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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