Tyler Independent School District Benefit Plan B

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Clinton Allison
5 years ago
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1 GRANDFATHER PLAN PPO Network: Access Direct Platinum/ , Local ; Access Direct Platinum but within TX- PHCS Healthy Directions Filing Limit: 90 Days Appeal Limit: 60 Days Submit claims to HealthFirst PO Box Eagan, MN Electronic ID #75234 Calendar Year/Lifetime Maximum: Unlimited Calendar Year Deductibles Cross-Apply Calendar Year Deductible 4th Qtr Individual Deductible Carryover: Yes Individual $700 $1,400 $700 Family $2,100 $4,200 $2,100 Outside The Calendar Year is waived for the following covered charges: Accidents Calendar Year Out-of-Pocket Maximum: The following charges do not apply toward the out-of-pocket maximum: Deductibles, Copayments, Penalties, Serious Mental Health, Mental Health/Substance Abuse Coinsurance, Pharmacy Coinsurance and Amounts over Maximum Allowable. Calendar Year Out-of-Pockets Cross- Apply Out-of-Pocket Individual $1,600 Unlimited $1,600 Family $4,800 Unlimited $4,800 Precertification required for Hospitalizations, Observation exceeding 72 hours, Skilled Nursing Facility Stays, Outpatient Surgery, MRIs, MRAs, PET Scans, Allergy Testing, DME exceeding $1,000, Hyperbaric Oxygen Therapy (HBO), Prophylactic Mastectomy, Prophylactic Salpingooophorectomy and hysterectomy, Special Pharmaceuticals (high cost Precertification: Call Hines & Associates Failure to precertify: $500 penalty per episode of care drugs whose total charges are greater than $500 for any one drug administered during a single outpatient encounter) The maximums listed below are the total for, Out-of-Network and Out-of Area expenses. For example, if a maximum of 60 days is listed twice under a service, the Calendar Year maximum is 60 days total, which may be split between, Out-of-Network and Out-of-Area providers Max Allowable - Charges will be adjusted to an amount based upon Medicare fee schedules for out-of-network physicians and out-of-network facilities, incurred by a member while he/she is covered under the Summary Plan Description for Covered Services. Network Providers have agreed to accept negotiated fees in addition to the members payment of any applicable coinsurance or co-payment. Non-Network Providers have not. Inpatient Hospital Services ETMC service area or services which cannot be Hospital Care/Outpatient Surgery ETMC service area or services which cannot be Emergency Room Facility/Physician ETMC service area or services which cannot be calendar year deducible 70% after calendar year $1,000/Confinement Ded, then 60% after CYD Not to exceed Max Allowable $1,000/Confinement Ded, then 50% after CYD Not to exceed Max Allowable calendar year 70% after calendar year 60% after CYD Not to exceed Max Allowable 50% after CYD Not to exceed Max Allowable $90 Copay (Waived if admitted) 70% after calendar year 60% after CYD Not to exceed Max Allowable 50% after CYD Not to exceed Max Allowable

2 Physician Services Office Visit All Other Physician Services 100% after $35 Copay after after 70% after 70% after Allergy Testing, Serum, and Injections after 70% after ADD/ADHD (Attention Deficit Disorder) - Autism Charges for Meds re-check after 70% after Ambulance Services -Limited to five (5) ground and two (2) air transports per calendar year after 70% after Birth Control (Norplant, Injections, IUD's insertion/removal) after 70% after Birthing Center (Physician) after 70% after Blood and Plasma after 70% after Cardiac Rehabilitation after 70% after Cataract Surgery and Initial Contact Lenses or Glasses following surgery. after 70% after Chemotherapy or Radiation Oncology (Physician office or hospital) after 70% after Chiropractic Care (limited to 21 visits per Calendar Year after 70% after Cosmetic and Reconstructive Surgery Covers the correction of abnormal congenital conditions and reconstructive mammoplasties. after 70% after Diabetic Education (Diabetic shoes not covered) after 70% after Diagnostic Laboratory Services and X-ray **Professional fees are not covered for lab procedures performed by non-professional personnel in a hospital setting (Modifier 26) after 70% after Dialysis: The Plan does not use a preferred provider organization for dialysis services. The in-network and co-insurance will apply. Limited to not more than 120% of Medicare Allowable Rate. N/A N/A Dental Paid As Medical: Injury to or care of mouth, teeth and gums. Charges for injury to or care of the mouth, teeth, gums and alveolar processes will be covered charges under Medical Benefits only if that care is for the following oral surgical procedures: Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. Emergency repair due to injury to sound natural teeth. This repair must be made within 12 months from the date of an accident. Surgery needed to correct accidental injuries to the jaws, cheeks, lips, tongue, floor and roof of the mouth. after 70% after Excision of benign bony growths of the jaw and hard palate. External incision and drainage of cellulitis. Incision of sensory sinuses, salivary glands or ducts. Removal of Impacted or Embedded teeth.

3 Durable Medical Equipment & Prosthetics (Repairs are covered when the cost to repair is less than the replacement cost) after 70% after Foot care. Excludes Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions (except open cutting operations), and treatment of corns, calluses or toenails (unless needed in treatment of a metabolic or peripheral-vascular disease). after 70% after Home Health Care 22 Visits Calendar Year Maximum after 70% after Hospice Care 80 Visits Calendar Year Maximum (Includes Bereavement Counseling) after 70% after Imaging Services, CT Scan, MRI, PET Scan after 70% after Insulin Pump after 70% after IV Therapy after 70% after Jobst Compression Stockings (Limited to 3 pairs per calendar year) Mastectomy Bras (Limited to 4 per calendar year) after 70% after Maternity Care--Dependent daughters not covered after 70% after Midwife services of certified or registered nurse midwife after 70% after Newborn: Newborn is automatically covered for routine nursery care only. Employee has 60 days to enroll newborn for coverage to be effective from date of birth. Well Newborn during birth confinement (charges applied toward the Plan of the covered parent.) after 70% after Mental and Nervous Disorders/Substance Abuse Care: Coinsurance Amount does not apply to Annual Maximum Out-of-Pocket Inpatient Mental Health/Inpatient Substance Abuse 14 Days Calendar Year Max (Includes residential treatment) 70% after Outpatient Mental Health or Substance Abuse 30 day Calendar Year Max 70% after Serious Mental Disorders: Coinsurance Amount does not apply to Annual Maximum Out-of-Pocket Inpatient Mental Health 45 Days Calendar Year Max Outpatient Mental Health 45 Days Calendar Year Max 70% after 70% after Orthotics The initial purchase, fitting and repair of orthotic appliances such as braces, splints or other appliances, including shoe inserts, which are required for support for an injured or deformed part of the body as a result of a disabling congenital condition or an Injury or Sickness. after 70% after Pre-Admission Testing after 70% after

4 Preventive Care (Adult & Child) Colonoscopy, gynecological exams, immunizations, Flu Shots; Shingles Vaccine age 60 and older, laboratory tests, mammograms (Ages single baseline; Ages 40 and over one per calendar year), Bone Density office visits, pap smear, prostate screening, routine physical examinations, and x-rays. Child Care includes: immunizations, laboratory tests, office visits, routine physical examinations for age two and over, well baby exams, and x-rays. 100% up to $300 per calendar year waived, then Not Covered 100% up to $300 per calendar year waived, then 70% after Physical or Occupational Therapy (20 Visits per Calendar Year Max) after 70% after Private Duty Nursing after 70% after Second Surgical Opinion after 70% after Skilled Nursing Facility- 26 days per Calendar Year Maximum Non-Preferred is 60% & 50% for OON of Max Allowable after 70% after Sleep Disorders-Testing/Treatment 1 sleep study every 3 years maximum after 70% after Speech Therapy - Pre-Determination Required after 70% after Sterilization Procedures/Vasectomy-Tubal Ligation Testosterone Treatment/Initial exam and diagnostic testing only. Pre-Determination required prior to benefits being quoted for treatment The Pre-D needs to include two testosterone levels taken between 8 AM - 10 AM on two different days prior to treatment. If approved, the Pre-D will be valid for one year. after after 70% after 70% after Transplant-Related Charges Organ Transplant after 70% after Wig following a course of chemotherapy. Limited to 1 every 5 years after 70% after Vision Carrier: Block Vision Dental Carrier : Delta Dental Pharmacy Rx Carrier: Script Care Rx Bin: PCN: SCI Mail Order Pharmacy:

5 Breast Pump Excess Charges Exercise Equipment/Health Clubs Experimental/Investigational Treatment Tyler Independent School District Benefit Plan B Alcohol Supplies, care or treatment for an injury or sickness which occurred as a result of illegal use of alcohol Custodial and Maintenance Care Education or vocational testing Medical Exclusions Abortion unless the mothers life is endangered or if the result of rape or incest Complications of non-covered procedure Cosmetic and Reconstructive Surgery Eye Care Radial keratotomy or other eye surgery to correct near-sightedness, routine eye exam, lenses & exams for fitting. This does not apply to aphakic patients & lenses for corneal bandages Foot care except open cutting operations or needed in treatment of a metabolic or peripheral-vascular disease Foreign Travel Care, treatment or supplies if the sole purpose is to obtain medical services Genetic Testing Government coverage Care, treatment or supplies furnished by a program or agency funded by any government. This does not apply to Medicaid or when otherwise prohibited by law. Hair Loss including wigs, hair transplants or any drug whether or not prescribed by a Hazardous Hobby or Activity Hearing Aids and exams for fitting (Routine hearing exam covered under preventive Hospital Employee Illegal Acts Illegal drugs or medications Impotence Infertility Marriage and Family Counseling No Charge Non-Emergency Hospital admission No obligation to pay No Physician recommendation Not specified as covered Obesity Occupational Personal comfort or convenience items Physician interpretation of tests. Professional charges for interpretation or oversight of any test unless the interpreting physician provides a signed written report that analyzes each test individually and summarizes the implication the test has for the patient's health status. Pan design excludes Pregnancy of daughter Relative giving services Replacement braces unless necessitated by growth or change in health status Routine Care unless specifically covered in Schedule of Benefits Self-Inflicted Injury Services before or after coverage Sex change Smoking Cessation Surgical sterilization reversal Telemedicine Temporomandibular Joint Syndrome (TMJ) War

RSNA EMPLOYEE BENEFIT TRUST PLAN II S2502 NON GRANDFATHERED PLAN BENEFIT SHEET

RSNA EMPLOYEE BENEFIT TRUST PLAN II S2502 NON GRANDFATHERED PLAN BENEFIT SHEET BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to age 26 Filing Limit 1 year from date of service Mailing Address & PPO Company. Remit claims to: