Medical

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

To locate participating providers, go to the “Search for Network Providers” tool at www.benefits4nemours.com. Both the homepage and care page have the provider tool. The provider search will link to Aetna POS II (Red, White and Green plans’ network) or Aetna Select (Blue plan’s network) depending on which plan you are enrolled in. You may also call Quantum Health directly to get help with the provider search. Please note that changes in network status can occur at any time. 

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 Spousal Advantage Value Incentive (SAVI) plan. Your premium for SAVI is $0, and it will pay 100% of the out-of-pocket costs incurred from your spouse’s medical plan up to the Affordable Care Act (ACA) maximums (2025 limits are $9,200/single and $18,400/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 must waive your current Nemours medical coverage and enroll in SAVI (action must be taken for you and any applicable dependents). You and your spouse should weigh which plan works best for your circumstances.

What is the spousal surcharge for 2025?

The spousal surcharge for 2025 is $150 twice monthly. 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 if eligibility requirements are met. 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 or contact Quantum Health.

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 increases?

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 Quantum Health at 866.920.1929. A representative can send you a copy of the criteria.

OR

If you want to file an appeal to have your prescription drug covered, our plan has an appeals process. Please reach out to Quantum Health to help with appeals.

Dental

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, go to Delta Dental’s online provider search. Please note that changes in network status can occur at any time.

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. 

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.

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.

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, 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.

What should I do if I need both glasses and contact lenses?

Frames will be covered beginning Jan. 1 every new year. Frames in the VSP Premium plan will be covered once a year and for the VSP Base plan, they will be covered every other year. We 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. Use your full allowance at one time as there is no banking this benefit for future use in the same calendar year. 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.

Term Life Insurance and Accidental Death & Dismemberment

Describe your Evidence of Insurability (EOI) requirements. When would evidence be required (e.g., with change in election, when a salary increase causes an increase in benefit, after initial approval)? How often is EOI required?

EOI is needed for anyone applying for amounts above the guaranteed issue limit, anyone applying after the eligible enrollment period or anyone wanting to increase coverage. There is an exception during annual enrollment where an associate can increase his/her/their current coverage by $20,000 with no EOI needed if the increased amount is at or below the guaranteed issue amount. This applies to both associate and spouse coverage. We also require EOI when the person does not elect coverage initially. 

Disability

What is the most common cause of disability claims delays?

The most common reason that a disability claim is delayed is that the claim form is not complete. To most effectively ensure the processing of a claim, check to be sure that all questions on the form are answered, the policy number is on the form and that the employer portion is completed by the Benefits team. Reach out to our HR Solutions Call Center at 877.458.9699 and they will log a ticket for you with the Benefits team. 

Flexible Spending Accounts

What records do I keep for tax purposes?

Keep receipts for at least a year; the IRS requires auditing of certain debit card transactions. See the FSA debit card section for more information.

Can I use the health care FSA to pay for my spouse’s deductibles and/or co-payments if they are not covered by my group medical plan?

Yes. However, health care premiums deducted from your spouse’s paycheck and premiums for individual insurance policies are not eligible.

To what age may I use the dependent care FSA for daycare expenses incurred for my child?

You may submit expenses incurred for your dependent child before his/her/their 13th birthday, or longer if disabled.

Are expenses for before/after school programs considered eligible expenses?

Yes, but you must separate the cost of such care from the cost of the school. In other words, only the cost of care is covered, not the cost of school.

Are over-the-counter (OTC) medications covered?

Yes, OTC medications and supplies are eligible expenses.

IMPORTANT NOTE FOR DIRECT DEPOSIT OF REIMBURSEMENTS: Each individual bank has its own rules as to when it processes the direct deposit payments it receives. Associates should consult with their bank for details.

Other FAQs

Custom Network

Why is there a change in the level of benefits for these facilities?    

Nemours is equipped to provide the best care for our children. We are confident that guiding you to our facilities is a wise and simple decision for your child’s healthcare needs. Facility charges at the Children’s Hospital of Philadelphia (CHOP), St. Christopher’s Hospital for Children and Orlando Health Arnold Palmer will be covered at the out-of-network benefit level. Contact Quantum Health for the exception criteria to allow benefits at these facilities at the in-network benefit level when in the patient’s best interest. 

Are there any changes to the physician network? 

No, physicians at CHOP, St. Christopher’s Hospital for Children and Orlando Health Arnold Palmer are not affected by the custom network change. This includes primary care physicians and specialists. As long as they are in the Aetna network, they will be covered as in-network providers for Nemours.  

Can I continue to receive services from a provider that is employed by or affiliated with one of the facilities that are now out of network?   

Yes, with these changes, the physician network is not impacted and you can continue to receive services from Aetna providers. Urgent care and emergency care visits also will continue to be in-network. If you have questions or need to request an exception based on your circumstances, please contact Quantum Health at 844.460-2817 Monday – Friday from 8:30 a.m. – 10 p.m. or visit their website.

Are there any changes to the urgent care network at CHOP, St. Christopher’s Hospital for Children and Orlando Health Arnold Palmer? 

No, urgent care is not affected by the custom network change. Urgent care visits will continue to be covered in-network with applicable co-pays, deductibles, etc. As long as they are in the Aetna network, they will be paid in-network for Nemours. 

What if I have to use one of these facilities in the event of an emergency?  

There are no changes for emergency room coverage. Emergency room claims continue to be paid in-network in our Nemours plans for all facilities, as it is today. If there is an admission from the emergency room, that will also be covered at the in-network level.  

When will I see an impact of the custom network change? 

If you are scheduling an elective procedure/planning care (inpatient or outpatient) at CHOP, St. Christopher’s Hospital for Children or Orlando Health Arnold Palmer that could be performed at Nemours, it will be paid as out-of-network. For the Red, White and Green plans, the procedure is still covered but there will be at a 20% or 30% higher coinsurance level after the higher out-of-network deductible is met, depending upon which plan you are covered by. The details for each plan can be found here. Any amounts paid toward your in-network deductible count toward your out-of-network deductible, so you don’t have to start over if you use an out-of-network facility. Please note that the Blue plan does not have an out-of-network benefit. Primary care, emergency care and urgent care are not affected by the change and continue at the in-network level.  

Example: “My child needs orthopedic surgery. I’ve scheduled this at CHOP. Will this be paid as out-of-network?”  

Yes. This is an example of a claim affected by the custom network change. The facility charges at CHOP will be paid at the out-of-network level. Exceptions can be granted if the wait is too long at a Nemours facility.   

Example: “My child is having ear tubes scheduled on an outpatient basis at Orlando Health Arnold Palmer. Will this be paid as out-of-network?”  

Yes. This is an example of a claim affected by the custom network change. The facility charges at Orlando Health Arnold Palmer will be paid at the out-of-network level.  Exceptions can be granted if the wait is too long at a Nemours facility.   

Example: “I go to a CHOP’s physician’s office for my child’s care. Will this be out-of-network?”  

No. This will not be impacted and will be paid in-network.   

Example: “My child is ill and it is the middle of the night. Do I have to travel to Nemours for this emergency care?”  

No. Emergency care will be paid at the in-network level at all facilities.  

If I incur facility charges at the Children’s Hospital of Philadelphia, Orlando Health Arnold Palmer or St Christopher’s Children’s Hospital, will I be subject to balance billing? 

You will not be subject to balance billing at these facilities as long as they continue to be under contract with Aetna.  

Will transition of care be offered with the custom network change? 

Yes. Transition of care coverage allows a member to continue to receive treatment for a limited period of time at that facility and to have it covered at the in-network benefit level including: 

• A serious or complex condition such as:   
  • Members in the middle of an ongoing treatment plan such as chemotherapy or radiation therapy  
  • Members who have recently had surgery and need follow-up care  
  • Members who may need an organ or bone marrow transplant  
  • Members who are in a course of treatment for an acute condition where it would not be appropriate for them to transition to a new facility until that course of treatment is complete 
• A course of institutional or inpatient care from a facility  
• A non-elective surgery including post-operative care  
• A terminal illness receiving treatment for such illness  

Transitional coverage will continue beginning at enrollment and continuing for 90 days or until the member is no longer qualified as a continuing care patient under the definitions above with respect to the health care facility.  

What do I do if my child has ongoing care or a planned procedure at one of these facilities?  

Quantum will be contacting all associates expected to have ongoing care at one of these facilities to work on the transition of care plan. You may also call Quantum’s care coordinators for support in transitioning your child’s care to an in-network facility or determining if you are eligible for an exception due to not being able to get care timely, if there are access concerns or if the care is not able to be done at Nemours. Quantum may be reached at 844.460.2817 or chat with them online.

Will Quantum approve my ongoing treatment or do I have to call each time?  

Quantum will contact the facility on your behalf to review ongoing authorizations. They will inform you when the exception expires and assist in transitioning to an in-network facility. Notify Quantum if treatment plans change.  

What if I am not granted an exception but still choose to utilize these facilities?  

The services rendered would still be covered at the facility but at the out-of-network rate under the health plan. This could result in a higher deductible and coinsurance rate than in-network coverage for the Red, White and Green plans. Please note that the Blue plan does not have an out of network benefit.   

Example: White plan with associate + family coverage

What if I have problems scheduling an appointment at Nemours?  

The only change to our provider network is for these three facilities. The Aetna national network continues to be in place for many other facilities. Reach out to Quantum’s care coordinators for support and assistance for scheduling an appointment. Exceptions can be granted if you are not able to get care timely, if there are access concerns, or if the care is not able to be done at Nemours. 

Termination of Employment

What happens to my benefits if I terminate employment with Nemours?

Your benefits options vary depending on what you had in force prior to your termination. Different benefits have different continuation options. For example, medical, dental, vision and health care FSAs may be continued for specified periods of time through COBRA. Term life insurance may be ported or converted, and long-term care may be taken with you at exactly the same rates that you currently pay.

There are limits to the amount of time that you have to make elections to continue terminated coverage. You may find a detailed listing of benefits available upon termination (and information about those benefits) in the Termination of Benefits Summary.

How will my dependent child(ren)’s coverage be impacted by a status change or termination of employment?

Nemours provides coverage for your eligible dependent child(ren) until the end of the month during which they turn 26. You should be aware of how their benefits are impacted by certain circumstances such as turning 26. If you terminate employment with Nemours and are enrolled in COBRA-eligible benefits, you are and your covered dependent children are eligible for COBRA. The COBRA options available to your dependents may vary depending on your status as an active employee (whether you are full-time or part-time), and your dependent’s age as of termination.