, gamete intra
fallopian transfer (GIFT) and similar procedures that are incidental to
such insemination or fertilization methods • dental services, including
oral surgical services.
Hospital: A hospital does not include, as determined by us: • a
convalescent or extended care facility unit within or affiliated with the
hospital • a clinic • a nursing, rest or convalescent home • an extended
care facility • a facility operated mainly for care of the aged • sub-acute
care center • a health resort, spa or sanitarium.
Ambulatory Surgical Center: An Ambulatory Surgical Center means a
licensed facility where the patient is admitted to and discharged within
the same day, with the primary purpose to provide surgical procedures. It
has one or more physicians on duty whenever a patient is in the center.
An Ambulatory Surgical Center does not include, as determined by
us: • an office maintained by a physician for the practice of medicine
• a facility which provides services or overnight accommodations
for patients.
AD&D Exclusions - In addition to the general exclusions, this plan does
not cover any loss due to • injury you receive while operating, riding in
or descending from any aircraft, except as a fare-paying passenger in
a commercial aircraft on a regularly scheduled flight • illness or disease
• bacterial infections (unless due to accidental food poisoning) • injury
sustained while intoxicated • injury sustained while under the influence
of any controlled substance unless prescribed by and taken under the
direction of a physician • an intentionally self-inflicted injury or illness,
suicide or attempted suicide, whether a member is sane or insane • your
participation in a riot or in the commission of a crime.
Vision Exclusions - The vision plan does not cover: • vision care
services not recommended by a vision care provider • periodic vision
examinations except as stated in the policy • eye examinations required
by an employer as a condition of employment • vision care services
provided in connection with special procedures such as orthoptics and
visual training • lenses which do not provide vision correction • charges
for the replacement of lost or stolen lenses or frames within 24 months
of service • vision care services for any injury or illness arising out of, or
in the course of, any activity for pay, profit or gain. This exclusion applies
regardless of whether benefits under workers’ compensation or similar
laws have been claimed, paid, waived or compromised or whether you’re
covered under worker’s compensation insurance (n/a in SD). • vision
care services furnished by the U.S. Veterans Administration, except for
such vision care services which under the policy we are the primary
payor and the U.S. Veterans Administration is the secondary payor under
applicable federal law (n/a in MO) . • vision care services furnished by
any federal or state agency or a local political subdivision when the
member is not liable for the costs in the absence of insurance, unless
coverage under the policy is required by any state or federal law • vision
care services covered by Medicare, if a member has or is eligible for
Medicare, to the extent benefits are or would be available from Medicare
(n/a in MO) • vision care services for any injury or illness caused by:
(a) atomic or thermonuclear explosion or resulting radiation; or (b) any
type of military action, friendly or hostile (n/a in MO and WV) • vision
care services in connection with any illness or injury caused by your: (a)
engaging in an illegal occupation; or (b) commission of, or attempt to
commit a felony; or (c) self-inflicted injury • medical treatment provided
outside of the United States or Canada • vision care services provided
by practitioners who do not meet the definition of vision care provider
• vision care services provided when your coverage was not effective
under the policy. This includes vision care services provided either prior
to your effective date of coverage or after coverage terminated under
the policy. • vision care services for which you have no legal obligation
to pay • that portion of the amount billed for a vision care service
covered under the policy that exceeds our determination of the charge
for such vision care service • comprehensive low vision evaluations,
subsequent follow-up visits following such evaluation or low vision aids
for which prior notification was not sent to the Claim Administrator •
medically necessary contact lenses prescribed for you for which prior
notification was not approved by the Claim Administrator • eye refractive
surgery, except as specifically stated in the policy • preparation, fitting,
or purchase of eye glasses or contact lenses, or eye refractive surgery,
except as specifically stated in the policy; vision therapy, including
orthoptic therapy and pleoptic therapy.
General Exclusions – This policy provides no benefits for: • hospital
confinement, surgery services, or dental services for any illness or injury
arising out of, or in the course of, any activity for pay, profit or gain.
This exclusion applies regardless of whether benefits under workers’
compensation or similar laws have been claimed, paid, waived or
compromised or whether you’re covered under workers’ compensation
insurance • hospital confinement, surgery services, or dental services
furnished by any federal or state agency or a local political subdivision
when you are not liable for the costs in the absence of insurance, unless
coverage is required by any state or federal law • hospital confinement,
surgery services, or dental services for any injury or illness caused by:
(1) atomic or thermonuclear explosion or resulting radiation; or (2) any
type of military action, friendly or hostile • cosmetic treatment or surgery
• war, declared or undeclared • taking part in a riot, felony or insurrection
• services provided by members of a member’s immediate family or
anyone else living with him/her • hospital confinement, surgery services,
or dental services for which a proof of claim is not provided to us • health
care services which are experimental or investigative, except for the
investigational drugs used to treat the HIV virus as described in Section
632.895 (9), Wisconsin Statutes, as amended.
General Information - This brochure is only a general outline of
benefits, limitations, and exclusions. You can find a more detailed
description of coverage in the applicable certificate of insurance. A
certificate will be issued to each employee who becomes insured under
the plan.
The words “charge” and “charges” as used in this brochure mean an
amount we determine as reasonable, considering factors such as the
amount providers charge for similar services and supplies provided in the
same geographic area.
Coverage is subject to all terms and conditions of the policy, which is
your contract of insurance. The policy consists of the group master
policy, including the application and all policy riders and endorsements.
Exclusions
29958-088-1706
2017 The EPIC Life Insurance Company | www.EpicBenefits.com | All rights reserved