Options PPO
Benefits Summary
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Types of
Coverage |
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Network
Benefits /
Copayment Amounts |
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Non-Network Benefits / Copayment Amounts |
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This
Benefit Summary is intended only to highlight your Benefits and
should not be relied upon to fully determine coverage. This benefit
plan may not cover all of your health care expenses. More
complete descriptions of Benefits and the terms under which they are
provided are contained in the Summary Plan Description that you will
receive upon request from your Benefits Manager.
If this
Benefit Summary conflicts in any way with the Summary Plan
Description issued to your employer, the Summary Plan Description
shall prevail.
Terms
that are capitalized in the Benefit Summary are defined in the
Summary Plan Description.
Where
Benefits are subject to day, visit and/or dollar limits, such limits
apply to the combined use of Benefits whether in-Network or
out-of-Network, except where mandated by state law.
Network
Benefits are payable for Covered Health Services provided by or
under the direction of your Network physician.
*Prior
Notification is required for certain services. |
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Annual
Deductible: $250 per Covered
Person per calendar year, not to exceed $750 for all Covered Persons
in a family.
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Annual
Deductible: $500 per Covered
Person per calendar year, not to exceed $1,500 for all Covered
Persons in a family.
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Out-of-Pocket Maximum: $1,000
per Covered Person per calendar year, not to exceed $3,000 for all
Covered Persons in a family. The Out-of-Pocket Maximum does not
include the Annual Deductible. Copayments for some Covered Health
Services will never apply to the Out-of-Pocket Maximum as specified
in Section 1 of the SPD.
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Out-of-Pocket Maximum: $3,000
per Covered Person per calendar year, not to exceed $6,000 for all
Covered Persons in a family. The Out-of-Pocket Maximum does not
include the Annual Deductible. Copayments for some Covered Health
Services will never apply to the Out-of-Pocket Maximum as specified
in Section 1 of the SPD.
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Maximum
Plan Benefit: No Maximum Plan
Benefit. |
Maximum
Plan Benefit: $1,000,000 per
Covered Person. |
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1. Ambulance Services - Emergency only |
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Ground
Transportation: 10% of Eligible Expenses after deductible
Air
Transportation: 10% of Eligible Expenses after deductible |
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Same as
Network Benefit |
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2. Dental Services - Accident only |
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*10% of
Eligible Expenses after deductible
*Prior
notification is required before follow-up treatment begins. If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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*30% of
Eligible Expenses after deductible
*Prior
notification is required before follow-up treatment begins. If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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3. Durable Medical Equipment
Any combination of Network and Non-Network Benefits for Durable Medical Equipment are limited to $2,500 per
calendar year.
Notify Care Coordination
Please
remember that you must notify Care Coordination before obtaining any
single item of Durable Medical Equipment that costs more than
$1,000
(either purchase price or cumulative rental of a single
item).
If you don't notify us, you
will be responsible for paying all charges and no Benefits will be
paid. |
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*20% of
Eligible Expenses after deductible
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Not
Covered
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4. Emergency Health Services |
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$200
per visit
*Notification is required if results in an Inpatient Stay.
Copay waived if admitted. If you don’t
notify Care Coordination, there will be a pre-notification penalty
of $500. |
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Same as
Network Benefit
*Notification is required if results in an Inpatient Stay.
Copay waived if admitted. If you don’t
notify Care Coordination, there will be a pre-notification penalty
of $500. |
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5. Eye Examinations
Refractive eye examinations are limited to one every other calendar
year from a Network Provider. |
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$30 per
visit |
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30% of
Eligible Expenses after deductible
Eye
Examinations for refractive errors are not covered. |
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6. Home Health Care
Any combination of Network and Non-Network Benefits are limited to 60 visits for skilled care services per
calendar year. |
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*20% of
Eligible Expenses after deductible
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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Not
Covered |
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7. Hospice Care
Any combination of Network and Non-Network Benefits are limited to 360 days during the entire period of time a
Covered Person is covered under the Plan. |
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*10% of
Eligible Expenses after deductible
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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*30% of
Eligible Expenses after deductible
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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8. Hospital - Inpatient Stay |
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*$250
per Inpatient Stay per day, the 10% of Eligible Expenses. (up to 2
day maximum) after deductible
If your
doctor who is performing any of the procedures while in the hospital
is a non-network provider, the whole event is not covered.
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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*$250
per Inpatient Stay per day (up to 2 day maximum), then 30% of
Eligible Expenses after deductible
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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9. Injections Received in a Physician’s Office |
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No
Copayment |
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$10 per
visit |
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10. Maternity Services |
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Same as
8, 11, 12 and 13
No
Copayment applies to Physician office visits for prenatal care after
the first visit.
*Notification is required if Inpatient Stay exceeds 48 hours
following a normal vaginal delivery or 96 hours following a cesarean
section delivery. If you don’t
notify Care Coordination, there will be a pre-notification penalty
of $500. |
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Same as
8, 11, 12 and 13
*Notification is required if Inpatient Stay exceeds 48 hours
following a normal vaginal delivery or 96 hours following a cesarean
section delivery. If you don’t notify Care Coordination, there will
be a pre-notification penalty of $500. |
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11. Outpatient Surgery, Diagnostic and
Therapeutic Services |
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Outpatient Surgery |
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10% of
Eligible Expenses after deductible |
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30% of
Eligible Expenses after deductible |
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Outpatient Diagnostic Services |
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For lab
and radiology/Xray: No Copayment
For
mammography testing: No Copayment |
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30% of
Eligible Expenses after deductible |
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Outpatient Diagnostic/Therapeutic Services
- CT Scans, Pet Scans, MRI and Nuclear Medicine |
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10% of
Eligible Expenses after deductible |
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30% of
Eligible Expenses after deductible |
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Outpatient Therapeutic Treatments (Dialysis, intravenous
chemotherapy or other intravenous infusion therapy, etc). |
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10% of
Eligible Expenses after deductible |
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30% of
Eligible Expenses after deductible |
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12. Physician’s Office Services |
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PCP:
$20 per visit. No Copayment applies when a Physician charge is not
assessed.
Specialist: $30 per visit |
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30% of
Eligible Expenses after deductible.
No
Benefits for preventive care:R
Routine
Exam
Preventive Exam
Pap
Smear
PSA
Child
Immunizations
Preventive Care Immunizations
Well
Baby Care
Well
Child Care |
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13. Professional Fees for Surgical and Medical Services |
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10% of
Eligible Expenses after deductible |
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30% of
Eligible Expenses after deductible |
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14. Prosthetic Devices
Any combination of Network and Non-Network Benefits for prosthetic devices are limited to $2,500 per calendar
year. |
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*20% of
Eligible Expenses after deductible
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Not
Covered |
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15. Reconstructive Procedures |
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*Same as
8, 11, 12, 13 and 14
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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*Same as
8, 11, 12, 13 and 14
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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16. Rehabilitation Services -Outpatient Therapy
Any combination of Network and Non-Network Benefits are limited as follows: 40 visits of physical therapy; 40
visits of occupational therapy; 40 visits of speech therapy; 40
visits of pulmonary rehabilitation; and 40 visits of cardiac
rehabilitation per calendar year. |
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$20 per
visit |
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30% of
Eligible Expenses after deductible |
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17. Skilled Nursing Facility/Inpatient Rehabilitation Facility
Services
Any combination of Network and Non-Network Benefits are limited to 60 days per calendar year. |
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*10% of
Eligible Expenses after deductible
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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*30% of
Eligible Expenses after deductible
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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18. Transplantation Services |
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*10% of
Eligible Expenses after deductible
*If you
don’t notify Care Coordination, there will be a pre-notification
penalty of $500. |
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Not
Covered
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19. Urgent Care Center Services |
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$30 per
visit |
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30% of
Eligible Expenses after deductible |
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20. Pharmacy |
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Retail (Mandatory generic drugs):
$10
copay – generic
$25
copay – brand, preferred
$40
copay – brand, non-preferred
Mail Order (Mandatory mail order for maintenance drugs after a 90
day retail period for new prescriptions, and mandatory generic
drugs):
$20
copay – generic
$50
copay – brand, preferred
$80
copay – brand, non-preferred |
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Not
Covered |
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Additional
Benefits |
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Mental
Health and Substance Abuse Services – Outpatient
Any
combination of Network and Non-Network
Benefits are limited to 20 visits per calendar year. |
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$30 per
individual visit; $25 per group visit. |
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30% of
Eligible Expenses after deductible |
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Mental
Health and Substance Abuse Services – Inpatient and Intermediate
Must
receive prior authorization through the Mental Health/Substance
Abuse Designee, otherwise there
will be a pre-notification penalty of $500. Any combination of
Network and Non-Network Benefits are limited to 30 days per calendar
year. |
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$250
per Inpatient Stay per day (up to a 2 day maximum), then 10% of
Eligible Expenses after deductible.
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$250
per Inpatient Stay per day (up to 2 day maximum), then 30% of
Eligible Expenses after deductible
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Spinal
Treatment/Chiropractic Care
Benefits include diagnosis and related services and are limited to
one visit and treatment per day. Any combination of
Network and Non-Network Benefits are limited to 20 visits per
calendar year. |
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$30 per
visit |
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30% of
Eligible Expenses after deductible |
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Gastric Bypass |
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Not
Covered |
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Not
Covered |
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Infertility |
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Not
Covered |
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Not
Covered |
Except as may be
specifically provided in Section 1 of the Summary Plan Description (SPD)
or through a Rider to the Plan, the following are not covered:
A. Alternative
Treatments
Acupressure;
hypnotism; rolfing; massage therapy; aromatherapy; acupuncture; and
other forms of alternative treatment.
B. Comfort or
Convenience
Personal comfort or
convenience items or services such as television; telephone; barber or
beauty service; guest service; supplies, equipment and similar
incidental services and supplies for personal comfort including air
conditioners, air purifiers and filters, batteries and battery chargers,
dehumidifiers and humidifiers; devices or computers to assist in
communication and speech.
C. Dental
Except as
specifically described as covered in Section 1 of the SPD for services
to repair a sound natural tooth that has documented accident-related
damage, dental services are excluded. There is no coverage for services
provided for the prevention, diagnosis, and treatment of the teeth,
jawbones or gums (including extraction, restoration, and replacement of
teeth, medical or surgical treatments of dental conditions, and services
to improve dental clinical outcomes). Dental implants and dental braces
are excluded. Dental x-rays, supplies and appliances and all associated
expenses arising out of such dental services (including hospitalizations
and anesthesia) are excluded, except as might otherwise be required for
transplant preparation, initiation of immunosuppressives, or the direct
treatment of acute traumatic Injury, cancer, or cleft palate. Treatment
for congenitally missing, malpositioned, or super numerary teeth is
excluded, even if part of a Congenital Anomaly.
D. Drugs
Prescription drug
products for outpatient use that are filled by a prescription order or
refill. Self-injectable medications. Non-injectable medications given in
a Physician’s office except as required in an Emergency.
Over-the-counter drugs and treatments.
E. Experimental,
Investigational or Unproven Services
Experimental,
Investigational or Unproven Services are excluded. The fact that an
Experimental, Investigational or Unproven Service, treatment, device or
pharmacological regimen is the only available treatment for a particular
condition will not result in Benefits if the procedure is considered to
be Experimental, Investigational or Unproven in the treatment of that
particular condition.
F. Foot Care
Routine foot care
(including the cutting or removal of corns and calluses); nail trimming,
cutting, or debriding; hygienic and preventive maintenance foot care;
treatment of flat feet or subluxation of the foot; shoe orthotics.
G. Medical
Supplies and Appliances
Devices used
specifically as safety items or to affect performance primarily in
sports-related activities. Prescribed or non-prescribed medical supplies
and disposable supplies including but not limited to elastic stockings,
ace bandages, gauze and dressings, ostomy supplies, syringes and
diabetic test strips. Orthotic appliances that straighten or re-shape a
body part (including cranial banding and some types of braces). Tubings
and masks are not covered except when used with Durable Medical
Equipment as described in Section 1 of the SPD.
H. Mental
Health/Substance Abuse
Services performed
in connection with conditions not classified in the current edition of
the Diagnostic and Statistical Manual of the American Psychiatric
Association. Services that extend
beyond the period necessary for short-term evaluation, diagnosis,
treatment, or crisis intervention. Mental Health treatment of insomnia
and other sleep disorders, neurological disorders, and other disorders
with a known physical basis.
Treatment of
conduct and impulse control disorders, personality disorders,
paraphilias and other Mental Illnesses that will not substantially
improve beyond the current level of functioning, or that are not subject
to favorable modification or management
according to prevailing national standards of clinical practice, as
reasonably determined by the Mental Health/Substance Abuse Designee.
Services utilizing
methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol),
Cyclazocine, or their equivalents.
Treatment provided in connection with or to comply with involuntary
commitments, police detentions and other similar arrangements, unless
authorized by the Mental Health/Substance Abuse Designee. Residential
treatment services. Services or supplies that in the reasonable judgment
of the Mental Health/Substance Abuse Designee are not, for example,
consistent with certain national standards or professional research
further described in Section 2 of the SPD.
I. Nutrition
Megavitamin and
nutrition based therapy; nutritional counseling for either individuals
or groups. Enteral feedings and other nutritional and electrolyte
supplements, including infant formula and donor breast milk.
J. Physical
Appearance
Cosmetic Procedures
including, but not limited to, pharmacological regimens; nutritional
procedures or treatments; salabrasion, chemosurgery and other such skin
abrasion procedures associated with the removal of scars, tattoos,
and/or which are performed as a treatment for acne. Replacement of an
existing breast implant is excluded if the earlier breast implant was a
Cosmetic Procedure. (Replacement of an existing breast implant is
considered reconstructive if the initial breast implant followed
mastectomy.)
Physical
conditioning programs such as athletic training, bodybuilding, exercise,
fitness, flexibility, and diversion or general motivation. Weight loss
programs for medical and non-medical reasons. Wigs, regardless of the
reason for the hair loss.
K. Providers
Services performed by a provider with your
same legal residence or who is a family member by birth or marriage,
including spouse, brother, sister, parent or child. This includes any
service the provider may perform on himself or herself. Services
provided at a free-standing or Hospital-based diagnostic facility
without an order written by a Physician or other provider as further
described in Section 2 of the SPD (this exclusion does not apply to
mammography testing).
L. Reproduction
Health services and
associated expenses for infertility treatments.
Surrogate parenting.
The reversal of voluntary sterilization.
M. Services
Provided under Another Plan
Health services for
which other coverage is required by federal, state or local law to be
purchased or provided through other arrangements, including but not
limited to coverage required by workers’ compensation, no-fault
automobile insurance, or similar legislation. If coverage under workers’
compensation or similar legislation is optional because you could elect
it, or could have it elected for you, Benefits will not be paid for any
Injury, Mental Illness or Sickness that would have been covered under
workers’ compensation or similar legislation had that coverage been
elected.
Health services for
treatment of military service-related disabilities, when you are legally
entitled to other coverage and facilities are reasonably available to
you. Health services while on active military duty.
N. Transplants
Health services for
organ or tissue transplants are excluded, except those specified as
covered in Section 1 of the SPD. Any solid organ transplant that is
performed as a treatment for cancer.
Health services
connected with the removal of an organ or tissue from you for purposes
of a transplant to another person. Health services for transplants
involving mechanical or animal organs.
Any multiple organ
transplant not listed as a Covered Health Service in Section 1 of the
SPD.
O. Travel
Health services
provided in a foreign country, unless required as Emergency Health
Services.
Travel or
transportation expenses, even though prescribed by a Physician. Some
travel expenses related to covered transplantation services may be
reimbursed at our discretion.
P. Vision and
Hearing
Purchase cost of eye
glasses, contact lenses, or hearing aids. Fitting charge for hearing
aids, eye glasses or contact lenses. Eye exercise therapy. Surgery that
is intended to allow you to see better without glasses or other vision
correction including radial keratotomy, laser, and other refractive eye
surgery.
Q. Other
Exclusions
Health services and
supplies that do not meet the definition of a Covered Health Service -
see definition in Section 10 of the SPD.
Physical,
psychiatric or psychological examinations, testing, vaccinations,
immunizations or treatments otherwise covered under the Plan, when such
services are: (1) required solely for purposes of career, education,
sports or camp, travel, employment, insurance, marriage or adoption; (2)
relating to judicial or administrative proceedings or orders; (3)
conducted for purposes of medical research; or (4) to obtain or maintain
a license of any type.
Health services
received as a result of war or any act of war, whether declared or
undeclared or caused during service in the armed forces of any country.
Health services
received after the date your coverage under the Plan ends, including
health services for medical conditions arising prior to the date your
coverage under the Plan ends.
Health services for
which you have no legal responsibility to pay, or for which a charge
would not ordinarily be made in the absence of coverage under the Plan.
In the event that a
Non-Network provider waives Copayments and/or the Annual
Deductible for a particular health service, no Benefits are provided for
the health service for which Copayments and/or the Annual Deductible are
waived.
Charges in excess of
Eligible Expenses or in excess of any specified limitation.
Services for the
evaluation and treatment of temporomandibular joint syndrome (TMJ),
whether the services are considered to be medical or dental in nature.
Upper and lower jaw
bone surgery except as required for direct treatment of acute traumatic
Injury or cancer. Orthognathic surgery, jaw alignment, and treatment for
the temporomandibular joint, except as a treatment of obstructive sleep
apnea.
Surgical treatment
and non-surgical treatment of obesity (including morbid obesity).
Growth hormone
therapy; sex transformation operations; treatment of benign gynecomastia
(abnormal breast enlargement in males); medical and surgical treatment
of excessive sweating (hyperhidrosis); medical and surgical treatment
for snoring, except when provided as part of treatment for documented
obstructive sleep apnea. Oral appliances for snoring.
Custodial care;
domiciliary care; private duty nursing; respite care; rest cures.
Psychosurgery.
Speech therapy except as required for treatment of a speech impediment
or speech dysfunction that results from Injury, stroke or Congenital
Anomaly.
