Schedule of Medical Benefits: 2013-14

 

Medical Plan Costs

Medical Plan Services

  • Complementary Health Care Services
  • Extended Care Services
  • Miscellaneious Services

  • Organ Transplants
  • Travel


    Medical Plan Services

    Traditional Plan
    In-Network
    Coinsurance
    Traditional Plan
    Out-of-
    Network
    Coinsurance
    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% 25% 35%
    Ancillary Services 25% 35% 25% 35%
    Surgical Services
    (see Summary Plan Description for surgeries requiring prior authorization)
    25% 35% 25% 35%

    Medical Plan Services

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

    Hospital Services (Outpatient facility charges)

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

    Medical Plan Services

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

    Physician/Professional Provider Services (not listed elsewhere)

    Office visit 25% 35% $15 copay/visit 35%
    Inpatient Physician Services 25% 35% 25% 35%
    Lab/Ancillary/Miscellaneous Charges 25% 35% 25% 35%
    Second Surgical Opinion 0%
    (no deductible)
    0%
    (no deductible)
    $15 copay/visit
    for room charges only - lab, x-ray & other
    procedures apply
    deductible/coinsurance
    35%

    Medical Plan Services

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

    Emergency Services

    Ambulance Services for Medical Emergency 25% 25% $200 copay $200 copay
    Emergency Room Facility Charges 25% 25% $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% 25% 25%

    Medical Plan Services

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

    Urgent Care Services

    Facility/Professional Charges 25% 25% $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% 25% 25%

    Medical Plan Services

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

    Maternity Services

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

    Medical Plan Services

    Traditional Plan
    In-Network
    Coinsurance
    Traditional Plan
    Out-of-
    Network
    Coinsurance
    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%
    (no deductible)
    limited to Prevenitve services listed. Other preventive services
    subject to deductible and co-insurance
    35% $0 copay
    (no deductible)
    limited to preventive services listed.Other preventive services
    subject to deductible and co-insurance
    35%

    Medical Plan Services

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

    Mental Health Services

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

    Medical Plan Services

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

    Chemical Dependency

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

    Medical Plan Services

    Traditional Plan
    In-Network
    Coinsurance
    Traditional Plan
    Out-of-
    Network
    Coinsurance
    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
    25%
    Max: 30 days/yr
    35%
    Max: 30 days/yr
    Outpatient Services 25%
    Max: 30 days/yr
    35%
    Max: 30 days/yr
    $15 copay/visit
    Max: 30 visits/yr
    35%
    Max: 30 visits/yr

    Medical Plan Services

    Traditional Plan
    In-Network
    Coinsurance
    Traditional Plan
    Out-of-
    Network
    Coinsurance
    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 any combination for complementary health care

    Members pay charges over $25/visit

    Max: 15 visits/yr in any combination for complementary health care

    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 any combination for complementary health care

    Members pay charges over $25/visit

    Max: 15 visits/yr in any combination for complementary health care

    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 Max: 15 visits/yr in combination for complementary health care
    Max: 15 visits/yr in combination for complementary health care
    $15/visit
    Max: 20 visits/yr
    35%
    Max: 20 visits/yr

    Medical Plan Services

    Traditional Plan
    In-Network
    Coinsurance
    Traditional Plan
    Out-of-
    Network
    Coinsurance
    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)
    25%
    Max: 90 days/yr
    35%
    Max: 90 days/yr
    $15 copay/visit
    Max: 30 visits/yr
    35%
    Max: 30 visits/yr
    Hospice 25%
    Max: 6 months
    25%
    Max: 6 months
    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
    25%
    Max: 30 days/yr
    35%
    Max: 30 days/yr

    Medical Plan Services

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

    Miscellaneous Services

    Allergy Shots 25%
    No deductible
    35%
    No deductible
    $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
    25%
    Max: $100 for foot orthotics (per ft)/yr
    25%
    Max: $100 for foot orthotics (per ft)/yr
    35%
    Max: $100 for foot orthotics (per ft)/yr
    PKU Supplies
    (Includes treatment & medical foods)
    25% 25% 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
    0%
    (no deductible)
    Max: 8 visits/yr
    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 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 25%
    Surgical
    treatment only
    Not covered
    Infertility Treatment
    (biological infertility only)
    (prior authorization required for all plans providing coverage)
    Not covered Not covered 25%
    Max: 3 artificial
    inseminations/
    lifetime
    Not covered

    Medical Plan Services

    Traditional Plan
    In-Network
    Coinsurance
    Traditional Plan
    Out-of-
    Network
    Coinsurance
    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% 35% 25% Not covered

    Medical Plan Services

    Traditional Plan
    In-Network
    Coinsurance
    Traditional Plan
    Out-of-
    Network
    Coinsurance
    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
    0%
    up to $1,500/yr.
    with Prior
    authorization
    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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