Schedule of Medical Benefits: 2013-14

Medical Plan Costs

Medical Plan Services

Medical Plan Services

    Managed Care
In-Network
Coinsurance

Managed Care
Out-of-Network
Coinsurance

Hospital Inpatient Services Pre-certification of non-emergency inpatient hospitalization is strongly recommended

Room Charges     25% 35%
Ancillary Services     25% 35%
Surgical Services
(see Summary Plan Description for surgeries requiring prior authorization)
    25% 35%

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Hospital Services (Outpatient facility charges)

Outpatient Services     25% 35%
Outpatient Surgi-Center     25% 35%

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Physician/Professional Provider Services (not listed elsewhere)

Office visit     $15 copay/visit 35%
Inpatient Physician Services     25% 35%
Lab/Ancillary/Miscellaneous Charges     25% 35%
Eye Exam     0%
one per plan year
35%
one per plan year
Second Surgical Opinion     $15 copay/visit
for room charges only - lab, x-ray & other
procedures apply
deductible/coinsurance
35%

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Emergency Services

Ambulance Services for Medical Emergency     $200 copay $200 copay
Emergency Room Facility Charges     $125 copay/visit
for room charges only lab, x-ray & other
procedures apply
deductible/coinsurance (waived if immediately admitted to hospital)
$125 copay/visit for room charges only lab, x-ray & other
procedures apply deductible/coinsurance (waived if immediately admitted to hospital)
Professional Charges     25% 25%

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Urgent Care Services

Facility/Professional Charges     $50 copay/visit
for room charges only - lab, x-ray & other
procedures apply
deductible/coinsurance
$50 copay/visit
for room charges only - lab, x-ray & other
procedures apply
deductible/coinsurance
Lab & Diagnostic Charges     25% 25%

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Maternity Services

Hospital Charges     25% 35%
Physician Charges
(delivery & inpatient)
    25% (waived if enrolled in WellBaby Program within first trimester) 35%
Prenatal Offices Visits     $15 copay/visit (waived if enrolled in WellBaby Program within first trimester) 35%

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Preventive Services

Preventive screenings/
immunizations/flu shots
(adult & child Wellcare)


Click here for Preventive Services covered at 100%
allowable and for age recommendations
    $0 copay
(no deductible)
limited to preventive services listed.Other preventive services
subject to deductible and co-insurance
35%

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Mental Health Services

Inpatient Services
(Pre-certification is strongly
recommended)
    25% 35%
Outpatient Services     First 4 visits
$0 copay then
$15 copay/visit
35%

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Chemical Dependency

Inpatient Services
(pre-certification is strongly
recommended)
    25% 35%
Outpatient Services     First 4 visits
$0 copay then
$15 copay/visit
35%

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Rehabilitative Services Physical, Occupational, Cardiac, Respiratory, Pulmonary & Speech Therapy

Inpatient Services
(Pre-certification is strongly
recommended)
    25%
Max: 30 days/yr
35%
Max: 30 days/yr
Outpatient Services     $15 copay/visit
Max: 30 visits/yr
35%
Max: 30 visits/yr

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Complementary Health Care Services

Acupuncture    

Members pay charges over $25/visit

Max: 15 visits/yr in combination with Naturopathic

Members pay charges over $25/visit

Max: 15 visits/yr in combination with Naturopathic

Naturopathic    

Members pay charges over $25/visit

Max: 15 visits/yr in combination with Acupuncture

Members pay charges over $25/visit

Max: 15 visits/yr in combination with Acupuncture

Chiropractic     $15/visit
Max: 20 visits/yr
35%
Max: 20 visits/yr

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Extended Care Services

Home Health Care
(Physician ordered prior authorization is strongly recommended (or required) by most plans. See Plan Descriptions)
    $15 copay/visit
Max: 30 visits/yr
35%
Max: 30 visits/yr
Hospice     25%
Max: 6 months
35%
Max: 6 months
Skilled Nursing
(Prior authorization is strongly
recommended (or required) by most
plans. See Plan Descriptions)
    25%
Max: 30 days/yr
35%
Max: 30 days/yr

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Miscellaneous Services

Allergy Shots     $15 copay/visit 35%
Durable Medical Equipment,
Prosthetic Appliances & Orthotics
(Prior authorization is required for amounts greater than $2,500)
    25%
Max: $100 for foot orthotics (per ft)/yr
35%
Max: $100 for foot orthotics (per ft)/yr
PKU Supplies
(Includes treatment & medical foods)
    0% (no deductible) 35%
Education Programs on Disease Processes (when ordered by a physician)
& Dietary/Nutritional Counseling
(When medically necessary & physician ordered. Prior authorization required for
managed care plans and strongly recommended for traditional plans)
    0%
(no deductible)
Max: 8 visits/yr
Not covered
Obesity Management
(Prior authorization required by all plans)
    25%
OON not covered. Must be enrolled in Take Control for non-surgical
treatment
Not covered
TMJ
(Prior authorization required by managed care plans & strongly recommended for traditional plans)
    25%
Surgical
treatment only
Not covered
Infertility Treatment
(biological infertility only)
(prior authorization required for all plans providing coverage)
    25%
Max: 3 artificial
inseminations/
lifetime
Not covered

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Organ Transplants

Transplant Services
(Prior authorization required for managed care plans & strongly recommended for traditional plans)
    25% Not covered

Medical Plan Services

    Managed Care
In-Network
Coinsurance
Managed Care
Out-of-Network
Coinsurance

Travel

Travel for patient only
(if services are not available in local community)

    0%
up to $1,500/yr. with
Prior authorization

-up to $5,000/yr. in conjunction with transplants only
with Prior
authorization
Not covered

 

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