The MITRE Corporation Plan
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1 Benefit Type Plan Year Type Calendar Year Annual Medical Out of (for certain services) Employee Employee + 1 Family Annual Prescription Drug Out of Employee Employee + 1 Family Copayments: One copay per provider is charged per day. Visits: If multiple visits occur on the same day, each visit counts toward the applicable benefit limit. Wellness Exams Adults (Including Well Woman) Includes vision and hearing screenings. See Vision Exams for Refractions and Hearing Exams for audiologic testing. Wellness Exams Children Includes vision and hearing screenings. See Vision Exams for Refractions and Hearing Exams for audiologic testing. Preventive Screenings Immunizations (Preventive) Coverage applies to Adults and Children. OUTPATIENT VISITS (Office or Outpatient Facility) Primary Care cost share will be charged for Family Practice, General Internal Medicine and General Pediatrics specialties. Specialty Care cost share will be charged for visits with all other medical specialties. Frequency and Age Limits (if any) will be managed by KP Provider. Office Visits Primary care Specialty care $30 Allergy Office Visit $30 Injection only (Administration and materials) $30 Testing $30 Cardiac Rehab $30 Chemotherapy Services $30 Dialysis Services $30 Family Planning Office Visit Counseling, Implantable or Injectable Contraceptives Health Education Includes classes for Self Management of Asthma, Diabetes and Coronary Disease. The MITRE Corporation Plan Benefit Summary Effective Date: 1/1/2017 Administered by Kaiser Permanente PLAN FEATURES You Pay and/or Maximums $1,500 $1,500 $2,000 Each family Member has an individual Out-of- within the family Out-of-. The individual cannot contribute to the family Out-of- more than amount of a single Out-of-Pocket Maximum. Note the out-of-pocket limits are not integrated. ROUTINE PREVENTIVE EXAMS Preventive Lab and X-ray screenings not specifically listed under the Preventive Screenings section are treated the same as nonpreventive Lab and Xray Services. See Preventive Services Listing, Screenings and Immunizations for a comprehensive list of Covered Services. Frequency and Age Limits managed by Network Provider except where noted.
2 OUTPATIENT VISITS (Office or Outpatient Facility) (cont'd) Hearing Exam (routine) Includes audiometry exam Hearing Aids Includes tests to determine appropriate model, fitting, counseling, and adjustments Benefit allowance Allowance frequency House Calls $0 Unlimited Unlimited Infusion Services Injections and Immunizations Non-routine including immunizations for travel Nutrition Visits $30 Radiation Therapy $30 Respiratory/Pulmonary Therapy $30 Vision Exam (routine) Includes refraction exam HOSPITAL / SURGERY CHARGES Inpatient Hospital Includes room and board for private and semi-private rooms; ICU/CCU, Acute Rehab, Inpatient Professional Services, Medically Necessary Private Duty Nursing, Ancillary Services, Supplies. Per admission 0 Ambulance Emergency Ground and Air Ambulance Scheduled Ground Ambulance Non-Network or Network Hospital to Network Hospital Home to doctor s office Hospital to hospital Skilled nursing facility to dialysis center and return Emergency Services Coverage for Accident and Illness. Copay $150 waived if admitted. Urgent and After Hours Care Urgent Care and After Hours settings Outpatient Surgery Performed in Outpatient Hospital or Ambulatory $100 Surgery Center. Bariatric Surgery Office Visit $30 Outpatient Surgery $100 Inpatient Hospital 0 Organ Transplants: Includes organ acquisition, diagnostic testing for donor and recipient Office Visit $30 Outpatient Surgery $100 Inpatient Hospital 0 Travel and Lodging for Organ Transplants Includes coverage for recipient, companion and donor for transportation, lodging and daily expenses. Daily expenses include incidental expenses such as meals and does not include personal expenses. Transportation Limits None N/A Lodging Limits None N/A Daily Expense Limits Reimbursement up to $50 per N/A day per person Benefit Lifetime Maximum None N/A MATERNITY Routine Pre-Natal and Post-Partum Care Visit to confirm pregnancy $30 Pre-natal and first post-partum visit Hospital Inpatient Includes contracted Birthing Center Per admission 0 N/A
3 Maternity - Newborn Eligible Well Newborn Professional charges are covered under Well Newborn; Facility charges under the mother. Eligible Sick Newborn Professional and Facility charges are covered under the Sick Newborn DIAGNOSTIC TESTS & PROCEDURES Diagnostic Lab & Xray (Outpatient) High Tech/Advanced Radiology - CT, MRI, Nuclear Medicine and PET (Outpatient) $100 INFERTILITY SERVICES Includes further diagnosis and treatment of Infertility after initial diagnosis of infertility is made. Covered treatments include IVF, Artificial insemination, Surgery in addition to medically appropriate advanced reproductive services. Lifetime Maximum (excludes prescription drugs) $25,000 Inpatient Hospital 0 Office Visit $30 Diagnostic Lab & Xray Outpatient Hospital or Ambulatory Surgery Center $100 MENTAL HEALTH & CHEMICAL DEPENDENCY SERVICES Mental Health - Inpatient Per admission Partial Hospitalization or Intensive Outpatient Per episode Mental Health Outpatient Individual Visit Cost Share Group Visit Cost Share 0 Chemical Dependency - Inpatient Detox covered under 0 Medical benefits. Per admission Chemical Dependency - Partial Hospitalization or Intensive Outpatient Per episode Chemical Dependency Outpatient Individual Visit Cost Share Group Visit Cost Share PHYSICAL, OCCUPATIONAL & SPEECH THERAPIES Outpatient Cost Share for therapies is applied on a 'per day' basis and visit counts on a 'per visit' basis. Physical Therapy $30 Occupational Therapy $30 Speech Therapy $30 SKILLED CARE Home Health Care Includes Nurse visits (2 hrs), Aide visits (4 hours), therapy visits and supplies. Limited to 40 visits per calendar year Home Infusion Requires skilled or medical administration. Includes Infusions and Supplies Hospice Skilled Nursing Facility Per admission Days per calendar year OTHER SERVICES Acupuncture (self referred) $30 combined with Chiropractic Chiropractic Care (self referred) $30 combined with Acupuncture
4 Dental Care Includes Preparation of the Jaw for Radiation Treatment, Dental Anesthesia under certain circumstances, medical and surgical treatment of TMJ. Cost Share based on location where Services are received and provider type. OTHER SERVICES (cont'd) Durable Medical Equipment Breast Feeding Pump Prosthetics and Orthotics Special Oral Foods Amino Acid Modified Products and PKU Fitness Reimbursement 0 per calendar year OUTPATIENT PRESCRIPTION DRUGS Outpatient Prescription Drugs Retail (must be obtained from KP medical center pharmacies unless otherwise specified) - Generic - Copay at Network Pharmacy CA $10/30 days - Copay at Network Pharmacy CO $5/30 days - Copay at Network Pharmacy MAS $10/30 days - Copay at Community/Network Pharmacy (MAS only) /30 days - Formulary Brand - Copay at Network Pharmacy CA /30 days - Copay at Network Pharmacy CO $15/30 days - Copay at Network Pharmacy MAS /30 days - Copay at Community/Network Pharmacy (MAS only) $40/30 days - Non-Formulary Brand - Copay at Network Pharmacy CA $35/30 days - Copay at Network Pharmacy CO $30/30 days - Copay at Network Pharmacy MAS $35/30 days - Copay at Community/Network Pharmacy (MAS only) $55/30 days Mail Order Drugs - Generic - Copay CA: /up to100 days - Copay CO: $10/up to 90 days $10/up to 30 days - Formulary Brand - Copay CA: $40/up to100 days - Copay CO $30/up to 90 days /up to 30 days OUTPATIENT PRESCRIPTION DRUGS (cont'd) - Non-Formulary Brand - Copay CA: $35/up to 30 days 2x Copay 31 to 100 days - Copay CO $60/up to 90 days $35/up to 30 days Blood and Blood Products Diabetic Coverage - Oral Medications and Insulin Generic/Formulary Brand - Diabetic testing supplies (meters, test strips) Generic/Formulary Brand - Diabetic administration devices (syringes) Generic/Formulary Brand Smoking Cessation Weight Loss 50%
5 ACA Mandated Drugs Contraceptive Devices (diaphragms, cervical caps, etc.) and Drugs Emergency Contraception
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