Form

Purpose

Enrollment

JBT 1400 Hour Employee Request for Benefits Package/Enrollment Procedures and Summary of Benefits (32 KB PDF)

Summarizes JBT benefits available to 1400 Hour employees.

Return the "Request for Benefits Package” section to request enrollment materials from the JBT.

Enrollment Form for 1400 Hour Employees (233 KB PDF)

Complete and return this form to enroll yourself and your eligible dependents in JBT benefits.

New Entrants: JBT Non-1400 Hour Employee Request for Benefits Package/Enrollment Procedures and Summary of Benefits (76 KB PDF)

Summarizes JBT benefits available to Non-1400 Hour employees.

Upon earning initial eligibility, return the "Request for Benefits Package” section to request enrollment materials from the JBT.

Enrollment Form for Non-1400 Hour Employees—New Entrants (207 KB PDF)

Complete and return this form to enroll yourself and your eligible dependents in JBT benefits.

Plan Administration

JBT Change of Address Form (53 KB PDF)

Use this form if you move and need to change your address with the JBT Administrative office.

JBT Student Status Form (67 KB PDF)

This form is required if you are enrolling eligible dependents age 19 and over. It is used to verify their full-time student status.

JBT Request for Continuation of Coverage for Totally Disabled Children (106 KB PDF)

Use this form to cover your disabled child age 19 and over.

JBT Major Medical Extension for Total Disability (32 KB PDF)

In the event you become disabled, use this form to certify your disability with the JBT Administrative office. This is required to continue your medical coverage.

Third Party Injury Questionnaire and Reimbursement Agreement (347 KB PDF)

This form is used when the JBT receives a claim from a third party related to your illness or accident.

If you receive this form by mail, return it to the JBT Administrative office as instructed.

Filing Claims

JBT Medical Claim Form (151 KB PDF)

You or your doctor/provider needs to submit this form to the JBT Administrative Office when you receive care from a non-preferred provider.

PacifiCare Annual Out-of-Pocket Maximum Reimbursement Claim Instructions (78 KB PDF)

The annual out-of-pocket maximum for 1400 Hour employees is $5,000 per person with a 3-person maximum per family. To help reduce your annual out-of-pocket costs, the JBT will reimburse you for covered expenses after you reach $2,000 in out-of-pocket expenses (per person) until those expenses reach $5,000. Thereafter, PacifiCare will pay covered expenses in full.

Submit this form to the JBT Administrative Office to be reimbursed for eligible expenses.

JBT Dental Treatment Plan and Claim Form (276 KB PDF)

You or your dentist needs to submit this form to the JBT Administrative office to pre-authorize your dental treatment. This form is required if your treatment will be over $300. If you seek care from a non-network dentist, you also need to submit this form.

Document

Purpose

1400 Hour Plan Summary Plan Description (1.1 MB PDF)

Describes the plan’s eligibility rules, covered services and expenses, exclusions, claims review and claims determination procedures.

JBT Medical and other plan benefits are described in detail.

1400 Hour Plan SMM—2010 (32 KB PDF)

Distributed in January 2010, this document provides amendments to the 1400 Hour Plan Summary Plan Description. This document is a companion to the 1400 Hour Plan Summary Plan Description.

Non-1400 Hour Plan Summary Plan Description

Contact the JBT Administrative office at 1-800-JBT-HELP (1-800-528-4357) to request a copy.

Describes the plan’s eligibility rules, covered services and expenses, exclusions, claims review and claims determination procedures.

JBT Medical and other plan benefits are described in detail.

Non-1400 Hour Plan SMM—2010 (32 KB PDF)

Distributed in January 2010, this document provides amendments to the Non-1400 Hour Plan Summary Plan Description. This document is a companion to the Non-1400 Hour Plan Summary Plan Description.

JBT Notice of Privacy Practices (254 KB PDF)

This notice describes participants’ rights under the HIPAA privacy rule.

Medical Plans

Medical Plan Comparison Chart (32 KB PDF)

Provides a high-level summary and comparison of the JBT-sponsored medical plans, including the JBT Medical plan, Kaiser Permanente HMO and PacifiCare HMO.

Kaiser Permanente HMO Evidence of Coverage (496 KB PDF)

Serves as the official plan documentation for the Kaiser Permanente HMO plan, explaining eligibility, coverage levels, exclusions, claims review and claims determination procedures.

PacifiCare HMO Evidence of Coverage booklets and Plan summaries for Medical and Prescription Drug Coverage:

• PacifiCare HMO Evidence of Coverage (568 KB PDF)
• PacifiCare Medical Coverage Summary (124 KB PDF)
• PacifiCare Prescription Drug Evidence of Coverage (112 KB PDF)
• PacifiCare Prescription Drug Coverage Summary (84 KB PDF)

Serves as the official plan documentation for the PacifiCare HMO plan, explaining eligibility, coverage levels, exclusions, claims review and claims determination procedures.

Mammogram Network Provider List (20 KB PDF)

Lists the radiology providers who agree to accept JBT’s payment in full for mammogram services (available to JBT Medical plan participants only). You will incur no out-of-pocket expense for a mammogram if you visit a provider on this list.

Dental

Table of Dental Allowances (44 KB PDF)

Shows the maximum charges allowed by the plan for dental care.

Participating Dentist Network Brochure (40 KB PDF)

Lists the dental providers who participate in the JBT plan’s network. You’ll receive a higher level of benefits when you visit a network provider.

Mental Health

MHN Evidence of Coverage Booklet

Contact MHN at 1-800-528-0646 to request a copy.

Explains eligibility, coverage levels, exclusions, claims review and claims determination procedures for eligible participants’ mental health care services, provided through MHN.

Life Insurance

Group Life Insurance Evidence of Coverage:

• JBT Life Insurance Evidence of Coverage
• JBT Life Insurance Evidence of Coverage Rider Notice

Contact Prudential at 1-800-524-0542 to request copies of these documents.

Serves as the official plan document for the JBT life insurance plan, explaining eligibility, coverage levels, exclusions, claims review and claims determination procedures.

myhealthIQ Program

Sample myhealthIQ Health Risk Report (212 KB PDF)

Shows sample results from the myhealthIQ screening.