2013 - Utah

Utah Basic Plus 2013

Utah Basic Plus

Benefits Summary

2013

7-18-13

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Utah Basic Plus 2013

Employee Rates

Bi-weekly Medical Contributions

Open Enrollment Dates

For March 31 ¨C June 30, the State will not contribute any

Health Savings Account money.

Medical. . . . . . . . . . . . . . . . . . . . . March 22 - March 29

Employer

HOW TO ENROLL

Online enrollment is not available for this special enrollment. If you would like to enroll complete the paper

enrollment for and submit to PEHP by March 29.

Employee

Utah Basic Plus (Advantage and Summit)

Single

$95.55

0.00

Double

$201.57

0.00

Family

$318.16

0.00

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Utah Basic Plus 2013 ? Medical Benefits Grid

Advantage Care & Summit Care

Refer to the Utah Basic Plus Plan Master Policy for specific criteria for the benefits

listed below, as well as information on Limitations and Exclusions.

Contracted Provider

DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS

Medical Deductible

$3,000 per individual, $6,000 per family

Plan Year Out-of-Pocket Maximum

Includes Deductibles and Coinsurance

$6,050 per individual, $12,100 per family

Maximum Annual Benefit

None

Pre-existing Condition Waiting Period

Does not apply to any individual up to age 19

12-month Waiting Period¡ª waived or reduced with evidence of prior Creditable Coverage

INPATIENT FACILITY SERVICES

Medical and Surgical | Requires Pre-notification

70% of MAF after Deductible

Non-contracted Providers will be paid up to 70% of MAF after Deductible for Emergency

Life-threatening hospital admissions only, Members may be balance billed.

Skilled Nursing Facility

Non-custodial.

Requires Pre-authorization and Medical Case Management

70% of MAF after Deductible

Hospice | Up to six months in a three-year period.

Requires Pre-authorization and Medical Case Management

70% of MAF after Deductible

Rehabilitation | Requires Pre-authorization and Medical

Case Management.

70% of MAF after Deductible

Mental Health/Substance Abuse

Requires Pre-authorization.

70% of MAF after Deductible

OUTPATIENT FACILITY SERVICES

Outpatient Facility and Ambulatory Surgery

70% of MAF after Deductible

Ambulance (ground or air)

Medical emergencies only, as determined by PEHP

70% of MAF after Deductible

Emergency Room

Medical emergencies only, as determined by PEHP.

70% of MAF after Deductible.

Non-contracted Providers will be paid up to MAF after Deductible, Member may be balance billed

Urgent Care Facility

70% of MAF after Deductible

Diagnostic Tests, X-rays

70% of MAF after Deductible

Chemotherapy, Radiation, and Dialysis

70% of MAF after Deductible

Physical, Occupational, and Speech Therapy

(rehabilitation/habilitation)

Limited to 20 visits per plan year for all therapy types combined.

Pre-authorization required only for home visits

70% of MAF after Deductible

MAF = Maximum Allowable Fee

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Utah Basic Plus 2013 ? Medical Benefits Grid

Contracted Provider

PROFESSIONAL SERVICES

Inpatient Physician Visits

70% of MAF after Deductible

Emergency Room Physician Visits

70% of MAF after Deductible

Surgery and Anesthesia

70% of MAF after Deductible

Primary Care Office Visits

70% of MAF after Deductible

Specialist Office Visits

70% of MAF after Deductible

Diagnostic Tests, X-rays

70% of MAF after Deductible

Mental Health/Substance Abuse*

No Pre-authorization required for outpatient service. Inpatient

services require Pre-authorization

70% of MAF after Deductible

PRESCRIPTION DRUGS

Retail Pharmacy | Up to 30-day supply

Preferred generic: 50% of discounted cost after Deductible

Preferred brand name: 50% of discounted cost after Deductible

Specialty Injectible Medications,

office/outpatient

Up to 30-day supply

70% of MAF after Deductible.

No maximum Coinsurance

Specialty Injectible Medications,

through specialty vendor Accredo

Up to 30-day supply

70% of MAF after Deductible.

No maximum Coinsurance

Specialty Oral Medications,

through specialty vendor Accredo

Up to 30-day supply

50% of MAF after Deductible.

No maximum Coinsurance

MISCELLANEOUS SERVICES

Adoption | See Limitations

70% after Deductible, up to $4,000 per adoption

Allergy Serum

70% of MAF after Deductible

Chiropractic Care

Not covered

Durable Medical Equipment, DME

DME over $750, rentals, that exceed 60 days, or as indicated

in Appendix A of the Master Policy require Pre-authorization.

Maximum limits apply on many items. See the Master Policy for

benefit limits. Note: Sleep Disorder equipment is not covered

70% of MAF after Deductible

Medical Supplies

70% of MAF after Deductible

Home Health/Skilled Nursing

Up to 30 visits per plan year.

Requires Pre-authorization and Medical Case Management

70% of MAF after Deductible

Infertility Services

Not covered

Injections

Requires Pre-authorization if over $750

70% of MAF after Deductible

Temporomandibular Joint Dysfunction

Not covered

Sleep Studies

Not covered

MAF = Maximum Allowable Fee

*Life assistance counseling through Blomquist Hale Counseling Group is not available for members enrolled in Utah Basic Plus.

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Utah Basic Plus 2013 ? Medical Benefits Grid

Contracted Provider

WELLCARE PROGRAM | ANNUAL ROUTINE CARE

Affordable Care Act Preventive Services

See Master Policy for complete list

100% of MAF

Routine Physical Exams

1 visit per plan year

100% of MAF

Pap Smear

1 visit per plan year

100% of MAF

Mammogram

1 visit per plan year, age 40 and above

100% of MAF

Routine Well-Child Exams

100% of MAF

Immunizations

100% of MAF

Routine Vision Exams

1 visit per plan year age 5-18

70% of MAF after Deductible

Routine Hearing Exams

Not covered

Diabetes Education

Must be for the diagnosis of diabetes

70% of MAF after Deductible

Pediatric Dental Services**

Routine cleaning, exams, x-rays and fluoride.

Two times per plan year. Through age 18.

Sealants once every five years. See Master Policy for details.

70% of MAF after Deductible

Pediatric Vision Services

Lenses only. One time per plan year. Can see Provider of choice

70% of MAF after Deductible

MAF = Maximum Allowable Fee

**Payable only as secondary to a dental plan or if member does not have a separate dental plan.

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