Add/Edit Benefit Plans
Search for, then click the desired submission to view its profile.
Scroll to the Quote Scenarios section of the submission profile and click the desired scenario to display its Scenario window.
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Click Benefit Plan to display plan information.
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Click Separate Benefit Plan if you want to split the benefit plan into a current plan, and a proposed plan and edit the two seperately.
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Click Edit to edit and create classes for the plan. All plans have one Class by default. To add a class, click the plus symbol to the right of the Plan pane.
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Adds a new class.
Deletes the class.
Specify Plan information for the class as follows:
Give the class a name in this field.
If the class includes medical coverage, slide the toggle to Yes. Defaults to Yes.
If the class includes prescription drug card coverage, slide the toggle to Yes. Defaults to No.
If the class includes dental coverage, slide the toggle to Yes. Defaults to No.
If the class includes vision coverage, slide the toggle to Yes. Defaults to No.
If the class includes short term disability coverage, slide the toggle to Yes. Defaults to No.
Specify the number and percent enrolled in the plan for the class using the two fields. Defaults to the data provided in your census.
If you enabled Medical coverage for the class, the Medical section for the class appears.
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Specify medical coverage details for the class as follows.
General
Copays
Use the drop-down to specify what medical copays are included in. Choices are:
Copays apply toward coinsurance out of pocket maximums.
Copays do not apply toward maximums. This is the default.
Copays apply toward the total out of pocket maximum.
Other Provisions
Slide the toggle to Yes to enable extension of benefits.
Slide the toggle to Yes to vary utilization by coinsurance level.
Slide the toggle to Yes to include infertility benefits.
Specify what percent of plan participation is by dependents in this field.
Specify the percent of employer dependent contribution in this field.
Wellcare
Specify the wellcare benefits from the drop-down.
Organ Transplant
Slide the toggle to Yes if the plan includes organ transplants.
Enter the organ transplant benefit here.
Slide the toggle to Yes if there is no limit to the organ transplant benefit.
Mental Health
Specify the annual day limit for inpatient mental health care from this drop-down.
Specify the level of outpatient mental health care coverage from this drop-down.
Specify the ultimate coinsurance percent for mental health care.
Specify the maximum benefit amount for mental health care here.
The maximum number of allowed visits for mental health care here.
Substance Abuse
Specify the annual day limit for inpatient substance abuse care from this drop-down.
Specify the level of outpatient substance abuse care coverage from this drop-down.
Specify the ultimate coinsurance percent for substance abuse care.
Specify the maximum benefit amount for substance abuse care here.
Specify the maximum number of allowed visits for substance abuse care here.
If you enabled Prescription Drug Card coverage for the class, the Prescription Drug Card section for the class appears.
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Specify prescription coverage details for the class as follows.
Options
Slide the toggle to Yes if the benefit is four-tier.
Slide the toggle to Yes to include specialty.
Slide the toggle to Yes to include mail order prescriptions. Adds a Mail Order column to Copays.
Slide the toggle to Yes to include out of network prescriptions. Adds an Out Net column to copays.
Specify the annual deductible criteria using this drop-down.
Specify deductible coverage rules using this drop-down.
Copays – Annual Deductible
Annual deductible for generic medications.
Annual deductible for formulary medications.
Annual deductible for non-formulary medications.
Annual deductible for lifestyle medications.
Annual deductible for specialty medications.
Slide the toggle to Yes to waive annual deductibles.
Copays – Coinsurance
Enter the coinsurance percent, and minimum and maximum coinsurance for generic medications in the corresponding Coinsurance, Min, and Max. fields.
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Enter the coinsurance percent, and minimum and maximum coinsurance for formulary medications in the corresponding Coinsurance, Min, and Max field.
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Enter the coinsurance percent, and minimum and maximum coinsurance for non-formulary medications in the corresponding Coinsurance, Min, and Max field.
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Enter the coinsurance percent, and minimum and maximum coinsurance for lifestyle medications in the corresponding Coinsurance, Min, and Max field.
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Enter the coinsurance percent, and minimum and maximum coinsurance for lifestyle medications in the corresponding Coinsurance, Min, and Max field.
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Copays
Annual maximum copay goes here.
Slide the toggle to Yes if oral contraceptives are included in copays.
Maximum Out-of-Pocket
Maximum out-of-pocket goes here.
Slide the toggle to Yes if generic medications must be used when available.
Slide the toggle to Yes if you want to combine prescription maximum out-of-pocket with medical.
Average Discounts
The average discount for generic medications goes here.
The average discount for formulary medications goes here.
The average discount for non-formulary medications goes here.
The average discount for lifestyle medications goes here.
The average discount for speciality medications does here.
Percentage of Retail Prescriptions
The percentage of retail prescriptions redirected to mail order.
The percentage of retail prescriptions redirected to out-of-network.
Utilization
Percent utilization for generic medications.
Percent utilization for formulary medications.
Percent utilization for non-formulary medications.
Perecent utilization for lifestyle medications.
Percent utilization for specialty medications.
Loadings
Loading amount per prescription fee.
Loading as a percent of claim cost.
If you enabled Prescription Dental coverage for the class, the Dental section for the class appears.
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Specify dental coverage details for the class as follows.
Deductible amount for dental coverage goes here.
Slide the toggle to Yes if the deductible applies to class 1.
Coinsurance percentage for preventative dental care.
Coinsurance percentage for basic restorative dental care.
Coinsurance percentage for major restorative dental care.
Maximum coinsurance amount for dental care.
Slide the toggle to Yes if orthodontic work is covered.
Coinsurance percentage for orthodontic work. Available when Orthodontia is set to Yes.
Lifetime maximum for orthodontic work. Available when Orthodontia is set to Yes.
Slide the toggle to Yes if adult orthodontic work is covered.
If you enabled Vision coverage for the class, the Vision section for the class appears.
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Specify vision coverage details for the class as follows.
Specify the vision benefit plan from the drop-down.
Fee per unit for eye exams.
Fee per unit for regular lenses.
Fee per unit for bifocal lenses.
Fee per unit for trifocal lenses.
Fee per unit for lenticular lenses.
Fee per unit for eyeglass frames.
Fee per unit for medically necessary contact lenses.
Fee per unit for cosmetic contact lenses.
Copay amount.
If you enabled Short-Term Disability coverage for the class, the Weekly Income section for the class appears.
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Specify disability coverage details for the class as follows.
Select the disability benefit plan from the drop-down.
The amount of weekly income paid under Worker's Compensation.
Click Save.