MPS ST. LUKE'S HEALTH SYSTEM ain.net
ST. LUKE'S HEALTH SYSTEM
OPTION 1 04/01/2021
SCHEDULE OF BENEFITS
SELECTHEALTH NETWORK / PPO PRODUCT
Administered by SelectHealth
IN-NETWORK
When using in-network providers, you are responsible to pay the amounts in this column.
OUT-OF-NETWORK
When using out-of-network providers, you are responsible to pay the amounts in this column.
CONDITIONS AND LIMITATIONS
Lifetime Maximum Plan Payment
None
Pre-Existing Conditions (PEC)
None
Benefit Accumulator Period
plan year
MEDICAL DEDUCTIBLE AND MEDICAL OUT-OF-POCKET5,6
IN-NETWORK
OUT-OF-NETWORK
Self Only Coverage, 1 person enrolled - per plan year
Deductible
$800
Out-of-Pocket Maximum
$3,500
None
Family Coverage, 2 or more enrolled - per plan year
Deductible - per person/family
$800/$1,600
Out-of-Pocket Maximum - per person/family
$3,500/$7,000
None
(Medical and Pharmacy Included in the Out-of-Pocket Maximum)
INPATIENT SERVICES Medical and Surgical4 Hospice4 Skilled Nursing Facility4 - Up to 30 days per plan year Inpatient Rehab Therapy: Physical, Speech, Occupational4
PROFESSIONAL SERVICES
Office Visits Primary Care Provider (PCP)1 Secondary Care Provider (SCP)1
Mental Health Office Visits
Allergy Tests
Allergy Treatment and Serum Medical and Surgical Professional Services4
Primary Care Provider (PCP)1
T Secondary Care Provider (SCP)1
PREVENTIVE SERVICES AS OUTLINED BY THE ACA2,3
O Primary Care Provider (PCP)1 N Secondary Care Provider (SCP)1
Adult and Pediatric Immunizations
O Elective Immunizations - herpes zoster (shingles), rotavirus D Diagnostic Tests: Minor
Other Preventive Services
IN-NETWORK
E 20% after Deductible T Covered 100%
20% after Deductible
U 20% after Deductible IB IN-NETWORK R$25
$50
T $25 IS 20% after Deductible D 20% after Deductible
10% after Deductible 20% after Deductible
IN-NETWORK Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100%
OUT-OF-NETWORK 40% after Deductible Covered 100% 40% after Deductible 40% after Deductible
OUT-OF-NETWORK
40% after Deductible 40% after Deductible 40% after Deductible 40% after Deductible 40% after Deductible
40% after Deductible 40% after Deductible OUT-OF-NETWORK
Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered
VISION SERVICES
IN-NETWORK
OUT-OF-NETWORK
Preventive Eye Exams
Administered by VSP
Not Covered
All Other Eye Exams
$50
40% after Deductible
OUTPATIENT SERVICES4 Outpatient Facility and Ambulatory Surgical Ambulance (Air or Ground) - Emergencies Only Ambulance (Air or Ground) - Inter-facility Transfers 4 Emergency Room - Facility and Physician Emergency Room - Diagnostic Tests Urgent Care Facilities Urgent Care Facilities - Diagnostic Tests
IN-NETWORK 20% after Deductible 20% after Deductible
Covered 100% $250
20% after Deductible $25
20% after Deductible
OUT-OF-NETWORK 40% after Deductible See In-Network Benefit See In-Network Benefit See In-Network Benefit See In-Network Benefit 40% after Deductible 40% after Deductible
Chemotherapy, Radiation and Dialysis Diagnostic Tests: Minor2 Diagnostic Tests: Major2
20% after Deductible 20% after Deductible 20% after Deductible
40% after Deductible 40% after Deductible 40% after Deductible
Home Health and Outpatient Private Nurse Hospice4
20% after Deductible Covered 100%
40% after Deductible Covered 100%
Outpatient Rehab/Habilitative Therapy: Physical, Speech, Occupational
20% after Deductible
40% after Deductible
See other side for additional benefits
ST. LUKE'S HEALTH SYSTEM
OPTION 1 04/01/2021
SCHEDULE OF BENEFITS
IN-NETWORK
OUT-OF-NETWORK
SELECTHEALTH NETWORK / PPO PRODUCT
Administered by SelectHealth
MISCELLANEOUS SERVICES Durable Medical Equipment (DME)4 Miscellaneous Medical Supplies (MMS)3 Maternity4 Cochlear Implants4 - Up to $100,000 lifetime Hearing Aids or Auditory Osseointegrated Devices4
IN-NETWORK 20% after Deductible 20% after Deductible See Professional, Inpatient or Outpatient
20% after Deductible See Professional, Inpatient or Outpatient
OUT-OF-NETWORK 40% after Deductible 40% after Deductible 40% after Deductible
40% after Deductible 50% after Deductible
One device every 36 months per ear. Up to 45 language/speech therapy visits
during the 12 months after the delivery of the covered device.
Infertility - Select Services Donor Fees for Covered Organ Transplants2,4
Not Covered 20% after Deductible
Not Covered 40% after Deductible
Transplant Travel Expenses - Up to $10,000 for Donor and/or Recipient
Covered 100%
TMJ (Temporomandibular Joint) Services - Up to $1,000 annual max
Chiropractic - Up to $600 per participant per plan year Injectable Drugs and Specialty Medications4 Bariatric Surgery - Only at St. Luke's Hospital, Limited to 1 per lifetime 2,4
(Preauthorization is required. If preauthorization is not obtained, the bariatric
services will not be covered.)
OPTIONAL BENEFITS Mental Health and Chemical Dependency4
Office Visits Inpatient Facility4 Inpatient Professional4 Outpatient4 Residential Treatment2,4
Diabetes Self-Management Education Services - Up to $500 per plan year
NOT Lower Back Pain Services
20% after Deductible 20% after Deductible
E 20% after Deductible T *$2,000 copay, then 20% after Deductible
IBU IN-NETWORK RSee Professional Services
20% after Deductible
T10% after Deductible IS $25
20% after Deductible
D 20% after Deductible
40% after Deductible 40% after Deductible 40% after Deductible
Not Covered
OUT-OF-NETWORK
See Professional Services 40% after Deductible 40% after Deductible 40% after Deductible 40% after Deductible 40% after Deductible
Treatment for lower back pain coordinated through the St. Luke's Center for Spine Wellness (CSW) will be covered as follows: Initial evaluation will be covered at 100%, and CSW-referred services/providers will be covered at $25 copay (office visit) or 90% (co-insurance), Deductible waived. Surgical services and treatment not coordinated through CSW will be covered at the applicable standard benefits.
Value-Based Benefits - Diabetes
Services with no cost share for members with diabetes:
(The enhanced benefit only applies when using a Participating BrightPath provider.) -Two office visits, **one retinal exam, **one LDL cholesterol test, **one urinary
O micro albumin test (**not required for children ................
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