Under the BBI DPPO dental plan, there is an annual maximum benefit. If you have claims that exceed this annual maximum benefit, they will not be covered by the plan. Our annual maximum benefit is $1,500 per person in the DPPO dental plan. (There is not an annual maximum for the BBI DHMO dental plan.)
However, if you receive preventive care, your annual maximum benefit will increase by $250 the following year, up to a maximum benefit of $2,000. For example, if you and your 2 children received preventive care in 2019 under the BBI DPPO dental plan, the annual maximum benefit for each of you in 2020 will be $1,750. If you and your 2 children again receive preventive care in 2020, the annual maximum benefits will rise to the maximum of $2,000 each for 2021. However, if your spouse does not receive preventive care in 2019 or 2020, their annual maximum benefit remains at $1,500 in each year.
The practice when medical care providers (such as doctors, hospitals, or other medical practitioners) bill you for the portion of the bill not covered by insurance. This should only occur if you receive out-of-network care.
Under our DPPO plan, basic care is covered at 80% in network. This includes services such as fillings, root canals, and extractions. Refer to your patient charge schedule for DHMO coverage.
The person you assign to receive your life insurance benefit. You can also assign a secondary, or contingent, beneficiary in case your regular, or primary, beneficiary has passed away.
A drug that was recently developed by a pharmaceutical company. It’s usually more expensive than generic drugs. If your drug begins with a capital letter in the Formulary, it’s a brand drug. Generic drugs begin with lower case letters in the Formulary. For example, Lipitor is a brand drug and its generic equivalent is atorvastatin.
When there are two brand drugs that are chemically equivalent — meaning they treat the same issue in the same way — one will be preferred and the other will be non-preferred. You will pay a higher cost for a non-preferred brand drug. Talk to your doctor if you’d like to see if there are lower cost options that will work for you.
A percentage amount that you are responsible for paying after you’ve met your deductible but before you’ve met your out-of-pocket maximum.
The ability to retain life insurance benefits following your loss of coverage with Bloomin’ Brands. You generally must elect to convert your coverage to an individual whole life policy within 30 days of the termination of coverage and begin making payments directly to the life insurance company. This is usually a more expensive option than porting your life insurance coverage.
Usually a fixed dollar amount you are required to pay to receive services.
The amount of claims expense you must pay before your insurance plan begins to pay benefits.
Evidence of Insurability (EOI)
A questionnaire an employee completes by answering questions about their physical condition and medical history. From this information, the life or disability insurance company evaluates whether they can insure them. Information on the questionnaire is never returned to Bloomin’ Brands.
Goods or services that are not covered by a health plan.
Explanation of Benefits (EOB)
A document sent to you by the insurance company explaining how your claim was paid and why some charges may not be covered.
The list of prescription drugs covered by the health insurance plan. To check if your drug is covered by the health plan, log in at www.express-scripts.com.
A drug that is chemically equivalent to a brand drug but typically costs less. If there is a generic drug available, but you choose to take the brand version of the drug, you will pay the full cost of the brand drug.
Health Reimbursement Account (HRA)
A fund that only Bloomin’ Brands can contribute to on your behalf if you are enrolled in either the Choice or Value HRA medical option. This fund is opened on your behalf when you enroll in one of the HRA medical options. The money deposited into this account can be used for eligible expenses. If you change medical plans or leave Bloomin’ Brands, you cannot take this money with you.
Health Savings Account (HSA)
A bank account that you and Bloomin’ Brands can contribute to on your behalf if you are enrolled in either the Choice or Value HSA medical option. You must take action to open this account. The money deposited into this account can be used for eligible medical, prescription drug, dental and vision expenses. If you change medical plans or leave Bloomin’ Brands, you are able to take this money with you.
For medical, dental, and vision coverage, you can access a network of providers that our insurance partners have contracted with to negotiate lower charges for your claims. By using an in-network provider, you generally spend less on your care and are protected from balance billing.
You are encouraged to refill your maintenance medications through Express Scripts (ESI) mail order facility or a retail pharmacy in the Smart90 network. Your doctor would need to call in a 90-day supply of your prescription to ESI and, once you put your credit card on file, they will begin mailing your prescription directly to the home address you have entered in BBI Connect. Or, you may fill your 90-day maintenance prescriptions through a retail pharmacy in the Smart90 network. The Smart90 network includes all Walgreens retail pharmacies. If you do not take advantage of the mail order or Smart90 retail pharmacy program, you will begin to be charged the full cost of the medication after 2 fills at a retail pharmacy.
These are drugs you take on a regular basis such as cholesterol or hypertension medication. This does not include prescriptions you take on an irregular basis such as antibiotics.
Under our DPPO plan, major care is covered at 50% after you meet your deductible. Examples of Major Care include bridges, crowns, and dentures. Refer to your patient charge schedule for DHMO coverage.
Term used by insurers to describe medical treatment that is appropriate and in accordance with generally accepted standards of medical practice.
Out of Network
Under our medical, dental, and vision plans, you have the option of receiving care from providers who are not in the networks set up by our insurance partners. The providers may bill any charge they like for the care they have provided you. Our insurance partners will reimburse the provider up to the amount that is allowed less any deductible or coinsurance amount you may owe. The provider then may balance bill you for the amount they were not paid by the insurance company.
The maximum amount you are responsible to pay for eligible, covered expenses during a calendar year. If you receive non-covered services (such as cosmetic surgery), or are balance billed by an out-of-network provider, these expenses will not help you meet your out-of-pocket maximum.
If a service is subject to pre-authorization, your doctor must get authorization on your behalf from the medical, prescription drug, or dental insurance company to provide the care or drug they think is most appropriate for you. This allows the service or drug to be reviewed by another doctor to confirm its appropriateness and safety on your behalf.
A medical condition you had in the 6 months prior to being enrolled in the short or long-term disability plan. You will not be covered for any pre-existing conditions for 12 months after joining the disability plans. This includes pregnancy. There are no pre-existing condition exclusions under the medical plan.
Services or immunizations that are appropriate for your age and gender. These are typically covered at 100% by the health plan. For example, well-woman or well-baby visits, mammograms, and colonoscopies are considered preventive screenings. Under the dental plan, preventive care includes exams, cleanings, and x-rays.
If a preventive screening finds an issue, such as polyps in a colonoscopy, the screening will then be considered diagnostic and become subject to deductible and coinsurance. Even if what the test found turns out not to be a true issue, future screenings may be billed as diagnostic. If you are charged for what you think should be a preventive service, speak to your doctor’s billing office to confirm they are submitting your claim to the insurance plan correctly.
Prescription drugs that are considered preventive by Express Scripts are covered at 100%. Log in to Express Scripts’ website, www.express-scripts.com to confirm if any drug you are on is considered preventive.
Reasonable and Customary (R&C)
If you use an out-of-network dental provider, your claim will be paid at what is considered reasonable and customary (R&C) for your geographic area. Any amount your dentist charges above what is R&C will be your responsibility. This is the amount you will be balance billed. Our dental plan pays at the 90th percentile of R&C, meaning it pays what 90 out of 100 dentists would consider a reasonable charge for your area.
Certain drugs are considered specialty drugs if they are injectable, manufactured in a special way or have special handling instructions (must be refrigerated, for example). To be covered by the health plan, you must use Express Scripts specialty pharmacy, Accredo. If you think one of your prescription drugs is a specialty drug, call Express Scripts at 1-866-725-2520 to ask them. You can also ask to speak to a pharmacist if you have any questions about your medications.
A program that requires you try a lower cost version of a brand drug (usually a generic) that has been shown to have the same effect as the drug you were prescribed.
If any definitions in the Summary Plan Descriptions vary from the above, the definitions in the Summary Plan Descriptions prevail.