Plan A - WEBeci

Schedule of Medical Benefits ? East Lakeland Plan A

PPO: MHP 1-800-748-1879 OR PPO: MPCN 1-800-931-8533 PRE-CERTIFICATION: AHH 800-874-2378

PreCertification is required for inpatient hospitalization only.

NETWORK PROVIDERS NON-NETWORK PROVIDERS Note: The maximums listed below are the total for Network and Non-Network expenses. For example, if a maximum of 60 days is listed twice under a service, the Calendar Year maximum is 60 days total which may be split between Network and Non-Network providers. DEDUCTIBLE, PER CALENDAR YEAR

Per Covered Person Per Family Unit

$750 $2,250

COPAYMENTS

Physician visits

$35

60% after deductible

Specialist visits Urgent Care Services

$50 $100

60% after deductible 60% after deductible

Emergency Care

$100

$100

The Urgent Care and Emergency Room copayment is waived if the patient is admitted to a

Hospital on an emergency basis. The utilization review administrator must be notified within 48

hours of the admission even if the patient is discharged within 48 hours of the admission. Please

refer to the Employee ID card for the precertification telephone number.

MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR

Per Covered Person

$3,000

$4,750

Per Family Unit

$9,000

$14,250

Note: The Maximum Out-of-Pocket Expense for Network and Non-Network Providers is Combined

The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are

reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of

the Calendar Year unless stated otherwise.

The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%.

Cost containment penalties Amounts over Usual and Reasonable Charges Charges for Services this Plan does not cover

The following charges do apply toward the out-of-pocket maximum for Network Providers only:

Deductibles

Coinsurance

Copayments

COVERED CHARGES Note: Benefits are payable as shown below. However, to the extent

that a service is specifically described in the Summary of Benefits and Coverage and it is

not specifically addressed below, benefits will be payable at the levels shown in the

Summary of Benefits and Coverage.

Hospital Services

Room and Board

75% after deductible the

60% after deductible the

semiprivate room rate

semiprivate room rate

Intensive Care Unit

75% after deductible

60% after deductible

same as semiprivate room rate same as semiprivate room rate

Emergency Room Visit

Medical

75% after deductible

75% after deductible

Emergency/Accidental Injury Copayment applies

Copayment applies

Skilled Nursing Facility

75% after deductible

60% after deductible

? the facility's semiprivate ? the facility's semiprivate

room rate

room rate

? starts within 14 days of

? starts within 14 days of

Hospital confinement of

Hospital confinement of

at least 3 days

at least 3 days

? 100 days Calendar Year ? 100 days Calendar Year

maximum

maximum

PPO: MHP 1-800-748-1879 OR PPO: MPCN 1-800-931-8533

PRE-CERTIFICATION: AHH 800-874-2378

PreCertification is required for inpatient hospitalization only.

NETWORK PROVIDERS NON-NETWORK PROVIDERS

Urgent Care Services

75% after deductible

60% after deductible

Copayment applies

Physician Services

Inpatient visits

75% after deductible

60% after deductible

Office visits

100% after copayment

60% after deductible

Includes all related services

performed in the

office(Excludes office

surgery)

Specialist office visits

100% after copayment

60% after deductible

Allergy testing

100% after copayment

60% after deductible

Allergy serum and injections 100% after copayment

60% after deductible

Diagnostic Testing (X-ray & 75% after deductible

60% after deductible

Lab) Includes Physician

Charges/Facility Charges

Imaging Services (MRI,

75% after deductible

60% after deductible

CT/PET Scans, etc.) Includes

Physician Charges/Facility

Charges

Home Health Care

75% after deductible

60% after deductible

100 visit Calendar Year

100 visit Calendar Year

maximum

maximum

Hospice Care

75% after deductible

60% after deductible

The maximum facility room rate

will be the Semi-Private Room

Rate

Ambulance Service

75% after deductible

75% after deductible

Occupational Therapy

75% after deductible

60% after deductible

Speech Therapy

75% after deductible

60% after deductible

Physical Therapy

75% after deductible

60% after deductible

Durable Medical Equipment 75% after deductible

60% after deductible

Prosthetics

75% after deductible

60% after deductible

Spinal Manipulation

75% after deductible

60% after deductible

Chiropractic

20 visits Calendar Year

20 visits Calendar Year

maximum

maximum

Mental Disorders

Inpatient

75% after deductible

60% after deductible

Outpatient Office Visits

100% after copayment

60% after deductible

Intermediate Outpatient Care 100% after copayment

60% after deductible

Substance Abuse

Inpatient

75% after deductible

60% after deductible

Outpatient Office Visits

100% after copayment

60% after deductible

Intermediate Outpatient Care 100% after copayment

60% after deductible

Preventive Care

Routine Well Adult Care

100%

60% after deductible

Includes: Standard Preventive Care, office visits, pap smear, mammogram, prostate screening,

gynecological exam, routine physical examination, x-rays, laboratory tests, immunizations/flu

shots, colonoscopies, vision tests and other preventive care and services required by applicable

law if provided by a Network Provider.

Frequency limits for mammogram

Ages 40 and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . annually

Immunizations for Adults

Routine Well Newborn Care 100%

60% after deductible

Routine Well Child Care

100%

60% after dedcutible

PPO: MHP 1-800-748-1879 OR PPO: MPCN 1-800-931-8533

PRE-CERTIFICATION: AHH 800-874-2378

PreCertification is required for inpatient hospitalization only.

NETWORK PROVIDERS NON-NETWORK PROVIDERS

Pregnancy

75% after deductible

60% after deductible

Dependent daughters not covered.

**Note: All services received at East Lakeland OB/GYN Associates will be paid at 100%. Services performed outside of East Lakeland OB/GYN Associates will not be covered unless the service/procedure is a service/procedure East Lakeland OB/GYN Associates does not provide or is outside of their specialty.

PRESCRIPTION DRUG BENEFIT SCHEDULE

PRESCRIPTION DRUG BENEFIT

NETWORK

NON-NETWORK

Pharmacy Option (30 Day Supply)

Generic Drugs Brand Name Drugs Specialty Drugs

$10 Co-pay 30% Co-pay 30% Co-pay to a maximum OOP of $250/month

Refer to the Prescription Drug Section for details on the Prescription Drug benefit. Mail Order Prescriptions are NOT COVERED under this Plan.

A Covered Person will be allowed to obtain the initial fill of a Specialty Drug at a retail pharmacy; any refills thereafter must be obtained through Scriptcare's Specialty Pharmacy.

PLAN EXCLUSIONS

Note: All exclusions related to Prescription Drugs are shown in the Prescription Drug Plan.

Note: All exclusions related to Dental are shown in the Dental Plan.

For all Basic and Major Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered:

(1) Abortion. Services, supplies, care or treatment in connection with an abortion.

(2) Acupressure. Expenses for acupressure will not be considered eligible.

(3) Acupuncture.

(4) Biofeedback.

(5) Certain Care Facilities. Services provided by an institution which is primarily a rest home, a place for the aged, a nursing home, a convalescent home (other than a convalescent facility for extended care due to a covered illness or injury), a place of custodial care, or any other place of like character.

(6) Complications of non-covered treatments. Care, services or treatment required as a result of complications from a treatment not covered under the Plan are not covered. Complications from a noncovered abortion are covered.

(7) Cosmetic Procedures. Any surgery or procedure, the primary purpose of which is to improve or change the appearance of any portion of the body, but which does not restore bodily function, correct a disease state, or improve a physiological function. Cosmetic Procedures include cosmetic surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery (including reimplantation). This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. This exclusion does not apply to surgery to restore function if the body area has been altered by injury, disease, trauma, congenital/developmental Anomalies, or previous covered therapeutic processes.

(8) Court ordered Exams. Any exams which a Plan Participant has been ordered by a court, judge, or any other legal authority to undergo.

(9) Custodial care. Services or supplies provided mainly as a rest cure, maintenance, Custodial Care or domiciliary care consisting chiefly of room and board.

(10) Dental. Charges incurred for treatment on or to the teeth, the nerves or roots of the teeth, gingival tissue or a molar process and any other dental, orthodontic, or oral surgical charges unless expressly included elsewhere in this Plan document.

(11) Driving Under the Influence. Charges incurred when the Plan Participant was driving a motor vehicle and his/her blood-alcohol level is over the legal limit in the state where the Plan Participant was driving.

(12) Educational or vocational testing. Services for educational or vocational testing or training.

(13) Excess charges. The part of an expense for care and treatment of an Injury or Sickness that is in excess of the Usual and Reasonable Charge.

(14) Exercise programs. Exercise programs for treatment of any condition, except for Physician-supervised cardiac rehabilitation, occupational or physical therapy if covered by this Plan.

(15) Experimental or not Medically Necessary. Care and treatment that is either Experimental/Investigational or not Medically Necessary.

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