BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Customized COB Dependents Children birth to 26 Filing Limit 12 months For employees that work in a WKHS location within the primary HealthPlus service area Mailing Address & PPO Company. Remit claims to: Willis Knighton Health Plus of Louisiana: P.O. Box 2947, Covington, LA 70434, Emdeon Payor ID# 07205 For employees that work in a WKHS location outside of the primary HealthPlus service area: Mailing Address & PPO Company. Remit claims to: Willis Knighton Health Plus of Louisiana and 360 Alliance Network P.O. Box 2947, Covington, LA 70434, Emdeon Payor ID# 07205 Don t forget to get a copy of the Patient s ID Card for claim filing directions in order to expedite claims processing Pre Existing Does not apply Utilization Review: MedCom Care Management (800) 643 4416. Must precertify services listed 72 hours prior to admission or service Emergency admissions within 48 hours All facility to facility transfers Any Non Participating Provider referral or transfer of a Participant, or any use of a Non Participating provider for services, except for an Urgent Care Facility outside of the HealthPlus Service Area. Balloon Sinuplasty Bone growth stimulators of any type Electrical stimulator trials or insertions in a Physician s office Genetic Testing Heart Catheterizations Injections greater than $2000 in a Physician s office Inpatient confinements Oral surgery, except wisdom teeth extraction in a physician s office Outpatient Imaging: PET, Spect Scan, and MRA and Interventional Radiology procedures using a surgery billing code (e.g. biopsy catheter insertion); however, cardiac SPECT scans and HIDA scans do not require precertification Outpatient surgeries or day surgeries, except in a physician s office (however, if a surgery is specifically listed as requiring precertification, it must be precertified even if performed in a physician s office) Varicose Vein treatment / Sclerotherapy Penalty: Services will not be covered. The plan will not allow retro precertification. See Plan Document for further details. Page 1 of 7
ANNUAL MAXIMUM BENEFIT Unlimited DEDUCTIBLE, PER CALENDAR YEAR Per Participant $0 Per Family $0 MAXIMUM OUT OF POCKET EXPENSES, PER CALENDAR YEAR Per Participant $6,550 Per Family $13,100 NOTE: The following charges do not apply toward the out of pocket expense amount and are never paid at : Prescription drug card Brand Name Drug Penalties HEALTH BENEFITS: COPAYMENTS AND BENEFIT PERCENTAGES Accident Benefit Acupuncture Ambulance Bariatric Surgery Behavioral/Mental Health and Substance Use Disorders Inpatient Residential Treatment Behavioral/Mental Health and Substance Use Disorders Outpatient $100 copay $100 copay $50 copay per day to a maximum of $400, then Office Visits including psychotherapy in the office (Covered services rendered by a Mental Health or Substance Abuse professional) $15 copay Services other than in a Physician s office Includes Partial Hospitalization, Blood Chemotherapy, Radiation, and Proton Therapy Proton Therapy is covered Clinical Trials (as defined by this Plan for cancer or other lifethreatening diseases or conditions) Includes coverage for routine patient costs associated with participation in approved Clinical Trials only. If one or more PPO providers are participating in a Clinical Trial, the Plan may require that the qualified individual participate in the Clinical Trial with the PPO provider. The Plan will cover Non PPO providers outside the state in which the qualified individual resides only if there is not a PPO provider conducting the same trial in state. Chiropractic Treatment Non Surgical Treatment of the Spine Dental Covered under Separate Dental plan Covered under Medical (Refer Impacted Wisdom Teeth to Physician Services Surgeon for physician benefit. Facility charges will follow facility ). Page 2 of 7
Diabetes Self management Training Limited to 1 self management evaluation and training program per Member. Coverage for additional self management diabetes training shall be provided if a physician prescribes such additional training based upon its Medically Necessity because of a significant change in the Member s symptoms or conditions (subject to copayment). Nutritional counseling for diabetes is covered up to 3 visits per calendar year. Diagnostic Testing (Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) ( for Interventional Radiology procedures using a surgical billing code, outpatient imaging: PET, SPECT scan and MRA; however cardiac SPECT scans and HIDA scans do not require precertification) $125 copay Copay applies per day. No copay applies to stress tests, nuclear stress tests, or PET scans if test was ordered on a different visit and copay was taken for that visit at specified cardiologists. A current list of PPO network providers is available, without charge, from Health Plus or through the website located at www.mywkhealthplus.com. If you have any questions about how to do this, please contact Gilsbar at 1 800 390 1639. Diagnostic Testing (X ray, lab) Inpatient Diagnostic Testing (X ray, lab) Outpatient Hospital for genetic testing All outpatient drug testing will be subject to a medical necessity review Diagnostic Testing (X ray, lab) Stand Alone Facility for genetic testing All outpatient drug testing will be subject to a medical necessity review Diagnostic Testing (X ray, lab) Office All outpatient drug testing will be subject to a medical necessity review Dialysis Durable Medical Equipment for bone growth stimulators Insulin infusion pumps are limited to one pump every 3 years 75% Emergency Room Copay waived if admitted directly to Hospital from Emergency room Extended Care/Skilled Nursing Facility (60 days Calendar Year maximum) Foot Conditions Physicians' services in connection with corns, calluses or toenails are excluded, unless the charges are for the partial or complete removal of the nail roots. Routine foot care and foot orthotics are not covered Gastric Bypass Hearing Aid Covered only for dependents under the age of 18 Limited to one hearing aid per ear every 36 months. Hearing Exam Covered only for dependents under the age of 18 PCP $150 copay $100 copay per admission, $150 copay Bariatric Surgery Specialist Home Health Care (100 visits Calendar Year maximum) $45 copay Page 3 of 7
Hospice Care (210 days Lifetime maximum) Bereavement Counseling by Hospice provider. For other bereavement counseling services refer to Behavioral/Mental Health and Substance Use Disorders Outpatient Hospital / Facility Inpatient Room and Board is limited to the semiprivate room rate, or if the Hospital has private rooms only, the private room rate billed. ICU as billed. Hospital / Facility Outpatient for outpatient surgeries or day surgeries. Ambulatory Surgery, Outpatient Surgery, Same Day Hospital, Observation, Sleep Studies $400 copay per admission, $125 copay Other Facility Services not listed elsewhere Infertility / Sterility Maternity Maternity related expenses for a dependent Child are not covered except as required by law for prenatal care. care care Prenatal care as required by federal law. Other eligible charges. Newborn Care (routine inpatient) The Hospital / Facility Inpatient copay will apply to the newborn only if admitted to the NICU or is discharged from the Hospital after the mother. services for if the newborn is admitted to the NICU or is discharged from the Hospital after the mother Non Surgical Treatment of the Spine Provider must send Letter of Medical Necessity and all notes. Obesity Organ Transplants Donor charges are covered. plan document for limitations & exclusions. Provider should notify Customer Contact Center prior to starting any transplant services, including initial evaluation. Case Management is strongly suggested. Organ Transplant Travel & Accommodation Orthotics / Prosthetics Foot orthotics are not covered 75% Physician Services Inpatient Visits Physician Services Inpatient Surgeon Physician Services Outpatient Visits (services other than in a Physician's office) Page 4 of 7
Physician Services Outpatient Surgeon (services other than in a Physician's office) Physician Services Office Visits Copay is per provider and applies to the office visit charge only. for injections greater than $2000, and in office electrical stimulators trials or insertions Primary Care Provider Specialist $45 copay All other eligible expenses rendered in the physician s office not covered under the copay including allergy testing and allergy treatment. Primary Care Physicians are: Family Practice, General Practice, Internal Medicine, OB/GYN, and Pediatrician. Physician Services In office Surgeon ( for day surgeries if the surgery is specifically listed as requiring precertification regardless of where it is performed) Prescription Drugs Inpatient Prescription Drugs Outpatient Preventive Care Benefit Preventive care includes the following once annually: routine office visit, physical exam, X ray & lab, occult blood test, colon exam, sigmoidoscopy, gynecological exam (well woman visits), pap smear, cholesterol screening, prostatic/testicular exam, smoking cessation. Hospital / Facility Inpatient Prescription Drug Benefits schedule and section Breast pumps are limited to one per plan year Services are also covered as recommended by the United States Preventive Services Task Force (USPSTF) and immunizations will be covered as recommended by the Centers for Disease Control (CDC). All services are limited to no more than once annually or as recommended by the USPSTF. Private Duty Nursing Page 5 of 7
Rehabilitation Services (Cardiac Rehab, Occupational, Physical, Speech, Pulmonary and Vision Therapies) Maximum copay of $200 per condition for cardiac rehab therapies for services performed at Willis Knighton facilities only. All phases covered up to the limit shown. Cardiac Rehab, Occupational, Physical and Speech therapy is limited to 120 visits combined per year. Pulmonary Therapy is not limited Vision Therapy Also, habilitative services for developmental delay, sensory integration delay, fine motor delay and gross motor delay for dependent children age 6 or younger are covered according to the therapy limitations shown above Sleep Disorder Covered only if medically necessary Sleep Study Other eligible expenses Sterilization Vasectomy Female Sterilization as required by federal law Temporomandibular Joint Syndrome Only the initial evaluation and testing to diagnose the condition is covered. The treatment is excluded. Urgent Care Facility (Includes all covered charges billed by facility) *Limited to coverage at WK Quick Care only **Limited to facilities outside the Health Plus service area (the 100 mile radius in the Shreveport/Bossier area) Vision Exam Wig After Chemotherapy Care $50 copay, * Care $50 copay, ** Vision Benefits section Page 6 of 7
PRESCRIPTION DRUG CARD INFORMATION RX Benefits / Express Scripts (800) 334 8134 Prior Authorizations Medco Express Scripts (800) 753 2851 RxBIN: 003858 RxPCN: A4 Rx Grp: 35242RX Prescriptions purchased through a non participating pharmacy are not covered Prescriptions purchased through a participating pharmacy, but the drug card is not used, must be filed with the prescription drug company. Prescription Drug Deductible (Deductible must be satisfied before will be paid; Deductible waived for generics) Per Participant, per Calendar Year $250 Prescription Drug Card Options Copayment Benefit Percentage Retail Pharmacy Option (30 day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. Smoking Cessation $0 Generic drug $10 High Cost Generic Drug $15 Preferred Brand Name drug $35 Non Preferred Brand Name drug $50 Chemotherapy Agents Available only through the Specialty Pharmacy Program. Specialty drugs (high dollar or injectable drugs) Available only through the Specialty Pharmacy Program. $0 $0 $100, after, after Mail Order Option (90 day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. Generic drug $25 High Cost Generic Drug $37.50 Preferred Brand Name drug $87.50 Non Preferred Brand Name drug $125 $0, after, after Page 7 of 7