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Fishermens Finest Inc.

(Crew)
Employee Benefits Enrollment Guide
Plan Year: 2015-2016
Fishermens Finest, Inc. is pleased to continue offering Crew Health, Voluntary
Dental, and Voluntary Vision. Elections made during open enrollment will become
effective March 1, 2015
North Pacific Fishing, Inc. offers you and your eligible family members a
comprehensive benefits program, which fulfills all of the Individual Affordable Care
Act mandates. We encourage you to take the time to educate yourself about your
options and choose the best coverage for you and your family.
Group Benefits for 2015-2016 Plan Year:

Crew Medical
Voluntary Dental
Voluntary Vision

Who is Eligible?
Employee is eligible when they return for their second contract.
How to Enroll?
The first step is to review your current benefit elections. Verify your personal
information and make any changes, if necessary. Make your benefit elections. Once
you have made your elections, you will not be able to change them until the next
open enrollment period unless you have a qualified change in status.
When to Enroll?
All enrollment forms need to be submitted to Courtney Banks by February 20,
2015. The benefits you elect during open enrollment will be effective from March 1,
2015 until February 28, 2016.
How to Make Changes?
Unless you have a qualified change in status, you cannot make changes to the
benefits you elect until the next open enrollment period. Qualified changes in status
include: marriage, divorce, legal separation, birth or adoption of a child, change in
childs dependent status, death of spouse, child or other qualified dependent,
change in residence due to an employment transfer for you or your spouse,
commencement or termination of adoption proceedings, or change in spouses
benefits or employment status.

Fishermens Finest, Benefits 2015-2016| Gowrie Group, www.gowrie.com, 800.262.8911.

Page: 1

Medical and Prescription Drug Plan HTH GeoBlue

Deductible

Payment Level One

Outside the
U.S.

Inside the U.S.


In Network

Inside the U.S.


Out of
Network

$250 Individual
$625 Family

$250 Individual
$625 Family

$500 Individual
$1,250 Family

100% of
Usual & Customary
Fee

80% of
Negotiated Rate
Covered

60% of
Usual & Customary Fee

Once coinsurance max


is satisfied the insurer
will pay 100% of the
negotiated rate.

Once coinsurance max


is satisfied the insurer
will pay 100% of the
usual & customary fee.

Payment Level Two

$2,000 per Insured per Policy Year


$5,000 per Family per Policy Year

Coinsurance Maximum

After $30 copayment,


the insurer will pay
100% of the
Negotiated Rate

Physician Office Visits

Insurer will pay 100%


of the Usual and
Customary Fee

Surgical Care

Insurer will pay 100%


of the Usual and
Customary Fee

80% of the Negotiated


Rate, until the
coinsurance max is
satisfied

Emergency Care

Insurer will pay 100%


of the Usual and
Customary Fee

80% of the Negotiated


Rate, until the
coinsurance max is
satisfied

Prescriptions
Outside the US
1. Prescription Drugs
2. Injectables
Prescriptions
Inside the US
1. Generic
2. Brand name
3. Injectables

$10 copayment per prescription


30% copayment per prescription

$10 copayment per prescription


$25 copayment per prescription
30% copayment per prescription

60% of the Usual and


Customary Fee, until
the coinsurance max is
satisfied
60% of the Usual and
Customary Fee, until
the coinsurance max is
satisfied
60% of the Usual and
Customary Fee, until
the coinsurance max is
satisfied

Fishermens Finest, Benefits 2015-2016| Gowrie Group, www.gowrie.com, 800.262.8911.

Page: 2

Voluntary Dental Insurance: Principal


Type of Service

In Network

Out of Network

$50 individual/$150 family per calendar year.


Waived for preventive services.

Deductible

Paid in full by insurance for covered


expenses

You pay 20% of


covered expenses

Basic Services

You pay 20% of


covered expenses

You pay 30% of


covered expenses

Major Services

You pay 50% of


covered expenses

You pay 60% of


covered expenses

Preventive Services

Yes: Children only


50% to $1,000 lifetime maximum

Orthodontics

TMJ

State mandated TMJ services will be covered


Basic None
Major None
Orthodontics- None

Waiting Periods

$1,500 for Preventive, Basic and Major Services

Annual Maximum

Principals Network

You may choose any dentist. However, using dentists participating in the
network should lower your out-of-pocket expenses.
www.principal.com

Voluntary Vision Plan: Vision Service Plan


In Network

Out of Network

Well Vision Exam

No Charge

Up to $50

Prescription Glasses

$20 copay

Lenses

Single Vision

Bifocal

Trifocal

Lenticular

100% covered

Once every 12
months
Once every 12
months

Up to $50

100% covered

Up to $75

100% covered
100% covered

Up to $100
Up to $125

Frames

$130 allowance

Up to $70

Once every 24
months

Elective Contact Lenses

$130 allowance

Up to $105

Once every 12
months

Fishermens Finest, Benefits 2015-2016| Gowrie Group, www.gowrie.com, 800.262.8911.

Once every 12
months

Page: 3

Questions & Answers


Changes that can be made effective March 1, 2015
Enroll or terminate individual and/or dependent coverage in the medical, dental,
and vision plans.

What Forms MUST be completed?


Premium Election Form to change individual/dependent coverage in the medical
plan.
Premium Election Form to change individual/dependent coverage in the dental
plan.
Premium Election Form to change individual/dependent coverage in vision plan.
Where do I find these forms?

Contact Courtney Banks for all forms.

When are the forms due and where do I return them?


All forms are due by February 20, 2015 and must be returned to Courtney Banks.
IMPORTANT NOTE: After the open enrollment period, you cannot make
changes to your coverage during the year unless you experience a
change in family status, such as:

Loss or gain of coverage through your spouse


Loss of eligibility of a covered dependent
Death of your covered spouse or child
Birth or adoption of a child
Marriage, divorce or legal separation
Switch from part-time employment to full-time employment

You have (30) days from a change in family status to make changes to
your current coverage.

Fishermens Finest, Benefits 2015-2016| Gowrie Group, www.gowrie.com, 800.262.8911.

Page: 4

Who do I contact with questions?


Contact

Position

Courtney Banks
Phone: 206-283-1137
Email: cbanks@fishermensfinest.com
Rick Bagnall
Phone: 860-399-3634
Email: rickb@gowrie.com
Barbie Murray
Phone: barbiem@gowrie.com
Email: 860-399-3630

Accounts Payable & Payroll Manager

Account Executive
Account Manager

Contact

Position

Geo Blue
Phone: 855-282-3517

Customer Service
Medical Benefits

Principal
Phone: 800-843-1371

Customer Service
Dental Benefits

VSP
Phone: 800-852-7600

Member Services
Vision Benefits

The information in this Enrollment Guide is presented for illustrative purposes and is
based on information provided by the employer. The text contained in this Guide
was taken from various summary plan descriptions and benefit information. While
every effort was taken to accurately report your benefits, discrepancies, or errors are
always possible. In case of discrepancy between the Guide and the actual plan
documents the actual plan documents will prevail. All information is confidential,
pursuant to the Health Insurance Portability and Accountability Act of 1996. If you
have any questions about your Guide, contact Human Resources.

Fishermens Finest, Benefits 2015-2016| Gowrie Group, www.gowrie.com, 800.262.8911.

Page: 5

: Fishermens Finest

Coverage Period: 03/01/2015 02/29/2016

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage for: Individual + Family | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.geo-blue.com or by calling 1-855-282-3517 (+1.610.254.5304 from outside the U.S.).
Important Questions

Answers

Why this Matters:

What is the overall


deductible?

Outside the U.S. $250 person /$625 Family.


Inside the U.S., in Network $250 person /$625
family. Inside the U.S., Out of Network - $500
person /$1,250 family. Doesnt apply to preventive
care and certain other services

You must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. Check your policy or
plan document to see when the deductible starts over (usually, at the
end of the Coverage Period). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.

Are there other


deductibles for specific
services?

No.

You dont have to meet deductible for specific services, but see
amount before this plan begins to pay for these services.

Is there an outof
pocket limit on my
expenses?

Yes. Outside the U.S., $0 person/ $0 family.


Inside U.S., in Network- $2,000 person/$5,000
family. Inside the U.S., out of Network-$2,000
person/$5,000 family.

The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.

What is not included in


the outofpocket limit?
Is there an overall
annual limit on what the
plan pays?

Premiums, balanced billed charges, copayments,


deductibles and health care the plan does not cover

Even though you pay these expenses, they dont count toward the outof-pocket limit.

No.

The chart starting on page 2 describes any limits on what the plan will
pay for specific covered services, such as office visits.

Does this plan use a


network of providers?

Yes. See www.geo-blue.com or call 1-855-2823517 for a list of participating providers.

If you use an in-network doctor or other health care provider, this


plan will pay some or all of the costs of covered services. Be aware,
your in-network doctor or hospital may use an out-of-network
provider for some services. Plans use the term in-network, preferred,
or participating for providers in their network. See the chart starting
on page 2 for how this plan pays different kinds of providers.

Do I need a referral to
see a specialist?

No. You dont need a referral to see a specialist.

You can see the specialist you choose without permission from this
plan.

Yes.

Some of the services this plan doesnt cover are listed on page 5. See
your policy or plan document for additional information about
excluded services.

Are there services this


plan doesnt cover?

Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.

1 of 8

: Fishermens Finest

Coverage Period: 03/01/2015 02/29/2016

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage for: Individual + Family | Plan Type: PPO

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you havent met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical
Event

If you visit a
health care
providers
office or clinic

If you have a
test

Services You May Need

Your Cost
Outside the
U.S.

Primary care visit to treat an


injury or illness

No charge

Specialist visit

No charge

Other practitioner office visit

No charge

Preventive care/
screening/immunization
Diagnostic test (x-ray, blood
work)
Imaging (CT/PET scans,
MRIs)

No charge
No charge
No charge

Your Cost If Your Cost If


You Use a
You Use a
U.S.
U. S. NonParticipating Participating
Provider
Provider
40%
$30 copay/visit
coinsurance
40%
$30 copay/visit
coinsurance
$30 copay/visit
40%
for
coinsurance for
chiropractor
chiropractor
and
and
acupuncture
acupuncture
40%
No charge
coinsurance
20%
40%
coinsurance
coinsurance
20%
40%
coinsurance
coinsurance

Limitations & Exceptions

none
none

Chiropractor limited to 20 visits per Policy Year

none
none
none

Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.

2 of 8

: Fishermens Finest

Coverage Period: 03/01/2015 02/29/2016

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage for: Individual + Family | Plan Type: PPO

Your Cost If Your Cost If


You Use a
You Use a
U.S.
U. S. NonParticipating Participating
Provider
Provider

Common
Medical
Event

Services You May Need

If you need
drugs to treat
your illness or
condition

Generic drugs

$10 copay/
prescription

$10 copay/
prescription

$10 copay/
prescription

Covers up to a 30-day supply

Brand drugs

$10 copay/
prescription

$25 copay/
prescription

$25 copay/
prescription

Covers up to a 30-day supply

Injectables

30%
coinsurance

30%
coinsurance

30%
coinsurance

Covers up to a 30-day supply

Facility fee (e.g., ambulatory


surgery center)

No charge

Physician/surgeon fees

No charge

20%
coinsurance
20%
coinsurance

40%
coinsurance
40%
coinsurance

Emergency room services

No charge

20%
coinsurance

40%
coinsurance

Emergency medical
transportation

No charge

20%
coinsurance

40%
coinsurance

Urgent care

No charge

Facility fee (e.g., hospital


room)

No charge

Physician/surgeon fee

No charge

20%
coinsurance
20%
coinsurance
20%
coinsurance

40%
coinsurance
40%
coinsurance
40%
coinsurance

More
information
about
prescription
drug coverage
is available at
www.geoblue.com
If you have
outpatient
surgery

If you need
immediate
medical
attention

If you have a
hospital stay

Your Cost
Outside the
U.S.

Limitations & Exceptions

none
none
If an Insured Person requires emergency treatment
of an Injury or Sickness and incurs covered
expenses at a non-Preferred Provider, Covered
Medical Expenses for the Emergency Medical
Care rendered during the course of the emergency
will be treated as if they had been incurred at a
Preferred Provider.
none
none
none

Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.

3 of 8

: Fishermens Finest

Coverage Period: 03/01/2015 02/29/2016

Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical
Event

Services You May Need

If you have
mental health,
behavioral
health, or
substance
abuse needs

Mental/Behavioral health
outpatient services
Mental/Behavioral health
inpatient services
Substance use disorder
outpatient services
Substance use disorder
inpatient services

If you are
pregnant

If you need
help
recovering or
have other
special health
needs

If your child
needs dental
or eye care

Your Cost
Outside the
U.S.
No charge
No charge
No charge
No charge

Prenatal and postnatal care

No charge

Delivery and all inpatient


services

No charge

Home health care

No charge

Rehabilitation services

No charge

Habilitation services

No charge

Skilled nursing care

No charge

Durable medical equipment

No charge

Hospice service

No charge

Eye exam
Glasses
Dental check-up

Not covered
Not covered
Not covered

Coverage for: Individual + Family | Plan Type: PPO

Your Cost If Your Cost If


You Use a
You Use a
U.S.
U. S. NonParticipating Participating
Provider
Provider
40%
$30 copay/visit
coinsurance
20%
40%
coinsurance
coinsurance
40%
$30 copay/visit
coinsurance
20%
40%
coinsurance
coinsurance
20%
40%
coinsurance
coinsurance
20%
40%
coinsurance
coinsurance
20%
40%
coinsurance
coinsurance
40%
$30 copay/visit
coinsurance
40%
$30 copay/visit
coinsurance
20%
40%
coinsurance
coinsurance
20%
40%
coinsurance
coinsurance
20%
40%
coinsurance
coinsurance
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered

Limitations & Exceptions

none
none
none
none
none
none
Limited to 120 visits per Policy Year

Limited to 30 visits per Policy Year

Limited to 120 days per Policy Year


none
none
Not covered
Not covered
Not covered

Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.

4 of 8

: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 03/01/2015 02/29/2016


Coverage for: Individual + Family | Plan Type: PPO

Excluded Services & Other Covered Services:


Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.)

Cosmetic surgery

Long-term care

Routine foot care

Dental care (Adult & Children)

Private-duty nursing

Weight loss programs

Infertility treatment

Routine eye care (Adult and Children)

Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these
services.)

Acupuncture (if prescribed for rehabilitation


purposes)

Bariatric surgery

Chiropractic care

Hearing aids (maximum of $1,000 every 3


years for Dependent Children under the Age
of 24)

Most coverage provided outside the United


States. See www.geo-blue.com.

Non-emergency care when traveling outside


the U.S.

Your Rights to Continue Coverage:


If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-855-282-3517. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.

5 of 8

: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 03/01/2015 02/29/2016


Coverage for: Individual + Family | Plan Type: PPO

Your Grievance and Appeals Rights:


If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: Customer Service at 1-855-282-3517. Additionally, you can contact your plan
administrator or the Department Labors Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Additionally, a consumer assistance program can help you file your appeal.

Language Access Services:


Spanish (Espaol): Para obtener asistencia en Espaol, llame al 1-855-282-3517
Chinese (): 1-855-282-3517

Does this Coverage Provide Minimum Essential Coverage?


The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does
provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?


The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.

To see examples of how this plan might cover costs for a sample medical situation, see the next page.

Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.

6 of 8

: Fishermens Finest

Coverage Period: 03/01/2015 02/29/2016

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

About these Coverage


Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.

This is
not a cost
estimator.
Dont use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.

Coverage for: Individual + Family | Plan Type: PPO

Having a baby

Managing type 2 diabetes

(normal delivery)

(routine maintenance of
a well-controlled condition)

 Amount owed to providers: $7,540


 Plan pays $5,720
 Patient pays $1,820

 Amount owed to providers: $5,400


 Plan pays $4,230
 Patient pays $1,170

Sample care costs:


Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total

$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540

Sample care costs:


Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total

$2,900
$1,300
$700
$300
$100
$100
$5,400

Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total

$250
$20
$1,400
$150
$1,820

Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total

$250
$400
$440
$80
$1,170

Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.

7 of 8

: Fishermens Finest
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 03/01/2015 02/29/2016


Coverage for: Individual + Family | Plan Type: PPO

Questions and answers about the Coverage Examples:


What are some of the
assumptions behind the
Coverage Examples?

Costs dont include premiums.


Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and arent specific to a
particular geographic area or health plan.
The patients condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.

What does a Coverage Example


show?

Can I use Coverage Examples


to compare plans?

For each treatment situation, the Coverage


Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isnt covered or payment is limited.

Yes. When you look at the Summary of

Does the Coverage Example


predict my own care needs?

 No. Treatments shown are just examples.

The care you would receive for this


condition could be different based on your
doctors advice, your age, how serious your
condition is, and many other factors.

Does the Coverage Example


predict my future expenses?

 No. Coverage Examples are not cost

estimators. You cant use the examples to


estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.

Benefits and Coverage for other plans,


youll find the same Coverage Examples.
When you compare plans, check the
Patient Pays box in each example. The
smaller that number, the more coverage
the plan provides.

Are there other costs I should


consider when comparing
plans?

Yes. An important cost is the premium

you pay. Generally, the lower your


premium, the more youll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.

Questions: Call 1-855-282-3517 or visit us at www.geo-blue.com. If you arent clear about any of the underlined terms used in this form, see the
Glossary. You can view the Glossary at www.geo-blue.com or call 1-855-282-3517 to request a copy.

8 of 8

Fishermens Finest, Inc.

Your Guide to GeoBlue Expat


Welcome to GeoBlue, a program designed to keep you safe and healthy as
you travel the world. Your GeoBlue Expat health insurance plan features a full
range of personal solutions, including concierge-level services and convenient
online and mobile self-service tools available on www.geo-blue.com. Register
online to learn about the extra care you receive when you travel with GeoBlue.

Register online to learn more about your


benefits.
Visit www.geo-blue.com to register and access important plan
information:
Print a temporary ID card
Review plan benefits
Locate Blue Cross and Blue Shield providers and hospitals
within the U.S.
Locate trusted providers and hospitals outside of the U.S.
You can also register through the GeoBlue app.

Need help with registration?


Visit how-to.geo-blue.com to watch the member tutorial video,
or contact us:
Inside the U.S.: 1.855.282.3517
Outside the U.S.: +1.610.254.5304
customerservice@geo-blue.com

Get your GeoBlue ID card.


It is important to have your GeoBlue ID card to access healthcare
services; you will need to present your ID card whenever you
receive medical care. This card can be accessed from multiple
sources:
GeoBlue ID card(s) will be mailed to you.
A temporary ID card is available in the Member Hub.
Customer Service can provide replacement ID cards.
You can show, fax or email your ID card through the
GeoBlue app.
When you receive your card, please check the information on your
ID card for accuracy. Call Customer Service if you find an error on
your card.

Download the GeoBlue app.


Download the GeoBlue app and login with the email address and
password you created when you registered on the website. If you
have not previously registered, you can register directly through
the app. The GeoBlue app provides you with the most convenient
access to your ID card and GeoBlues self-service tools.

GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association.
Made available in cooperation with Premera Blue Cross.

geo-blue.com

Medical Care Inside the U.S.

Medical Care Outside the U.S.

Finding care inside the U.S.:

Locating a doctor or facility outside the


U.S.:

GeoBlue members have access to the Blue Cross and Blue


Shield network within the U.S., Puerto Rico, and U.S. Virgin
Islands. To find a doctor or facility, visit the Find U.S. Doctors &
Hospitals section in the Member Hub on www.geo-blue.com or
in the GeoBlue app.
Contact us for assistance:
Toll free within the U.S.: 1.855.282.3517
Outside the U.S.: +1.610.254.5304
customerservice@geo-blue.com

Scheduling an appointment with a


Blue Cross and Blue Shield provider:
Call the provider to confirm they are in network and
schedule your appointment. You will need to show the provider
your GeoBlue ID card at the time of service.

Using an out-of-network provider:


If you receive care from an Out-of-Network provider, you
may need to pay out of pocket and submit a claim for
reimbursement. Submit claims electronically using the
GeoBlue app or the Filing eClaims link on the Member Hub
at www.geo-blue.com.

In the event of a medical emergency:


Members should go immediately to the nearest physician or
hospital and then call GeoBlue at the phone number for 24/7
Medical Assistance located on the back of your ID card.

Prescription benefits inside of the U.S.:


Present your ID card at any participating pharmacy and you will
be charged in accordance with your plan benefits.*

To find a contracted doctor or facility, visit the Find International


Doctors and Hospitals section in the Member Hub on
www.geo-blue.com or in the GeoBlue app. If you go to a
contracted provider and contact GeoBlue to arrange for Direct
Pay before your appointment, you will not need to pay out of
pocket for treatment.
Outside of the U.S. you are free to see any provider you choose
without a reduction of benefits.

Accessing care and arranging Direct Pay


with participating providers:
To avoid paying up front for medical care and submitting a
claim, schedule an appointment by:
Calling GeoBlue at +610.254.8771
Emailing globalhealth@geo-blue.com
Using www.geo-blue.com or the GeoBlue downloadable app
to find a provider, view a profile and complete a request form
If you prefer to make your own appointment, contact GeoBlue
with as much notice as possibletypically at least 24 hours prior
to your appointmentto request Direct Pay.
Members are required to pay any applicable co-payments,
coinsurance or deductibles at the time of service.

Making your own appointment?


If you make your own appointment, contact GeoBlue (with as
much notice as possible) to provide the doctors office with the
information required to arrange Direct Pay. This is necessary
when scheduling follow-up appointments as well. In many
countries providers require payment at the time of the visit
unless Direct Pay has been arranged.
Contact us to arrange for Direct Pay:
Use the GeoBlue app, select the provider and submit a
request for Direct Pay Only, Appointment Already Scheduled
Call Collect: +1.610.254.8771
Toll Free Inside the U.S.: 1.800.257.4823
globalhealth@geo-blue.com

Prescription benefits outside of the U.S.:


Utilize the international mail order process to fill your
prescription, or pay for your prescription and complete and
submit a claim form for reimbursement.
*Certain limitations and exclusions apply to your coverage under this plan and may affect your coverage. Your Certificate of Insurance is on file with your
Human Resources Department and in the Member Hub on www.geo-blue.com.

GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association.
Made available in cooperation with Premera Blue Cross.

www.geo-blue.com

GeoBlue provides you with an indispensable set of Personal Solutions. Call or


email us to enlist help with:
Appointment Scheduling with Direct Pay
outside the U.S.
Request a convenient, cashless office visit with one of
GeoBlues trusted English-speaking doctors.
Contact 24/7: +1.610.254.8771

Chronic Care and Maternity Support


Let GeoBlue line up the best local resources outside the U.S.
to manage cancer, heart disease, sports injuries, behavioral
conditions and maternity.
Contact 24/7: +1.610.254.8771

Informed Choice Consultation


Understand your local, regional or international treatment
options for serious unexpected medical problems that
occur outside the U.S. Then let GeoBlue help you put
a plan into action.
Contact 24/7: +1.610.254.8771

Global Counseling for Personal Issues*


For confidential assistance with any work, life, personal
or family issue, you can talk to professional counselors for
in-the-moment support and information about local resources
all around the world.
Available any day, any time, contact:
Inside the U.S.: 1.877.249.4765
Outside the U.S.: +44.208.987.6228
support@worldwideassist.co.uk

Global Wellness*
Set your baseline by taking the Health Assessment and then
work to improve your wellness via a one-on-one telephone
relationship with a Wellness Coach or by using one of the online
programs from the Mayo Clinic to address issues related to
fitness, weight, smoking and stress. Check out the smart, timely
advice on the best ways to manage diet and exercise around the
world at Travel Well (www.geo-blue.com).
To contact a Wellness Coach:
Inside the U.S.: 1.877.249.4752
Outside the U.S.: +44.208.987.6229
contactacoach@wellness-assist.com.

*Services are provided by WorkPlace Options, an independent company that is not affiliated with GeoBlue and does not provide Blue Cross or Blue Shield products or services.
WorkPlace Options is solely responsible for referring participants for counseling, coaching and work-life services by providers who are appropriately licensed by local authorities.
The evaluation and efficacy of any service delivered by a provider lies solely with the employee, spouse, dependent or other authorized party who inquires on behalf of the
participant. GeoBlue shall have no responsibility or liability whatsoever for any aspect of the provider counseling or the counselor/participant relationship.

Visit www.geo-blue.com or download the GeoBlue app to access these


self-service tools for navigating risks and finding the best care options:
Check your symptoms*

Translate medical terms

Translate symptoms into action with this authoritative triage


tool. You can decide to seek treatment in an emergency room,
schedule a doctor visit or employ home remedies.

Convert symptoms, diagnoses and treatment plans into the


twelve most common languages.

Find a doctor and schedule an


appointment outside the U.S.
Review detailed profiles of contracted doctors to find the best
match and then locate the office. In order to avoid paying upfront
for your medical care and having to submit a claim for
reimbursement, schedule your appointment through GeoBlue..

Understand health and security risks


Receive daily alerts detailing the latest security and health
issues in your destination. Dig into country or city-level profiles
on crime, terrorism and natural disasters.

Translate medications
Find country-specific equivalents for prescriptions and
over-the-counter medications.
*Available on geo-blue.com only.

GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association.
Made available in cooperation with Premera Blue Cross.

www.geo-blue.com

Submitting a Claim
If you are seeking reimbursement for covered services, you can quickly and conveniently submit claims electronically,
using the GeoBlue app or the Filing eClaims link on the Member Hub at www.geo-blue.com. Scanned paper
documents are delivered directly to our Claims Department, and your eClaims are saved in your Member Profile.
If you prefer to submit a claim via email, fax or postal mail, a printable claim form is available in the Member Hub on www.geo-blue.com.
Email: claims@geo-blue.com
Fax: +1.610.482.9623
Postal Mail: GeoBlue, Attn: Claims, One Radnor Corporate Center, Suite 100, Radnor, PA 19087
If a physician, ambulance company or other provider sends their bill directly to you, or you pay the medical provider at the time of service,
you will need to complete and submit a Claim Form. The Claim Form was developed for you to notify us of any covered health services for
which we have not already been billed.
Please read the following instructions about how to report health care services. Following these instructions will expedite
the payment of your claim.
1. Complete the claim form. Answer all questions, even if the answer is none or N/A. Be certain that the name on the bill you are
submitting is the same as that which is indicated on your ID card. If not, please enclose a short note of explanation. A signature is required
on all claim forms.
2. Attach the provider bill/documentation to the claim form and follow the instructions on the back of the form for submission to GeoBlue.
Bills must be itemized: Canceled checks, cash register receipts and non-itemized balance due statements cannot be processed.

Each itemized bill must include: name and address of provider (doctor, hospital, laboratory, ambulance service, etc.), name of
patient, date(s) of service, amount charged for each service, total charge, diagnosis or reason for treatment.

Outpatient Prescription Drugs: duplicate pharmacy generated receipts (not register tape) must include Rx number; date filled,
medication name, form, strength and quantity. (NOTE: All prescription drug charges will be reimbursed to the insured person only.)

3. Additional Information
If submitting expenses for more than one family member, please use a SEPARATE claim form for each person.
All claims should be filed with our office within the six (6) month period from the date of the incurred expense.
If you have questions regarding the completion of this claim form, please contact Customer Service.

To check your claim status, visit Claims in the Member Hub on www.geo-blue.com.

Contact Information
For questions about your medical plan:
Toll free within the U.S.: 1.855.282.3517
Outside the U.S.: +1.610.254.5304
customerservice@geo-blue.com

For medical assistance (including Direct Pay outside the U.S.):


Toll free within the U.S.: 1.800.257.4823
Collect Calls Accepted: +1.610.254.8771
globalhealth@geo-blue.com

2014 GeoBlue

Policyholder: Fishermens Finest

Voluntary Dental PPO Benefit


Summary
Effective Date: 03/01/2015
Predetermination of Benefits: Before treatment begins for inlays, onlays, single crowns, prosthetics,
periodontics and oral surgery, you may file a dental treatment plan with Principal Life Insurance Company before
treatment begins. Principal Life will provide a written response indicating benefits that may be payable for the
proposed treatment.
This chart provides you a brief summary of the key benefits of the dental coverage available from Principal Life
Insurance Company. Following the chart, you will find additional information to answer questions you may have.
For a complete list of all your dental coverage benefits and restrictions, please refer to your booklet or contact your
employer.
Eligibility
Job Class

All Other Members

Benefits Payable
Network

Dental Preferred Provider Organization (PPO)

Calendar Year Deductible

Coinsurance (Policy Pays)

In-Network

Non-Network

In-Network

Non-Network

Unit 1 Preventive

$0

$0

100%

80%

Unit 2 Basic

$50

$50

80%

70%

Unit 3 Major

$50

$50

50%

40%

Family Deductible Maximum

3 times the per person deductible amount

Combined Deductible

In-network deductibles for basic and major procedures are combined. Non-network
deductibles for basic and major procedures are combined.

Combined Maximums

Maximums for preventive, basic, and major procedures are combined. In-network Calendar
year maximums are $1,500 per person. Non-network Calendar year maximums are $1,500 per
person.

Maximum Accumulation

This allows for a portion of unused maximum benefit to carry over to next year's maximum
benefit amount. To qualify, you must have had a dental service performed within the
Calendar year and used less than the maximum threshold. The threshold is equal to the lesser
of 50% of the maximum benefit or $1000. If qualification is met, 50% of the threshold is
carried over to next year's maximum benefit. You can accumulate no more than four times the
carry over amount.

Additional Benefits
Lifetime Deductible
Unit 4 - Orthodontia

Child

Coinsurance (Policy Pays)

In-Network

Non-Network

In-Network

Non-Network

$0

$0

50%

50%

Lifetime Maximum:
In-Network: $1,000
Non-Network: $1,000

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How Are Dental Procedures Covered?


The list of common procedures shows what unit the procedure is included in and how often they are covered.

Unit 1
Preventive
Procedures

Unit 2
Basic
Procedures

Routine exams - two per calendar year


Routine cleaning (prophylaxis) - two per calendar year (Expectant mothers, diabetics and
those with heart disease receive one additional routine or periodontal cleaning within a
calendar year.)
Second Opinion Consultation
Fluoride one treatment each calendar year (covered only for dependent children under
age 16)
Space maintainers - covered only for dependent children under age 16; repairs not
covered
Sealants on first and second permanent molars for dependent children under age 16;
one each tooth each 36 months
Harmful Habit Appliance - covered only for dependent children under age 16
X-rays - Bitewing (one set every calendar year), occlusal, periapical
X-rays Full mouth survey (one every 60 months), extraoral
Periodontal prophylaxis - if three months have elapsed after active surgical periodontal
treatment; four per calendar year (Expectant mothers, diabetics and those with heart
disease receive one additional routine or periodontal cleaning within a calendar year.)
Emergency exams two per calendar year
Fillings and stainless steel crowns
Simple Oral Surgery
Complex Oral Surgical Procedures
Non-surgical Periodontics, including scaling and root planing - once each quadrant each
24 months (For expectant mothers, diabetics and those with heart disease, this procedure
is provided with no deductible and 100% coinsurance.)
Periodontal Surgical Procedures one each quadrant each 36 months
Simple Endodontics (root canal therapy for anterior teeth)
Complex Endodontics (root canal therapy for molar teeth)
Repairs to Partial Denture, Bridge, Crown, Relines, Rebasing, Tissue Conditioning and
Adjustment to Bridge/Denture, within policy limitations

Unit 3
Major
Procedures

General Anesthesia (covered only for specific procedures)/IV Sedation


Crowns each 84 months per tooth if tooth cannot be restored by a filling.
Inlays, Onlays, Cast Post and Core, Core Buildup - each 84 months per tooth
Bridges - Initial placement / Replacement of bridges 84 months old.
Dentures - Initial placement of complete or partial dentures / Replacement of complete or
partial dentures over 60 months old

Unit 4 - Orthodontic
Procedures

X-rays and other diagnostic procedures, fixed and removable appliances

There is Coordination of Benefits, which is a procedure for limiting benefits from two or more carriers to 100% of
the claimant's covered expenses.

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Understanding Your Dental Benefits


Am I Eligible For Coverage?
To be eligible for coverage, you must qualify as an eligible member and be considered actively at work.

You must be enrolled for dental coverage before it can be offered to your dependents. Eligible dependents
include your spouse, qualified domestic partner and children, including those of your qualified domestic partner.
Additional eligibility requirements may apply.

An annual enrollment applies. Members can enroll for dental coverage during the annual enrollment period and
not be subject to the late entrant waiting period. Certain restrictions apply.

How Do I Find A Participating Provider?

Use the Provider Directory on www.principal.com to locate nearby dentists or see if your dentist participates in
your network.
1

Visit www.principal.com.

Under the Quick Links heading on the left-hand side, click Provider Directory.

In the left-hand navigation under Providers/Networks, click Search For A Dental Provider.

Begin your search by picking the state where you would like to find a provider. Next, specify a network. Depending
on the network chosen, you may be transferred to a partner site.

Enter the name of the provider you are looking for (if known). If you are looking for a nearby dentist, enter the city
and state and/or ZIP code. Be sure to indicate how far you are willing to travel.

Select the desired specialty or use the No Specialty Preference default. Click Continue.

You may nominate your dentist for inclusion in our network. Please submit the dentist's name, address, phone
and specialty by calling 1-800-832-4450, or submit through www.principal.com.

What Are The Restrictions Of My Coverage?


This Benefit Summary is a summary only. For a complete list of benefit restrictions, please refer to your booklet.

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Limitations & Exclusions


Late Entrant Provision

Those members enrolling more than 31 days after becoming eligible will be effective on the
policy anniversary.

Missing Tooth

Benefits for the initial placement of bridges, partials and dentures are not covered if those
teeth were missing prior to becoming insured under the Principal Life policy. When the policy
replaces coverage under a prior plan, continuous coverage under the prior plan may be
applied to the missing tooth provision requirement.

Orthodontia

If there is orthodontia (ortho) treatment in progress on the coverage effective date and you
are covered under any prior group coverage for ortho, there will be immediate coverage for
treatment if proof is submitted that shows:
1) The lifetime maximum under any prior group coverage has not been exceeded,
2) Ortho treatment was started and bands or appliances were inserted while insured under
any prior group coverage, and
3) Ortho treatment has been continued while insured under this policy.
Principal Life will credit payments made by the prior carrier toward the Principal Life lifetime
ortho payment limit.
You will not be covered if ortho treatment is in progress prior to the effective date with
Principal Life and you are not covered under any prior group coverage for ortho.

Prevailing Charge

When using non-network providers, you pay any amount over the allowable charge.

Other Limitations

There are additional limitations to your coverage. A complete list is included in your booklet.

WELL GIVE YOU AN EDGE


Principal Life Insurance Company, Des Moines, Iowa 50392-0002, www.principal.com
This is a summary of dental coverage underwritten by or with administrative services provided by Principal Life Insurance Company. This
benefit summary is for administrative purposes and is not a complete statement of benefits and restrictions. Youll receive a benefit booklet
with details about your coverage. If there is a discrepancy between this summary and your benefit booklet, the benefit booklet prevails.
GP55773-13 | 11/2014 | 2014 Principal Financial Services, Inc.

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Fishermen's Finest and VSP provide you an affordable


eyecare plan.
Doctor Network...VSP Signature

Your Coverage with a VSP Doctor


WellVision Exam focuses on your eye health and
overall wellness
$0 copay ...................................... every 12 months
Prescription Glasses
$20 copay
Lenses................................................... every 12 months
Single vision, lined bifocal, and lined trifocal lenses
Polycarbonate lenses for dependent children
Frame.................................................... every 24 months
$130 allowance for a wide selection of frames
20% off the amount over your allowance
~OR~
Contact Lens Care
No copay .................................... every 12 months
$130 allowance for contacts and the contact lens exam
(fitting and evaluation). If you choose contact lenses you
will be eligible for a frame 12 months from the date the
contact lenses were obtained.
Current soft contact lens wearers may qualify for a special
program that includes a contact lens exam and initial
supply of lenses.

Extra Discounts and Savings


Glasses and Sunglasses
Average 35 - 40% savings on all non-covered lens
options
30% off additional glasses and sunglasses, including
lens options, from the same VSP doctor on the same
day as your WellVision Exam. Or get 20% off from any
VSP doctor within 12 months of your last WellVision
Exam
Contacts
15% off cost of contact lens exam (fitting and
evaluation)
Laser Vision Correction
Average 15% off the regular price or 5% off the
promotional price. Discounts only available from
contracted facilities.
After surgery, use your frame allowance (if eligible) for
sunglasses from any VSP doctor

Your Coverage with Other Providers


Visit vsp.com for details, if you plan to see a provider
other than a VSP doctor.
Exam .............................................................Up to $50.00
Single vision lenses ......................................Up to $50.00
Lined bifocal lenses ......................................Up to $75.00
Lined trifocal lenses ....................................Up to $100.00
Frame............................................................Up to $70.00
Contacts ......................................................Up to $105.00
VSP guarantees service from VSP doctors only. In the
event of a conflict between this information and your
organization's contract with VSP, the terms of the contract
will prevail.