Key Health Coverage Definitions

Before we run through the plans, let’s make sure we cover all the terminology.

Here is a glossary containing important definitions:

All Inclusive Out-of-Pocket Maximum
The maximum amount associates and their covered dependents will pay in a calendar year. Includes deductibles, coinsurance, and medical and prescription co-pays.

Allowable Charge
The carrier determines if the cost is reasonable for care and/or supplies. Providers that do not participate with the carrier (out-of-network) may ask for full payment of services. Claims may need to be submitted for payment; the carrier will pay the allowable charge to you, less any co-payment or coinsurance after the deductible. This is the same payment that the carrier pays to the participating (in-network) providers. The member is responsible for any balance remaining, after the carrier payment.

Annual Enrollment
A period of time when associates may enroll in health insurance and other benefits plans.

Balance Billing
Amount owed to an out-of-network provider after deductible, coinsurance and co-pays, after the carrier’s payment has been made.

The percentage of health care costs an individual must pay, once a deductible is met. For example, many plans pay 80% or 70% of the cost of care, and the patient is responsible for the remaining 20% or 30%. Some plans limit the amount of coinsurance a covered person must pay. See “Out-of-Pocket Maximum.”

Coordination of Benefits (Birthday Rule)
If both spouses are working and carry dependent coverage, the responsibility for primary coverage falls to the parent having the earlier birthday in the calendar year, regardless of which parent is older. Coordination of Benefits does not apply to Prescription Drug coverage.

A specified fee an individual pays for health care services or prescriptions. For example, the patient may pay a $30 co-payment for each doctor visit, or $10 for each prescription.

The amount an individual must pay for services before a health care plan begins to pay benefits. Most plans have a maximum family deductible that is satisfied by the combined expenses of all covered family members, generally two times the individual amount.

An “aggregate” deductible means that if more than one individual is covered, the family deductible must be met before expenses are paid. This applies to our Green Plan.

Additional members of an associate’s household that are eligible to be covered by the group’s policy. Generally, these are the spouse and the children of the associate.

Effective Date
The date on which an insurance policy or benefit plan goes into effect and coverage begins.

Conditions to be met in order to receive a benefit or participate in a group benefit plan. Eligibility varies by plan. For associates, it is generally based on employment status (i.e., non-benefits-eligible to benefits-eligible). Eligibility for dependents is based on the benefit, age and relationship to the associate.

Elimination period
The amount of time before the benefit payment will begin. Elimination periods typically refer to disability.

An emergency is defined as:

  • A condition serious enough to cause a prudent person to seek emergency care
  • A situation where a delay in care might cause permanent damage to your health
  • A situation where you have care within 48 hours from the onset of the condition

Note: if you use the emergency room and it is not considered an emergency, the claim will not be covered, and you will be responsible for all charges.

Evidence of Insurability (E of I)
A statement or proof of a person’s physical condition, occupation or other factors affecting his or her acceptance for insurance. May be required for life insurance over certain levels or for late enrollment.

Explanation of Benefits (EOB)
A statement from a health plan or insurance company sent to a group member who files a claim giving specific details about how and why benefits payments were or were not made. It summarizes the charges submitted and processed, the amount allowed, the amount paid, and the member balance, if any.

Guarantee Issue Amount (GI)
The amount of life insurance an insurance company is willing to issue without evidence of insurability (proof of good health).

Health Insurance Portability & Accountability Act (HIPAA)
Federal legislation that improves access to health insurance when changing jobs by restricting certain pre-existing condition limitations. HIPAA also guarantees availability and renewability of health insurance coverage for all employers regardless of claims experience or business size.

A person who occupies a hospital bed, crib or bassinet while under observation, care, diagnosis or treatment for at least 24 hours.

Inventory Information Approval System (IIAS)
An electronic inventory system that identifies items that are eligible for purchase through an FSA or HSA.

Life Status Change (Qualified Status Change / Family Status Change)
The only time, other than Annual Enrollment, when an associate may change Medical, Dental, Vision, Flexible Spending or other benefits coverage. Qualifying events include (but are not limited to) marriage or divorce, birth or adoption of a child, death of a spouse or dependent, gain or loss of associate or spouse’s employment, or a change in job status that affects benefits coverage. Changes in coverage must be made within 60 days of the date of the qualifying event.

Lifetime Maximum
The total amount a dental insurance policy will pay over the course of an individual’s lifetime.

Maximum Allowable Charge (MAC)
MAC is a method of reimbursement for charges. MAC is the discounted amount that is paid to an in-network provider for services rendered. A MAC plan pays an out-of-network provider at the same level as an in-network provider. All amounts above the MAC are the responsibility of the associate.

Medically Necessary
Services that are required to prevent harm to the patient or an adverse effect on the patient’s quality of life, as judged against generally accepted standards of medical practice. The term is most often used to determine whether or not a procedure or service is covered by insurance.

Newly Eligible
Refers to individuals that are benefits-eligible for the first time due either to a new hire or status change.

Administered by the Social Security Administration, Medicare is the federal government plan for paying certain hospital and medical expenses for those who qualify, primarily those individuals over age 65. Benefits are provided regardless of income level. The program is government-subsidized and government-operated.

A selected group of physicians, hospitals and other health care providers who participate in a managed care plan and agree to follow the plan’s procedures. Benefits for network care are generally optimized when using services provided by a participating professional.

Plan Year
The calendar or fiscal year on which the records of a benefit plan are kept. Health care plans, deductibles and benefits maximums are reset at the beginning of each plan year.

The ability to retain benefits coverage when changing jobs. For life insurance, this means changing the life insurance coverage to an individual term life policy that continues as long as the insured person pays the premiums.

Pre-Existing Condition
An injury or illness for which you have been diagnosed, received treatment or incurred expenses prior to the plan effective date. This term applies to disability benefits.

Pre-Tax Contribution
Contributions that are deducted from an associate’s paycheck before federal, most state and local, and Social Security taxes are figured, reducing taxable income.

Primary Coverage
The health coverage most responsible for paying your claims if you have duplicate coverage.

Carrier-approved professionals or facilities that provide health care services, including physicians, hospitals, nurse practitioners, chiropractors, physical therapists and others.

Providers, In-Network
Health care professionals and facilities that participate in a specific plan’s network. These also are known as participating or in-network providers. After payment of coinsurance or co-payments, the carrier will pay the remaining balance.

Providers, Out-of-Network
Health care professionals and facilities that do not participate in a specific plan’s network. These also are known as non-participating or out-of-network providers. Expenses incurred from these providers may not be covered or may be only partially covered. After payment of coinsurance or co-payments, the carrier will pay the balance equivalent to the amount paid to an in-network provider; any outstanding monies owed after the carrier’s payment will be the member’s responsibility.

Legally married spouses of associates are eligible to participate in the Nemours Children’s Benefits Program.

Summary Plan Description (SPD)
A government requirement for a written description of a benefit plan in an easy-to-read form, including a statement of eligibility, coverage, associate rights and appeal procedure. It is provided to participants, beneficiaries and the Department of Labor upon request.

The process of identifying and classifying the potential degree of risk represented by an associate who enrolls in coverage. Plans that require underwriting may ask associates to provide medical or personal information at the time of enrollment. This mostly applies to life insurance.

Waiting Period
The length of time you must be employed before you become eligible for benefits, (i.e., the first of the month following or coinciding with the date of hire).

To intentionally decline coverage in a benefits plan; some plans require proof of coverage elsewhere.

Medical and Prescription Plans

Nemours offers comprehensive medical coverage for associates and their covered dependents. This includes prescription drug coverage.

The medical plans are administered by Aetna. There are four levels of medical benefits — Red, Blue, White and Green. Contributions are made on a pre-tax basis. Plan types are described below.

  • Preferred Provider Organization (PPO): Offers you the freedom to seek care from any provider that you wish. If you seek care from an in-network (participating) provider, you will either pay a co-pay or deductible and coinsurance, and you will not be balance billed. Out-of-network charges will be paid at a lower level, and you will be responsible for any charges over Aetna’s recognized charge. You may be balance billed for services performed by an out-of-network (non-participating) provider.
  • Exclusive Provider Organization (EPO): An EPO shares essentially the same network as the PPO, but there are no out-of-network benefits associated with the EPO. In that respect, it is similar to an HMO. Emergency services and services that you are unable to choose (such as anesthesiology, ambulance and emergency room) will be paid at the in-network level.
  • High Deductible Health Plan (HDHP) with Health Savings Account (HSA): Provides both in- and out-of-network benefits through the same PPO; includes a Health Savings Account.

ID Cards

Digital medical ID cards are available within the Aetna app. Physical cards will be mailed to your home. All family members will have the same unique identifier. ID cards are not re-issued every year, so please keep your cards. If additional ID cards are necessary, please contact Aetna directly.

Participating Providers

The Nemours medical plans use the national Aetna network, so no matter where you live or work, there are in-network providers near you.

To locate participating providers, go to the “Find a Doctor” tool at For the plan name, select Choice POS II (Red, White or Green plans) or Aetna Select (Blue plan).

Transparency in Coverage Machine-Readable Files

The Transparency in Coverage Final Rules require our group health plans to provide information regarding in-network rates for covered items and services, out-of-network allowed amounts and billed charges for covered items and services. You can find those files here.*

In addition to the Aetna network, the following providers are available at no additional cost to you if you are enrolled in one of our Nemours medical plans.

  • Hinge Health offers virtual exercise therapy to help you take control of back, knee, hip, neck, shoulder or other joint pain. Work with a physical therapist and health coach anywhere, at your convenience. Best of all, there is no co-pay. Go to for more information.
  • Carrum Health provides access to surgical Centers of Excellence that can help connect you with the country’s top surgeons and guide you throughout your surgical journey. More than 100 procedures are covered including hip, knee, shoulder, spine and weight loss surgery. Most, if not all surgery costs are often covered.* Learn more at
  • Twin Health helps reverse Type 2 diabetes through a personalized program including easy-to-use devices (included) that track your health daily, and a dedicated care team that includes a provider, nurse and health coach. There is no cost to you for this benefit.  Find out more about this benefit at
  • 2nd.MD is a virtual expert medical consultation and navigation service. Specialists can help with diseases, cancer or chronic conditions; surgeries or procedures; or medication and treatment plans. We connect you with a board-certified, elite specialist for a virtual expert medical consultation via phone or video from the comfort of home. Visit
  • Brightline offers families nationwide mental health providers with virtual therapy, psychiatry and coaching for kids and teens under the age of 18. After creating an account and answering a few questions about your child(ren), you will be matched with a mental health provider to assist with depression, anxiety, ADHD, managing emotions and many more.  You pay nothing up front.  Your claim will be sent to Aetna and you will receive an invoice for your share of the cost. Get started at Virtual Mental Health Care for Kids and Teens | Brightline.
  • Gennev is here to assist women to prepare and get through menopause. All the providers are participating in-network and can assist with sleep and mental health, weight and body changes, heart and temperature changes, hair and skin changes, joint pain and more. Take a free assessment online to find out where you are on your menopause journey and receive customized recommendations and support. Providers are board-certified OB-GYNs with years of experience supporting patients through menopause and midlife. Online articles are available to help with boosting brain health, metabolic health and alternative treatments for those who are unable to receive hormone therapy. Start your journey now at

* Eligible associates: Individuals enrolled in high deductible plans must first meet their deductible (IRS minimum required deductibles), but co-pays and coinsurance will be waived. Per IRS rules, a portion of any covered travel expenses will be reported as taxable income.

Choosing the Right Medical Plan

Benefits are an important part of your total compensation at Nemours. Each associate is responsible for reviewing the information provided by Nemours, so that you can make an informed decision about your benefits. To help you choose the right benefits for you and your family, Nemours offers “Ask Emma” — an interactive decision support tool and so much more! She can help you make an informed and personalized decision across the range of Nemours benefits offerings.

  • Take the guesswork out of benefits enrollment
  • Explore Emma’s FAQs and cost calculator to find the plans that best fit you and your family
  • Personalized cost comparisons by health needs
  • Model future health scenarios for the whole family
  • Translate insurance jargon into easy-to-understand explanations

Benefits Summary — Red, Blue, and White Plans

View the latest summary chart for Red, Blue and White plans.

For services that require coinsurance, this applies after the deductible, with the exception of Prescription Drugs. 

Benefits Summary — Green Plan

The Green plan is a High Deductible Health Plan (HDHP) with a health savings account (HSA). You may enroll yourself, your spouse and your dependents in this plan.

The Green plan is a PPO, with both in- and out-of-network medical benefits. It uses the same Aetna network of participating providers as the other Nemours plans. Coverage includes office visits, diagnostic X-ray and laboratory, hospital, surgical, urgent and emergency care, mental health and many other services. In-network preventive care, including routine mammograms, is covered at 100%. Unlike the other Nemours health plans, you pay 100% of non-preventive medical services until you meet the plan’s annual deductible.

The Nemours prescription drug benefits are administered by Express Scripts and are included in the Green Plan. Most prescriptions are covered at 80% after your deductible; however, the plan also covers certain generic preventive medications (on the Standard Plus list) for a $10 co-pay. These are preventive medications not already covered at 100% and include medications for many chronic conditions including asthma and diabetes.

View the latest summary chart for the Green plan.

Health Savings Account

The Green Plan also includes a HSA to which you and Nemours may contribute. The HSA is administered by PayFlex. The Nemours contribution is up to $250 for an individual or $500 for a family. The Nemours contribution is made semi-monthly. You may also make pre-tax contributions to the plan through payroll deductions or contribute tax-deductible amounts directly into your account. Your reimbursement cannot exceed your account balance.

The total contribution allowed in 2023, including both employer and associate contributions, is $3,850 (individual) or $7,750 (family). If you are age 55 or older, you may contribute an additional $1,000 to the account annually.

You are eligible to contribute to the HSA if:

  • You are enrolled in a qualified High Deductible Health Plan

You are NOT eligible to contribute to the HSA if:

  • You are covered by a spouse or have retiree coverage at another employer;
  • You are claimed as a dependent on another person’s tax return (except for your spouse);
  • You are enrolled in an employer or spouse’s General Purpose FSA; or
  • You are enrolled in Medicaid, Medicare or TRICARE

Unlike traditional FSAs which are “use-it-or-lose-it,” unused funds contributed to the HSA may be rolled over from year to year and are available to you even if you are no longer employed by Nemours or if you move to another one of the medical plans. Associates who enroll in the Green Plan may also sign up for a Limited Purpose FSA which is only for dental and vision expenses and follow the same rules as the traditional FSA, such as “use it or lose it.”

Aetna Medicare Transition Services

Aetna offers an easier way to make sense of Medicare. Talk to a licensed insurance agent to help guide you through the decision-making process. Whether you are continuing to work beyond age 65 or if you are retiring, this is a free resource. Enrollment in one of the Nemours medical plans administered by Aetna is not required to use this service. Get help now at

Prescription Drug

Prescription drug benefits are administered by Express Scripts and are included in each of the Nemours medical plans (see summaries above).

ID Cards

ID cards will be mailed to your home. Associates with single coverage will get one card; associates with dependent coverage — regardless of the number of covered dependents — will get two ID cards with the associate’s name. Additional cards may be ordered by contacting Express Scripts.

How to Use the Program

Retail Prescriptions: Take your prescription(s) to any participating Express Scripts network pharmacy. Present your Express Scripts ID Card. You may purchase up to a 34-day supply of retail prescription drugs. If your doctor authorizes a refill, the same supply limitation will apply when your prescription is refilled. There may be prior authorizations, quantity limitations or step therapy required on certain prescription drugs. Drugs purchased from non-participating pharmacies will not be covered. Contact Express Scripts for a list of participating pharmacies or search for a participating pharmacy online.

The cost of prescriptions will vary, depending on whether you receive a generic drug, a preferred-brand drug or a non-preferred brand name drug. Express Scripts updates their formulary throughout the year. We encourage you to review the latest Express Scripts formulary lists and other information linked below.

2023 National Preferred Formulary Exclusions
2023 National Preferred Formulary Exclusion List Changes
2023 National Preferred Formulary – Alphabetical
2023 Rx Booklet
2023 Rx Plan Overview
2023 Specialty Medications



Generic drugs have been approved by the U.S. Food and Drug Administration (FDA) for quality and safety, and are absorbed in the same way as a brand name drug.

  • Chemically Equivalent: have the same active ingredients, in the same quantities, as a brand name drug. The only differences are fillers and dyes.
  • Therapeutically Equivalent: treat the same conditions as brand name drugs, but do not contain the same active ingredients.

Preferred Brand

Preferred brand name drugs are drugs still protected by patents (meaning no chemically equivalent generic is available). The FDA has approved these higher-cost drugs after trials show they are safe and effective. When a generic drug is introduced for a preferred brand name drug, the brand name will automatically move from Preferred Brand to Non- Preferred Brand. Check our carrier links regularly for updates.

Non-Preferred Brand

Associates will pay the most for non-preferred brand name drugs (which are listed in this tier for a variety of reasons). These drugs are non-preferred because there are other, lower-cost brand name drug(s) that are just as effective.

Generic Preferred Program

If you have a prescription for a brand name drug, and a chemically equivalent generic drug is available, you will have the option of choosing either the generic equivalent or the brand name drug. If you choose the brand name drug, you will pay the brand coinsurance or co-pay plus the difference in cost between the generic and the brand name drug.

Maintenance Medications – Smart90

Maintenance medications are ongoing, long-term prescriptions for conditions such as high blood pressure, high cholesterol and diabetes. Smart90 is a program managed by Express Scripts that gives you two ways to get a 90-day supply of your maintenance medications. You can conveniently fill these prescriptions either through home delivery (mail order) from the Express Scripts Pharmacy or from Walgreens, the Smart90 network pharmacy for our plan. Your physician must write the prescription for a 90-day supply.

You are allowed two fills of maintenance medications from other retail pharmacies before you must switch to Walgreens or home delivery. If you continue to use 30-day supplies or fill at a pharmacy that is not part of the Smart90 network, you will pay 100% of the cost of your maintenance medication. Please note that you may fill 90-day prescriptions for maintenance medications without penalty at Nemours outpatient pharmacies as noted below.

For more information regarding the Smart90 program, please contact Express Scripts directly, via their website or toll-free number listed in Contacts.

Cholesterol Care Value Program

Specialty drugs for high cholesterol – called PCSK9 inhibitors – are managed through Express Scripts Cholesterol Care Value Program. These drugs require prior authorization to be covered and, if approved, must be filled through Accredo, the Express Scripts specialty pharmacy (see Nemours Children’s Outpatient Pharmacies section below).

Accredo Program

Specialty medications (usually high cost or injectable drugs) must be filled through Accredo, a leading specialty pharmacy, and may require prior authorization. Through the Accredo program, you will have access to:

  • A patient care coordinator who serves as your personal advocate and point of contact
  • Delivery of your specialty medications directly to you or your doctor
  • Supplies to administer your medications — at no additional cost
  • Care management programs to help you get the most from your medications

If you are taking a specialty medication, your first prescription fill may be at your normal retail pharmacy. You will then receive correspondence from Express Scripts on how to transfer your prescription to Accredo.

SaveOn SP Program

A specialty pharmacy co-payment assistance program (also referred to as the SaveOn SP Program) is administered by Express Scripts. Please note that while participation in the SaveOn SP Program is voluntary, and must be affirmatively elected by a participant — certain specialty prescription drugs will be considered non-essential health benefits under the Plan. If you participate in the SaveOn SP Program, the cost of these specialty drugs to you will be $0. If you do not elect to participate in the SaveOn SP Program, you will be responsible for the copayments of the specialty drugs, which may be significantly increased. Regardless of whether you participate in the SaveOn SP Program, the cost of such specialty prescription drugs will not be supplied toward satisfying your maximum out-of-pocket limit under the Plan’s medical options.

Additional information regarding the SaveOn SP Program will be made available to you by Express Scripts.

Nemours Children’s Outpatient Pharmacies

Associates may also fill prescriptions for themselves and their families at the Nemours Children Hospital, Delaware or at Nemours Children’s Health, Jacksonville. A 90-day supply of a maintenance medication can be filled at these Nemours outpatient pharmacies for only two times the applicable co-pay or coinsurance. While the 90-day supply will be the most cost-effective option, in most cases, there are some exceptions due to certain retail pharmacy pricing arrangements.

Spousal Advantage Incentive (SAVI) Plan

For those who are eligible, SAVI provides you with a unique opportunity to have no out of pocket medical costs other than the premium you pay for alternative coverage. If you have access to eligible alternate group medical and prescription drug coverage, SAVI offers 100% coverage with $0 out of pocket for medical. You will be reimbursed for ALL eligible co-pays, co-insurance and deductibles incurred through your alternate medical plan up to the maximum out-of- pocket limits under the Affordable Care Act ($9,100/single and $18,200/family per year). No premium contribution will be deducted from your Nemours Children’s paycheck. You will not be charged the Nemours $300 monthly spousal surcharge if you enroll in SAVI. If you are currently enrolled in the SAVI plan, you are eligible to continue your enrollment into the next plan year. However, you will have to re-enroll using our online benefits system every year.

Please note that the following alternative medical plans are not compatible with SAVI, so you are not eligible if your alternative medical plan is:

  • Medicaid
  • Medicare
  • A high deductible plan with an active HSA contribution (this includes both associate and Nemours contributions)

If you have questions about SAVI, please contact Catilize Health at 877.872.4232, email

Voluntary Vision Plan

Nemours offers a voluntary vision program through Vision Service Plan (VSP) on a pre-tax basis. There are two levels: the Base option and the Premium option.

Benefits Standard Premium
Eye Exam (1/year) $10 co-pay $10 co-pay
Single Vision, Lined Bi-focal, Lined Tri-focal and Lenticular Lenses $25 co-pay $25 co-pay
Progressive Lenses $0 – $175 co-pay, depending on type of lenses $0 – $175 co-pay, depending on type of lenses
Frame (Base: every 24 mo. Premium: every 12 mo.) $130 – $150 allowance, 20% discount on balance, ($70 Costco & Walmart/Sam’s Club allowance) $180 – $200 allowance, 20% discount on balance, ($100 Costco & Walmart/Sam’s Club allowance)
Contact Lens Services (exam & fitting) Up to $60 co-pay Up to $60 co-pay
Contacts (instead of glasses) $120 allowance $150 allowance
Out-of-Network Benefits
Exam — up to $40 Lined Bifocal Lenses — up to $50 Progressive Lenses — up to $50
Frame — up to $70 Lined Trifocal Lenses — up to $65 Contacts — up to $105
Single Vision Lenses — up to $30    

To Utilize Your VSP Benefits:

  1. Consult your VSP booklet for coverage details.
  2. Find a VSP provider online or by phone 24-hours-a-day.
  3. Make an appointment with a VSP provider and identify yourself as a VSP member.

There is no ID card, so be sure to identify that you are a VSP member. Your provider will take care of the rest.

NOTE: Our medical plan also includes a vision discount program, and covers one eye exam every 12 months. Your medical and VSP discounts cannot be combined.


Nemours provides Dental benefits through Delta Dental. There are three levels of dental coverage: Red, Blue and White. Contributions are taken on a pre-tax basis.  Preventive services on the dental plans do not count toward your annual maximum paid by Delta Dental.

Passive PPO Network

A passive PPO allows you to choose any dentist. Although the reimbursement percentages are the same for in- or out-of-network coverage, you will save on out-of-pocket expenses by receiving services from an in-network dentist as out-of-network providers can balance bill. The Nemours plan uses both the Delta Premier and PPO networks.

You can go online to find an in-network provider in your area; use the contact information located in the Contacts section. Definitions of “Reasonable & Customary” and “Maximum Allowable Charge” are available in the Key Health Coverage Definitions section of this online guide. Please note that changes in network status can occur at any time. Check with your provider prior to your next appointment.

ID Cards

ID cards and a welcome letter that lists all covered dependents will be mailed to your home. Each enrolled associate will receive two ID cards. Dependent ID cards will not be provided. View the latest summary chart for Dental plans.

Frequency Schedule

The following procedures have limitations on the frequency with which the procedures can be performed, as follows:

*See Summary Plan Description for details regarding preventive exam benefits.

Wellness Program

Associate Wellness seeks to create a culture of wellness, setting you up for success with resources that support your goals. Nemours takes a holistic approach by supporting the physical, emotional, financial and social dimensions of wellness.

Wellness benefits include:

  • Low-cost fitness centers at Nemours Children’s Hospital, Delaware, Nemours Children’s Hospital, Florida and the Home Office
  • Access to group fitness classes and personal training (at select locations)
  • Gym/Fitness App Reimbursement Program for benefits-eligible associates
  • Free health coaching for benefits-eligible associates, spouses and dependents over age 18
  • Wellness challenges
  • Reduced cost membership to WeightWatchers for benefits-eligible associates, spouses and dependents over 18
  • Resources for meditation and stress management
  • Rewards for participating in healthy activities

All of the Nemours Wellness program resources and benefits are housed on Wellness-Connect, a user-friendly, robust wellness portal. Wellness-Connect is also available as an app so that you can reach your wellness goals on the go! Log on to Wellness-Connect by clicking the Associate Wellness tile on Nemours Net or visit

Wellness Incentive

Nemours wants to reward you for engaging in healthy activities. That is why you can earn 20% off your medical insurance premiums with the Wellness Incentive Program! Save hundreds of dollars on your medical insurance premiums by completing the activities. Complete the activities by Nov. 30, 2023, to earn the discounted insurance premium rate for the 2024 plan year. Learn more about the incentive program and track your progress on Wellness-Connect.

NOTE: When you access your benefits record during annual enrollment, you will see the “With Wellness” medical contribution rates. This will change to the “Without Wellness” medical rate in January if you fail to complete your required activities by the deadline of Nov. 30, 2023.

New to Nemours? Associates hired on or after Sept. 1, 2023, will receive the “With Wellness” rate through the remainder of 2023 and throughout 2024.

Health Advocacy Services

Health Advocate is a confidential, HIPAA-compliant service that is designed to help you make the most of your health care and health benefits. Health Advocate has a team of Personal Health Advocates — typically, registered nurses supported by medical directors and benefits and claims specialists — ready to serve as a resource to you and your family when you need one-on-one assistance with health care or insurance issues.

Health Advocate is provided to all benefits-eligible associates, at no cost to you and regardless of whether or not you are enrolled in the Nemours Children’s Benefits plan. This benefit covers your eligible family members, including your parents and parents-in-law. Health Advocate can help you and your eligible family members:

  • Find the right doctors within your plan’s network
  • Schedule appointments with hard-to-reach specialists
  • Resolve insurance claims and untangle medical bills
  • Obtain prior authorizations and assist with appeals
  • Estimate the cost of health care services
  • Understand tests, treatments and medications
  • Locate elder care and support services
  • Facilitate the transfer of medical records
  • Find the newest medical treatments available

Health – Frequently Asked Questions


Where can I find a list of available doctors/hospitals?

Go to “Find a Doctor” at Select Choice POS II (Red, White and Green Plans) or Aetna Select (Blue Plan).

For step-by-step instructions, click here.

What fertility benefits are being offered in the medical plans and are they available in all four plans?

Nemours Children’s provides comprehensive and inclusive fertility benefits and additional pregnancy and parenting support resources. The benefit design allows you and your doctor to pursue the most effective treatment and provides coverage for two smart cycles. These fertility benefits are available to associates enrolled in any one of the four medical plans (Red, White, Blue or Green).

What if my spouse’s employer offers benefits?

If you are currently enrolled in a Nemours plan but have the opportunity to enroll in your spouse’s plan (non-Nemours), you will want to consider our SAVI plan. Your premium for SAVI is $0, and it will pay 100% of the out-of-pocket costs incurred from your spouses’ medical plan up to the Affordable Care Act (ACA) maximums (2023 limits are $9,100/single and $18,200/family per year).

Note that SAVI is available if you are a new associate and enroll in alternative coverage (except for Medicaid, Medicare, TRICARE and HSA plans) or if you are a current associate enrolled in a Nemours benefit plan and enroll in alternative coverage with the exceptions previously noted. You and your spouse should weigh which plan works best for your circumstances.

What is the spousal surcharge for 2023?

The spousal surcharge for 2023 is $300 per month. This surcharge is applicable only when your spouse has access to medical coverage through his/her/their employer and you decide to cover him/her/them through a Nemours medical plan. If your spouse is not covered by Nemours, there is not a spousal surcharge. Note that the spousal surcharge will continue to be waived if you both work at Nemours. If your spouse has access to medical coverage from his/her/their employer, you can avoid the spousal surcharge and lower your out-of-pocket costs by enrolling in the SAVI Plan. Note that you are required to update the status of your spouse’s coverage availability during annual enrollment.

Which of the plans has the greatest tax advantage?

The Green Plan includes a health savings account (HSA). An HSA account offers a triple tax advantage to those who enroll in it. Associates can contribute tax free, earn tax-free interest on their investments and use the funds for eligible medical expenses tax free.

Prescription Drug

How do I participate in the mail order drug plan with Express Scripts?

Refer to information available on the Express Scripts website.

How can I find out if the brand name drug that I am taking has a chemical equivalent?

A listing of chemically equivalent drugs is difficult to maintain because as brand name drugs lose their patents, new chemically equivalent generic drugs are manufactured.

You must register on the Express Scripts website; after doing so, you’ll be able to research your options as well as obtain pricing information. At the top right of your prescription, it shows generic and brand name; you can compare each on the site.

How can I avoid paying the difference in cost between a brand name drug and a chemically equivalent generic drug?

You may ask your doctor to circle “Substitution Allowed” on the prescription that he/she/they writes for you. By law, your pharmacist may only substitute a chemically equivalent generic if your doctor has circled “Substitution Allowed” rather than “Dispense as Written.”

There are certain exclusions to this rule as mandated by state law.

The brand name drug I am taking has a chemically equivalent generic drug available. I’ve tried the generic, and I had a bad reaction to the drug. What can I do?

Your physician may file an appeal with Express Scripts. They may provide you with a prior authorization that will allow you to fill your prescription without having to pay the difference in cost.

I use mail order for my prescription drugs. Will the Generics Preferred Program apply to my mail order medications?

Yes, this program will apply to mail order.

How will I be notified by Express Scripts if the cost of my mail order medication will be increasing?

If Express Scripts does not have a credit card on file for you, they will notify you if your order exceeds $150. If Express Scripts has a credit card on file for you, they will notify you if your order exceeds $500.

What happens if my doctor’s request for a prior authorization is denied?

Our pharmacy benefit plan’s guidelines exclude certain drugs from coverage. To learn more about what drugs are excluded under our plan, look in your plan summary.

For a copy of the criteria our plan uses to decide which prior authorizations will be covered, call Express Scripts. An agent can send you a copy of the criteria. The number to call is on the back of your prescription card.


If you want to file an appeal to have your prescription drug covered, our plan has an appeals process. Call Express Scripts at the number on the back of your prescription card to get the address to which you should send your appeal. You may also reach out to Health Advocate to help with appeals.

Voluntary Vision

Do I need an ID Card?

No, you do not need to present an ID card to prove coverage or confirm that you are eligible. Identify yourself as a VSP member to your eye care provider.

What will be covered through this benefit?

This vision benefit provides added discounts when services are sought through the preferred provider listing. See the summary of vision care benefits.

What providers are considered in-network?

For the most part, VSP only contracts with private ophthalmologists or optometrists. Most major eye care chains, such as Lenscrafters and Sears Vision are NOT covered as in-network providers by VSP because they do not meet VSP’s quality assurance standards.

However, many of these chains will provide discounts for their eyewear if you identify yourself as a VSP member.

Please note that changes in network status can occur at any time. Check with your provider prior to your next appointment.

My eye care provider is out-of-network. How do I get reimbursed for my expenses?

An out-of-network claim form is available from VSP. To access, click here.

Are my contact lenses “elective” or “necessary”?

If your contact lenses are considered medically necessary (in other words, you can’t wear glasses), they will be reimbursed at 100%.

If you have the option of wearing glasses or contacts, your contact lenses are considered “elective,” and your allowance will be determined by the plan you elect.

I need both glasses and contact lenses—what should I do?

Frames may only be reimbursed one year after filling a prescription for contact lenses. We therefore recommend that you fill your prescription for glasses and lenses FIRST, and then, in the following calendar year, fill a prescription for contact lenses.

Contact lenses/glasses lenses are considered interchangeable, so you may EITHER receive your allowance for lenses or for contacts in any given calendar year.

Are disposable contact lenses covered under this plan?

Yes. You may use your elective contact lens allowance toward disposable contact lenses. If your disposable lens charges are under the allowable amount for the calendar year, you may continue to be reimbursed for disposable lenses until you have reached the $120 or $150 allowance.

Thereafter, you may be eligible for discounts on your disposable lenses.

Are polycarbonate or bicarbonate lenses covered for adults?

Charges for polycarbonate or bicarbonate lenses are not covered under the normal lens co-pay. However, you may elect to pay the extra charge for poly- or bicarbonate lenses.

I understand that if I wear soft contact lenses, I may be eligible for additional discounts—how does this program work?

Ask your doctor if you might be eligible to participate.

Under the soft contact lens program, instead of having an allowance toward contacts AND the contact fitting exam, you will receive a 15% discount off the contact fitting exam, PLUS a $120 or $150 allowance toward contact lenses. This program will generally allow you to receive six months of soft contact lenses without cost.


What is a participating dentist and how do I locate one?

A general dentist or specialist who meets strict credentialing standards and accepts scheduled fees as payment-in-full for services rendered. To get a list of participating dentists, call 800.932.0783 to have a list faxed or mailed to you or go to the online provider search.

How does the Passive PPO Work?

With our plans, you receive a wide range of benefits whether or not you and/or each eligible dependent visit a participating dentist. But, when you visit a participating dentist (an “in-network dentist”), you have the opportunity to make the most of your benefit plan through access to lower out-of-pocket expenses. Out-of-network dental providers can balance bill.

Can I find out how much services will cost and what will be covered prior to treatment?

Delta Dental strongly recommends that you have a dentist submit a pre-treatment estimate for services in excess of $300. While you wait, your dentist can get a real-time pre-treatment estimate online or over the phone in minutes detailing what services the plan will cover and at what payment level. PPO plans pay for the least expensive clinically appropriate course of treatment. Therefore, licensed dental consultants review certain services such as crowns, bridges and periodontics for appropriateness and necessity.

Do I need an ID Card?

No, you do not need to present an ID card to prove coverage or confirm that you are eligible. However, Delta Dental does issue ID cards to help identify you as a member of the Nemours Delta Dental program, and claims filing information is provided in the online benefits Library.

How are composite fillings covered?

Composite (or tooth-colored) fillings on posterior teeth are considered an optional service. If you receive an optional service when the alternate benefit of amalgam (silver) fillings are available, Delta Dental will base the benefit on the lower cost of the amalgam filling. Members will be responsible for the difference in cost.