2015 Final Benefits Summary

Transcription

1 2015 Final Benefits Summary (Grandfathered Plan) Ashland School District Medical Benefits In- Out-of- Deductible Individual $300 Family $900 Out-of-Pocket (includes copays and coinsurance) Individual $2,500 Family $7,500 Non- Allergy Care (testing and injections) Alternative Care Maintenance therapy is not covered In Only Acupuncture In Only after Chiropractic Care 20 Visits / Per Calendar Year In Only after Massage Therapy (Medically Necessary - Prescription Required) (12 visits PCY ) In Only after Naturopathic Care In Only after Ambulance Services FCHA pre-authorization required for nonemergent air ambulance and inter-facility transport. In Only (no copay) Page 1 of 13

2 Non- Anesthesia In Only (if provided at a network facility) (if provided at a nonnetwork facility) Autologous Blood Donation/Blood Transfusion Bariatric Surgery/Weight loss In Only Not Covered Biofeedback Limited benefit, see Biofeedback for details. Not Covered Chemical Dependency FCHA pre-authorization required for inpatient, residential and partial hospitalization. Inpatient (facility) after $250 per confinement copay In Only Inpatient (professional) In Only Outpatient (facility and professional) In Only Office Visit related charges In Only after Clinical Trials Covered as specifically outlined under Clinical Trials. Dental Trauma FCHA pre-authorization required for follow-up services. In Only Diabetic Education and Diabetic Nutrition Education In Only Durable Medical Equipment FCHA pre-authorization required if purchases exceed $2,000 or $500 per month rental. Durable Medical Equipment In Only Page 2 of 13

3 Non- Medical Supplies In Only Oral Appliances When related to TMJ, applies to the TMJ plan year and lifetime maximums. In Only Orthopedic Appliances In Only Prosthetic Devices In Only End Stage Renal Disease (ESRD/Dialysis) FCHA pre-authorization required Covered as specifically outlined under End Stage Renal Disease/Dialysis in the Medical Benefits section below. Emergency Care Emergency Room (facility and professional) In Only after $100 copay (copay waived if admitted) after $100 copay (copay waived if admitted) Urgent Care In Only after Family Planning Office visits ( 2 visits PCY) Devices, implants and injections Sterilizations and termination of pregnancy In Only Foot Orthotics In Only Genetic Services FCHA pre-authorization required if over $500. BRCA Testing (genetic breast testing) In Only All other Genetic Testing In Only Page 3 of 13

4 Non- Genetic Counseling In Only after Habilitative Services Medical services that promote achieving developmental skills when impairments have caused delaying or blocking of initial acquisition of the skills. Habilitation can include cognitive, social, fine motor, gross motor, or other skills that contribute to mobility, communication, and performance of activities of daily living and enhance quality of life. Inpatient (facility and professional) after FCHA pre-authorization required. In Only $250 copay per confinement Outpatient (facility and professional) In Only In office In Only after Hearing Routine Hearing Exams No age limit (1PCY) In Only after Medically necessary Hearing Exams In Only after Hearing aids Not covered Not Covered Home Health Care FCHA pre-authorization required. Home Health Care (100 visits per calendar year) Hourly Nursing Services (560 hours Per Calendar Year) Phototherapy (home) (photo lights for newborn) Hospice FCHA pre-authorization required Hospice Care (at home) In Only Page 4 of 13

5 Non- Respite Care Not covered Not covered Hospice Inpatient and Outpatient facility In Only Professional Hospice and services In Only Hospital Inpatient Medical and Surgical Care FCHA pre-authorization required. Facility services after In Only $250 copay per confinement Inpatient doctor visits/ consultations In Only Inpatient professional services (surgeon) In Only Inpatient professional services (assistant surgeon, radiologist, pathologist and anesthesia) In Only (if provided at a network facility) (if provided at a nonnetwork facility) Hospital Outpatient Surgery and Services FCHA pre-authorization required for certain outpatient services; see Pre-authorization Requirements for details. Surgical (facility & professional services) In Only Ambulatory Surgery Center (ASC) In Only Page 5 of 13

6 Non- Outpatient (facility and professional services) (assistant surgeon, radiologist, pathologist and anesthesia) In Only (if provided at a network facility) (if provided at a nonnetwork facility) Infertility Diagnostic Services (Initial diagnosis only) In Only Infertility Diagnostic Office Visits (diagnosis only) In Only after Infusion Therapy FCHA pre-authorization required (includes infusion therapy provided in the home) In Only Lab and Radiology Services (non-routine, facility and professional services) FCHA pre-authorization required for PET scans. Hospital inpatient (professional fees) In Only Hospital outpatient (facility and professional fees) In Only Lab or x-ray facility In Only Doctor s office In Only Maternity and Newborn Care Inpatient Facility In Only after $250 copay per confinement Inpatient professional In Only Page 6 of 13

7 Non- Birthing Centers Birthing Center facility after $250 copay In Only per confinement Home Births In Only Birthing Center Professional In Only Mental Health Care FCHA pre-authorization required for inpatient, residential and partial hospitalization. Inpatient Facility In Only after $250 copay per confinement Inpatient professional In Only Partial Day Treatment (PDT) In Only Outpatient (facility and professional) In Only Office visit In Only after Nutritional Counseling (medical conditions requiring a special diet) In Only after Nutritional and Dietary Formulas (Please refer to Summary Plan Description) Oral Surgery (medical diagnosis only please refer to Summary Plan Description) Pharmacy Administered by MedImpact Retail (30 day supply) In Only In Only Generic Preferred Brands $15 $30 Reimbursement For Covered Prescription Products Will Be Based On The Lowest Contracted Amount Of Page 7 of 13

8 Non-Preferred Brands Retail (90 day supply) RX by Participating Retail Pharmacy Choice 90 Program $45 Non- A Participating Pharmacy Minus Any Applicable Deductible And/or Retail Co-pay Shown In This Schedule. Generic $45 Reimbursement For Covered Prescription Products Will Be Based Preferred Brands On The Lowest $90 Contracted Amount Of Non-Preferred Brands A Participating Pharmacy Minus Any Applicable Deductible $135 And/or Retail Co-pay Shown In This Schedule. Mail order (90 day supply) Generic Preferred Brands Non-Preferred Brands Specialty Pharmacy $30 $60 $90 Reimbursement For Covered Prescription Products Will Be Based On The Lowest Contracted Amount Of A Participating Pharmacy Minus Any Applicable Deductible And/or Retail Co-pay Shown In This Schedule. Specialty pharmacy focuses on high cost, high touch medication therapy for patients with complex disease states. Medications in specialty pharmacy range from oral to cutting edge injectable and biologic products. Generic Preferred Brands Non-Preferred Brands Compound Drugs Pre-authorization Required for charges greater than $400 $15 $30 $45 Reimbursement For Covered Prescription Products Will Be Based On The Lowest Contracted Amount Of A Participating Pharmacy Minus Any Applicable Deductible And/or Retail Co-pay Shown In This Schedule. Page 8 of 13

9 Non- Plastic and Reconstructive Services FCHA pre-authorization required. Limited benefit, see Plastic and Reconstructive Services for details. In Only Inpatient Facility Services In Only after $250 copay per confinement Inpatient doctor visits/ consultations In Only Outpatient (facility and professional services) (assistant surgeon, radiologist, pathologist and anesthesia) In Only (if provided at a network facility) (if provided at a nonnetwork facility) Podiatric Care See Podiatric Care for details on routine foot care. In Only Preventive Care Immunizations Immunizations for children and adults are covered in accordance with the recommendations set forth by the Centers for Disease Control and Prevention. See Preventive Care for details. In Only after FluMist covered. Travel immunizations are not covered. Periodic Exams (age 3 to adult, 1 PCY) In Only after Well Child Exam (first 12 months, 7 visits PCY) In Only after Well Child Exam (age 2 through 3, 3 visits PCY) In Only after Page 9 of 13

10 Non- Nutritional Counseling - first 3 visits per calendar year For visits 4 and beyond, refer to Nutritional Counseling or Diabetic Education. In Only after Screening Tests Screening tests are covered in accordance with the recommendations set forth by the US Preventive Services Task Force (USPSTF) and the Health Resources and Services Administration (HRSA). Below is a summary of the most commonly obtained preventive screening services (this is not meant to be an all-inclusive list). See Preventive Care for more details. Bone Density Screening In Only after $25 copay Colonoscopy The first colonoscopy per calendar year is covered under the Preventive Care benefit, regardless of diagnosis. Subsequent colonoscopies in the same calendar year are covered under the medical benefits, regardless of diagnosis no copay Fecal Occult Blood Test The first fecal occult blood test per calendar year is covered under the Preventive Care benefit, regardless of diagnosis. Subsequent fecal occult blood tests in the same calendar year are covered under the medical benefits, regardless of diagnosis no copay Mammogram The first mammogram per calendar year is covered under the Preventive Care benefit, regardless of diagnosis. Subsequent mammograms in the same calendar year are covered under the medical benefits, regardless of diagnosis In Only after $25 copay Pap Test no copay Prostate Cancer Screening (PSA) no copay Page 10 of 13

11 Non- Sigmoidoscopy The first sigmoidoscopy per calendar year is covered under the Preventive Care benefit, regardless of diagnosis. Subsequent sigmoidoscopies in the same calendar year are covered under the medical benefits, regardless of diagnosis no copay All Other Screening Tests In Only after $25 copay Professional Services Office Visit/Office Surgery In Only after All other related Office Visit Services In Only Rehabilitation Therapy (physical therapy, speech therapy, occupational therapy see Summary Plan Description for listing of other rehabilitation services) Inpatient (facility) Pre-authorization required In Only after $250 copay per confinement Inpatient (professional) In Only Outpatient (facility and professional; includes physical, speech, occupational) 25 visits per calendar year. In Only after After deductible Sleep Apnea Skilled Nursing Facility Pre-authorization required 90 days per calendar year Temporomandibular Joint (TMJ) Disorder ( Benefit per lifetime $1,200) FCHA pre-authorization required if inpatient. In Only TMJ Services In Only after Page 11 of 13

12 Non- TMJ Surgery Treatment Not Covered Tobacco Cessation Transplants (organ and bone marrow) FCHA pre-authorization required. Recipient services (facility and professional) after $250 copay per confinement Recipient services per admission (office visits) In Only after Donor services (facility and professional) Donor Services (office visit) In Only after Transportation and lodging $10,000 maximum Vision (routine eye exams) 1 PCY Page 12 of 13

13 Vision Coverage Ashland School District Vision Benefits Non- Vision Hardware ($350 limit PCY) Eyeglass lenses, frames and contact lenses (includes contact lens fitting) Dental Coverage Ashland School District Dental Benefits Deductible Out-of-Pocket Individual $50 $50 Family $150 $150 In- Out-of- Class A Expenses Preventive and Diagnostic Class B Expenses Basic Dental Class C Expenses Major Dental Services Page 13 of 13