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 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download