9. What are In-Network Benefits?
10. What are Out of Network Benefits?
11. What Optional Benefits are included? Excluded?
Other Documents:
Schedule of Benefits
Example Charges
Pekin Insurance Frequently Asked Questions:
Open Enrollment Dates?
- Adding a New Employee: If an employee or his dependents apply on or before the day they are eligible, they will become insured on the date they are eligible. If an employee or his dependents apply within 30 days after the date they are eligible, they will become insured on the premium due date following the date they apply.
- Late Enrollees: Employees who are late enrollees (as defined by the policy) will be eligible for coverage during the late enrollee "open enrollment period" which is held in November and December of each year. They are then subject to an 18-month pre-existing condition limitation period. Coverage for the late enrollee will become effective on January 1 following the date of the application.
- Certificates of Creditable Coverage: Need to verify prior coverage if employee was covered by insurance anytime the previous 12 months. Depending on the plan waiting period will determine when an employee becomes eligible for coverage. This information can be found on page 9 of the Choice+ brochure.
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What is considered a Qualifying Event?
- Marriage
- Divorce
- Birth of a Child
- Loss of Job
- For an expanded list, check your policy certificate or call customer service.
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How do I add dependents to my insurance?
- Adding a New Employee: If an employee or his dependents apply on or before the day they are eligible, they will become insured on the date they are eligible. If an employee or his dependents apply within 30 days after the date they are eligible, they will become insured on the premium due date following the date they apply.
- Late Enrollees: Employees who are late enrollees (as defined by the policy) will be eligible for coverage during the late enrollee "open enrollment period" which is held in November and December of each year. They are then subject to an 18-month pre-existing condition limitation period. Coverage for the late enrollee will become effective on January 1 following the date of the application.
- Certificates of Creditable Coverage: Need to verify prior coverage if employee was covered by insurance anytime the previous 12 months. Depending on the plan waiting period will determine when an employee becomes eligible for coverage. This information can be found on page 9 of the Choice+ brochure.
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Who do I call if I lose my drug (Rx) card or my Insurance card?
- It's a good idea to have all your contact numbers and policy/plan numbers recorded where you can find them. If you lose either card or both, contact customer service for replacements.
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What is the breakdown of the prescription drugs?
Prescription Co-pay Amounts:
- Generic Prescription Co-pay Amount - $10
- Preferred Brand Prescription Co-pay Amount - $35
- Brand Prescription Co-pay Amount - $50 or 50% of the cost of the drug, whichever is greater
- Always ask for GENERIC and utilize whenever possible
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Is there a drug website I can access to see the different brands for the breakdown?
- Your RX card website is: www.restat.com or call the RX help desk @ 1-800-248-1062
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Can I access the web to look at claims?
- www.pekininsurance.com
- Your information on the claim site is correct
- Click on HEALTHLINK
- Health claim inquiry
- USERID is social security number on your insurance card
- PASSWORD defaults to policy holder date of birth - update/change password under user setting
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Where can I find a physician in our network?
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What are In-Network Benefits?
- In-Network Individual Deductible Amount - $2,500
- In-Network Family Deductible Amount - $7,500
- In-Network Co-insurance Percentage - %100
- Emergency Room Co-pay Amount - $100
- In-Network Maximum Co-insurance Share Per Calendar Year
- Per Family - 0
- Per Individual - 0
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What are Out of Network Benefits?
- Out of Network Individual Deductible Amount - $5,000
- Out of Network Family Deductible Amount - $15,000
- Out of Network Coinsurance Percentage - %70
- Reasonable & Customary Percentile Level - 60th
- Out of Network Maximum Coinsurance Share Per Calendar Year
- Per Family - $9,000
- Per Individual - $4,500
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What Optional Benefits are included? Excluded?
Included:
- Pregnancy Like Any Illness
- Infertility & In Vitro Fertilization Benefit
- Contraceptive Benefit
- Mental Health Parity Benefit
- Federal Continuation of Health Insurance Coverage After Termination
Excluded:
- Wellness Benefit for Preventive Health Care (Preferred Provider Only)
- Maximum Wellness Benefit
- Hospital Benefits for Dental Surgery
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