Fund Name: Pipefitters Local 636 Fund ID: 7800 MEDICAL BENEFITS Revised: 10/30/18 MP Who is covered? Active Members and their Dependents HAP Po Box 02399 Detroit, MI 48202 800-957-4325 www.hap.org PRE-CERT Health Plan Advocate P: 866-942-1394 F: 616-828-0989 (see pre-cert listing) PRE-DETERMINATION (to verify medical necessity) Fax: 616-828-0989 Fund Office Member Services 888-646-8920 or 248-641-4936 All benefits subject to deductible unless otherwise noted. * after satisfaction of In-Network Deductible ** after satisfaction of Out-of-Network Deductible Eff. 1/1/15 Medicare Advantage is through HUMANA 800-733-9064 ** PURE HEALTHY BACK ** A NEW NON-SURGICAL TREATMENT FOR CHRONIC BACK AND NECK PAIN IS BEING OFFERED TO ALL ELIGIBLE PARTICIPANTS AND NON- MEDICARE PARTICIPANTS. TO SCHEDULE AN APPOINTMENT MEMBERS CAN CALL PURE HEALTHY BACK AT 248-506-3801. CO-PAYS AND DEDUCTIBLES ARE WAIVED! *Our system will be compliant to the ICD-10 coding requirements effective October 1, 2015*
PPO NETWORK HAP (Out of State CIGNA) DEDUCTIBLE $300 Individual $600 Family $600 Individual $1,200 Family $1,000 Individual $2,000 Family $2,000 Individual $4,000 Family In/Out deductibles satisfy each other OUT OF POCKET $2,500 Individual $5,000 Family $5,000 Individual $10,000 Family $5,000 Individual $10,000 Family $10,000 Individual $20,000 Family In/Out OOP s satisfy each other TROOP (Total Real OOP Maximums) $7,150 Individual $14,300 Family None $7,150 Individual $14,300 Family None Includes deductibles, co-insurance, & co-pays for medical and Rx ANNUAL MAXIMUM No Max DEPENDENT AGE LIMIT 26 TIMELY FILING LIMIT 1 Year PRE-EXISTING CONDITION None
Abortions Not Covered Accident $150 ER Co-pay (waived if admitted or for an accidental injury) Emergency Room Accident $150 Copay* $150 Copay** $150 Copay* $150 Copay** Emergency Room Physician $150 Copay* $150 Copay** $150 Copay* $150 Copay** Urgent Care Accident $20 Copay* 70% UCR** $20 Copay* 60% UCR** Work Related Not Covered MVA *FUND IS SECONDARY* Required no-fault insurance policy for motor vehicle(s) owned or registered by member or covered dependents must be in effect No-fault insurance policy must include PRIMARY coverage for any medical claims for injuries/illness arising from a motor vehicle accident involving the vehicle. Fights Not Covered Acupuncture Not Covered
Allergy Services Testing 100% 70% UCR** 70%* 60% UCR** Injections 100% 70% UCR** 70%* 60% UCR** Ambulance 80%* 70% UCR** 70%* 60% UCR** Must be Medically Necessary Birth Control Injections/Devices Oral Oral contraceptives are covered under Rx Chiropractic Services 100% after $20 Copay 70% UCR** 100% after $25Copay 60% UCR** Combined Max of 24 visits per calendar year COB Standard Medicare Medicare Advantage through HUMANA 800-733-9064 Consultations 100% after $20 Copay 70% UCR** 100% after $25 Copay 60% UCR** Court Ordered Tx Not Covered
Dental Surgery 80%* 70% UCR** 70%* 60% UCR** Pre-auth is required for Dental Implants: After dental benefits have been exhausted for the plan year. Pre-auth is required for Orthodontia: for Medically necessary Ortho Diagnostic X-rays/ Labs 80%* 70% UCR** 70%* 60% UCR** Pre-cert required through HPA for Bone Scan with spect 866-942-1394 Durable Medical Equipment 80%* 80% UCR** 70%* 70% UCR** Prosthetic Bras 80%* 80% UCR** 70%* 70% UCR** 2 per year after mastectomy Breast Pump 100% 80% UCR** 100% 70% UCR** Covers one, SINGLE electric pump Education/Counseling Not Covered (except for outpatient diabetes management program) Outpatient Diabetes Management Program 100% 70% UCR** 100% 60% UCR** No deductible or copay in-network See DME for medical supplies
Emergency Care $150 ER Co-pay waived if admitted or for an accidental injury ER: Accident 100% 100% ER: Illness 100% / $150 Copay 100% / $150 Copay ER Physician 100% 100% Urgent Care 100%/$20 Copay 70% UCR** 100%/$25 Copay 60% UCR** Extended Care Facility See Skilled Nursing Facility Foot Care Podiatry in office service 100%/$20 Copay 70% UCR** 100%/$25 Copay 60% UCR** Orthotics 80%* 70% UCR** 70%* 60% UCR** Hearing Care 100% of the HAP approved amount once every 36 months 100%UCR** 100% of the HAP approved amount once every 36 months 100%UCR** Includes: Exam, Hearing Aid Eval, Fitting, Monaural or Binaural hearing aid & Hearing aid conformity test.
Home Health Care 80%* 70% UCR** 70%* 60% UCR** Home IV Infusion 80%* 70% UCR** 70%* 60% UCR** Pre-determination required through HPA 866-942-1394 ALL IV Infusion Therapy through Americare is covered 100% - no deductible Hospice Care 100% 100% Pre-cert required through HPA 866-942-1394 Up to 28 pre-hospice counseling visits before electing hospice; when elected, four 90-day periods provided through participating hospice program only Hospitalization Pre-certification is required for in-patient admission through HPA 866-942-1394 R&B 80%* 70% UCR** 70%* 60% UCR** Semi-private room rate Ancillary 80%* 70% UCR** 70%* 60% UCR** Pre-cert? Yes, through HPA 866-942-1394 ICU/CCU 80%* 70% UCR** 70%* 60% UCR** Physician 80%* 70% UCR** 70%* 60% UCR**
Infertility Diagnosis 80%* 70% UCR** 70%* 60% UCR** Treatment Not Covered Injections 80%* 70% UCR** 70%* 60% UCR** Lab Tests 80%* 70% UCR** 70%* 60% UCR** Maternity Pre & Post Natal 100%* Not Covered 100%* Not Covered Delivery & Nursery Care 80%* 70% UCR** 70%* 60% UCR** Includes covered services provided by a Certified Nurse Midwife I/P Hospital 80%* 70% UCR** 70%* 60% UCR** Birthing Center 80%* 70% UCR** 70%* 60% UCR** Dependent Daughter 80%* 70% UCR** 70%* 60% UCR**
Mental Health Residential is NOT covered ADHD is covered Inpatient 80%* 70% UCR** 70%* 60% UCR** Outpatient: Facility - IOP & partial hospitalization Outpatient: Physician s office 100%/$20 Copay 70% UCR** 80%* 70% UCR** 70%* 60% UCR** 100%/$25 Copay Obesity Surgery 75% 75% 60% UCR** Pre-cert required through HPA for ALL Mental Health 866-942-1394 Surgery is covered once per lifetime up to a $25,000 maximum; must be pre-certified and meet plan guidelines Office Visits 100%/$20 Copay 70% UCR** 100%/$25 Copay 60% UCR** Includes DXL, Injections, etc. done in office Specialist or Other practitioner 100%/$20 Copay 70% UCR** 100%/$25Copay 60% UCR** Outpatient and Home Visits 80%* 70% UCR** 70%* 60% UCR** Pre-cert required through HPA 866-942-1394 Pain Management 80%* 70% UCR** 70%* 60% UCR** Penile Implants Provider must fax pre-determination to 616-828-0989 Private Duty Nursing 50%* 50%** 50%* 50%** Prosthetics 80%* 80%** 70%* 70%** Wigs Not Covered
ROUTINE PREVENTIVE SERVICES ALL ADULTS Routine Exam Once per calendar year Alcohol Misuse Screening and Counseling Aspirin to Prevent Cardiovascular Disease for Men and Women of certain ages 50 59 years of age Blood Pressure Screening Routine Chest X-rays/EKG/ Labs Once per calendar year Cholesterol Screening for Adults 100% Not Covered 100% Not Covered Colonoscopy Adults over 50 years 100% - (80%) Not Covered 100% - (70%) Not Covered 1 st colonoscopy of the year (routine or medically necessary) covered 100% - subsequent colonoscopies covered FULL PLAN 80% in network & 70% out of network STANDARD PLAN 70% in network & 60% out of network PRE-CERT REQUIRED THROUGH HPA
Depression Screening Diabetes Type 2 Screening Adults with high blood pressure Diet Counseling Adults at higher risk for chronic disease Domestic Violence Screening & Counseling Flexible Sigmoidoscopy Exam & Fecal Occult Blood Screening Once per calendar year Hepatitis B Screening People at high risk Hepatitis C Screening Adults at increased risk and One time for everyone born between 1945-1965 HIV Screening Everyone ages 15 to 65 and other ages at increased risk
Lung Cancer Screening Adults ages 55 80 at high risk for lung cancer Obesity Screening and Counseling PSA Testing Once per calendar year Annual STI Counseling; HIV Screening & Counseling Syphilis Screening Adults at higher risk Tobacco Use Screening All adults and cessation interventions for tobacco users ROUTINE PREVENTATIVE SERVICES MEN Annual Prostate Exam One Time Screening Men ages 65 75 and have ever smoked Abdominal Aortic Aneurysm
ROUTINE PREVENTATIVE SERVICES ALL WOMEN Breast Cancer Genetic Test Counseling (BRCA) Women at higher risk Breast Cancer Chemoprevention Counseling Women at higher risk Chlamydia Infection Screening Younger women and other women at higher risk Contraceptive Counseling Gonorrhea Screening Women at higher risk GYN/Pap Smear Once per calendar year HPV DNA Testing Once every 3 years; Women 30 & older Mammograms (includes 3D) Once per calendar year Osteoporosis Screening RH Incompatibility Screening Women over age 60 depending on risk factors Follow up testing for women at higher risk
ROUTINE PREVENTATIVE SERVICES PREGNANT WOMEN OR WOMEN WHO MAY BECOME PREGNANT Anemia Screening Breastfeeding Support & Counseling With the birth of a child Folic Acid Supplements Gestational Diabetes Screening 24-48 weeks pregnant And those at high risk of developing gestational diabetes Gonorrhea Screening All women at higher risk Hepatitis B Screening Pregnant women at their first prenatal visit RH Incompatibility Screening All pregnant women and follow up testing for women at higher risk Syphilis Screening Expanded Tobacco Intervention and Counseling For pregnant tobacco users Urinary Tract or other Infection Screening
IMMUNIZATIONS AND VACCINES ADULTS Diphtheria Hepatitis A Hepatitis B Herpes Zoster/Shingles Shot Human Papillomavirus (HPV) Influenza (Flu Shot) Measles Meningococcal
Mumps Pertussis Pneumococcal Rubella Tetanus Varicella (Chickenpox) ROUTINE PREVENTATIVE SERVICES CHILDREN Well Baby and Well Child Visits Frequencies: 6 visits birth thru 12 months 7 visits ages 1year thru 4years 1 visit ages 5years thru 17years
Alcohol and Drug Assessments For adolescents Autism Screening Children at 18 and 24 months Behavioral Assessments Blood Pressure Screening Cervical Dysplasia Screening For sexually active females Depression Screening For adolescents Developmental Screening Children under age 3 Dyslipidemia Screening Children at higher risk of lipid disorders Fluoride Chemoprevention Supplements For children without fluoride in their eater source Gonorrhea Preventative Medication For the eyes of all newborns
Hearing Screening For all newborns Height, Weight and Body Mass Index (BMI) Measurements Hematocrit or Hemoglobin Screening Hemoglobinopathies or Sickle Cell Screening For newborns Hepatitis B Screening Adolescents at high risk HIV Screening Adolescents at higher risk Hypothyroidism Screening For newborns Iron Supplements Children ages 6 to 12 months at risk for anemia Lead Screening For children at risk of exposure
Obesity Screening and Counseling Oral Health Risk Assessment For young children ages 1 to 11 months 1 to 4 years 5 to 10 years Phenylketonuria (PKU) Screening For newborns Sexually Transmitted Infection (STI) Prevention Counseling and Screening Adolescents at higher risk Tuberculin Testing For children at higher risk of tuberculosis Vision Screening IMMUNIZATIONS AND VACCINES CHILDREN Diphtheria, Tetanus, Pertussis (Whooping Cough) Haemophilus Influenza Type B
Hepatitis A Hepatitis B Human Papillomavirus (PVU) Inactivated Poliovirus Influenza (Flu Shot) Measles Meningococcal Pneumococcal Rotavirus Varicella (Chickenpox)
Second Surgical Opinion 80%* 70% UCR** 70%* 60% UCR** Skilled Nursing Facility 80%* 70% UCR** 70%* 60% UCR** 120 days per member per calendar year PRE-CERT REQUIRED THROUGH HPA 866-942-1394 Sleep Study 80%* 70% UCR** 70%* 60% UCR** Smoking Cessation Sterilization Voluntary 80%* (men) 100% (women) 70% UCR** 70%* (men) 100% (women) 60% UCR** Based on PPACA Reversal Not Covered Substance Abuse Treatment Inpatient 80%* 70% UCR** 70%* 60% UCR** Outpatient: Facility IOP & partial hospitalization 80%* 70% UCR** 70%* 60% UCR** Pre-cert required through HPA for ALL Substance Abuse 866-942-1394 Outpatient: Physician s office 100%/$20 Copay 70% UCR** 100%/$25 Copay 60% UCR**
Surgery (All Related Expenses) Vision Correction Therapy 80%* 70% UCR** 70%* 60% UCR** Not Covered Pre-cert required through HPA for inpatient and outpatient surgery See HPA Pre-Cert List 866-942-1394 ABA Therapy (eff 11/1/18) 100% 60% URC** 100% 60%URC ** Subject to Deductible Physical 80%* 70% UCR** 70%* 60% UCR** Occupational 80%* 70% UCR** 70%* 60% UCR** Speech 80%* 70% UCR** 70%* 60% UCR** IV Infusion 80%* 70% UCR** 70%* 60% UCR** Physical, Occupational, & Speech therapy have a combined maximum of 60 visits per calendar year 100% if Americare is utilized No deductible or copays Pre-cert required through HPA 866-942-1394 Radiation 80%* 70% UCR** 70%* 60% UCR** Radiation & Chemotherapy require pre-cert through HPA Chemotherapy 80%* 70% UCR** 70%* 60% UCR** 866-942-1394 Respiratory 80%* 70% UCR** 70%* 60% UCR** Hemodialysis 80%* 70% UCR** 70%* 60% UCR** Cardiac Rehab 80%* 70% UCR** 70%* 60% UCR** Massage Not Covered
TMJ 80%* 70% UCR** 70%* 60% UCR** Transplant Services Organ 80%* 70% UCR** 70%* 60% UCR** Bone Marrow 80%* 70% UCR** 70%* 60% UCR** Kidney/Cornea/Skin 80%* 70% UCR** 70%* 60% UCR** Specified oncology clinical trials 80%* 70% UCR** 70%* 60% UCR** Bone Density Test Pre-cert required through HPA for Bone Scan with Spect 866-942-1394