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Open Enrollment is the annual period when employees can review and make changes to their benefits elections for the upcoming plan year. This includes enrolling in coverage, changing plans, or adding/removing dependents.

Open Enrollment typically takes place in late October or early November. The exact dates are determined each year after we receive our renewal information, which usually arrives in October.

In most cases, benefits elections can only be changed during Open Enrollment. However, you may make changes during the year if you experience a qualifying life event (QLE), such as marriage, divorce, birth or adoption of a child, or loss of other coverage.

You must submit your change within 30 days of the qualifying event (60 days for a birth or adoption). Supporting documentation may be required.

A Qualifying Life Event (QLE) is a specific life change that allows you to make updates to your benefits outside of Open Enrollment.

Common examples of QLEs include:

Marriage or divorce

Birth or adoption of a child

Loss or gain of other coverage

Change in employment status (yours or your spouse’s)

You must report the event and submit any benefit changes within 30 days of the qualifying event (60 days for a birth or adoption) in order for the changes to be approved.

A High Deductible Health Plan (HDHP) and a Copay Plan differ in how you pay for care and how costs are structured.

HDHP (High Deductible Health Plan):

Lower paycheck deductions (lower premiums)

Higher deductible before the plan begins to pay

You pay the full cost of most services until the deductible is met

Eligible to open and contribute to a Health Savings Account (HSA), which offers tax advantages

Due to IRS rules, certain programs (such as Valenz) cannot provide true first-dollar coverage. This means you may need to pay for services upfront until you meet the required minimum deductible, and then submit for reimbursement if applicable

Copay Plan:

Higher paycheck deductions (higher premiums)

Lower deductible

You pay set copays for many services (like doctor visits and prescriptions)

More predictable out-of-pocket costs

The first-dollar coverage rule does not apply, meaning eligible services or programs may be covered without needing to meet a deductible first

In general:
An HDHP may be a good option if you want lower premiums and are comfortable with higher upfront costs, while a Copay Plan may be better if you prefer predictable costs when receiving care.

A deductible is the amount you pay out-of-pocket for covered healthcare services before your health insurance plan begins to pay.

Copay Plan:
The deductible is $500 (individual) / $1,000 (family). After you meet the deductible, the plan pays 80% of covered services and you pay 20% (coinsurance) until you reach your out-of-pocket maximum.

HDHP (High Deductible Health Plan):
The deductible is $6,000 (individual) / $12,000 (family). You pay the full cost of covered services until the deductible is met. After that, the plan pays 100% of eligible expenses.

Coinsurance is the percentage of the cost you share with your health insurance plan after you have met your deductible.

Copay Plan:
After meeting your deductible, you pay 20% of the cost of covered services, and the plan pays 80% until you reach your out-of-pocket maximum.

HDHP (High Deductible Health Plan):
After you meet your deductible, the plan pays 100% of covered services, so coinsurance does not apply.

The out-of-pocket maximum is the most you will pay for covered healthcare services during a plan year. Once you reach this limit, your health plan will pay 100% of eligible expenses for the rest of the year.

This total includes amounts you pay toward your deductible, copays, and coinsurance.

Copay Plan:
After you reach your out-of-pocket maximum, the plan pays 100% of covered services for the remainder of the plan year.

HDHP (High Deductible Health Plan):
Once you meet your deductible, the plan already pays 100% of covered services, so you effectively reach your out-of-pocket maximum at that point.

A Flexible Spending Account (FSA) and a Health Savings Account (HSA) both allow you to set aside pre-tax money for eligible healthcare expenses, but they work differently.

FSA (Flexible Spending Account):

Available regardless of your medical plan (if offered)

Allows you to set aside pre-tax money for eligible healthcare expenses

Provides tax savings by reducing your taxable income

Funds typically must be used within the plan year (“use it or lose it,” with limited exceptions if applicable)

HSA (Health Savings Account):

Only available if you are enrolled in a High Deductible Health Plan (HDHP)

Funds roll over year to year—there is no “use it or lose it” rule

The account is yours to keep, even if you leave employment

Can be used for current or future medical expenses

Offers tax advantages, including tax-free withdrawals for eligible expenses

In general:
An FSA is a great option for budgeting healthcare expenses within the year, while an HSA offers more long-term savings and flexibility.

At this time, GLP-1 medications are only covered when prescribed for a diagnosis of Type 2 Diabetes. They are not currently covered for weight loss alone.

For more information about coverage and specific medications, please contact SmithRx directly.