MEDICAL & RX BENEFIT MATRIX American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: 01-01-2011 MEDICAL & RX BENEFITS SCHEDULE OF BENEFITS MEDICAL BENEFITS COVERED SERVICE/PLAN IN-NETWORK OUT-OF-NETWORK CATEGORY Payment for in-network services is based on provider s negotiated amount. Provider cannot balance bill charges in excess of negotiated amount. Payment for out-of-network services is based on provider s customary & reasonable amount. Provider can balance bill charges in excess of C & R amount. GENERAL INFORMATION Deductible Individual - $500 Family - $1,500 Coinsurance Plan pays: 80% Patient pays: 20% Unless otherwise specified Out-of-Pocket Limit (Includes Deductible & Coinsurance Expense) Individual - $1,000 Family - $3,000 1. In and Out of Network Deductible amounts accumulate separately 2. Common accident does not apply 3. Deductible carry over does not apply 4. Family accumulation Eligible expenses incurred by all family members combined will be used to satisfy the family deductible (aggregate) Individual: $3,000 Family: $6,000 Thereafter, 100% until end of benefit period or maximum benefit reached Plan pays: 60% Patient pays: 40% Unless otherwise specified Individual: $6,000 Family: $12,000 Thereafter, 100% until end of benefit period or maximum benefit reached 1. In and Out of Network Out of Pocket amounts accumulate separately 2. Family accumulation Eligible expenses incurred by all family members combined will be used to satisfy the family OOP limit (aggregate) Lifetime Maximum Benefit Unlimited COVERED SERVICES Abortion Services All female participants Elective and non-elective covered Acupuncture Services Allergy Testing Allergy Serum 100% no deductible Allergy Injections $5 copay 1
Injection billed alone subject to $5 copay (In Network) Injection billed with OV subject to OV copay for both Allergy Office Visits $25 copay Ambulance Services Ground or Air Ambulatory Surgical Anesthesiologist Services Birthing Center Precert required for stays over 48 or 96 hours Birth Control 100% no deductible Only covers tubal ligation and vasectomy No coverage for any other form of birth control Birth Control Office Visit $25 copay Cardiac Rehabilitation Chemotherapy Phase 1 & 2 only Home programs, on-going conditioning and maintenance not covered Group uses Biologics 800-983-1590 Chiropractic Services OV & Manipulations - $25 copay All other services 12 visits per calendar year Cochlear Devices Dental Services Accident Services must be completed within 12 months of the accident/injury Dental Services Non Accident Benefits are payable for the removal of full bony impacted teeth or for other dental processes only if the patient s medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient Diagnostic Lab & X-ray, includes preadmission testing Durable Medical Equipment Life sustaining equipment such as, but not limited to, ventilators, respiratory assist devices, chest percussion devices for cystic fibrosis are not subject to calendar year maximum Rental to purchase price Repair covered must not exceed cost of replacement Replacement covered if necessary due to the participant s growth and development Replacement covered if item is worn or damaged and repair isn t possible 2
Education Services Emergency Room Educational materials and instruction for the following; Diabetic Ostomy $150 copay, 80% no deductible $150 copay, 80% no deductible Hearing Exams & Hearing Aids Hemodialysis Group uses DCC Copay waived if patient is admitted Home Health Care Services 90 visits per calendar year Hospice Services Hospital (Inpatient) Precert required Hospital (Outpatient) Surgery Hospital (Outpatient) Non surgical/routine Bereavement counseling and Respite care covered Private room covered up to the semi-private room rate Private room only hospital covered up to the lowest private room rate Medically necessary private room covered up to the lowest private room rate Infertility Services Maternity Services All female participants Routine ultrasound covered, unlimited for complicated pregnancy Medically necessary Amniocentesis covered Midwife services not covered Natural birthing classes (Lamaze) not covered Initial newborn services paid under the Mother Massage Therapy Medical and Surgical Supplies Support stocking covered Mental Health & Substance Abuse Inpatient Precert required Mental Health & Substance Abuse Outpatient OV& Psychotherapy - $25 copay 3
Morbid Obesity Weight Control The following are not covered: Family or marriage counseling (99510) Biofeedback MILIEU/situational therapy (902) Autism ADD/ADHD Group therapy (90853, 90857) Morbid Obesity Surgical Outpatient Occupational Therapy Orthotics (back, neck, knee, wrist, etc.) Orthopedic Shoes and Foot Orthotics Outpatient Physical Therapy Physician Office Visits for Non-Routine Care Physician Visits During Inpatient Hospital/SNF Confinement Podiatry Services Private Duty Nursing Services 20 visits per calendar year, additional visits available with medical necessity review $4,000 maximum per calendar year Repair covered if medically necessary and reasonable justification (warranty expiration is not reasonable justification) Orthopedic shoes are covered for diabetics All other orthopedic shoes covered only if attached to a brace Custom molded orthotics are not covered unless the orthotics are for an acquired deformity of the foot (such as claw toe, hallux rigidus, hallux valgus, hallux flexus, hallux malleus and hallux varus) Replacement of any eligible orthopedic shoe or orthotic will only be covered if medically necessary an not as a result of loss, theft or damage 20 visits per calendar year, additional visits available with medical necessity review B-12 injection covered for Crohn s disease and pernicious anemia Complete or partial removal of the nail matrix affected by disease, infection or fungus Surgical procedures or injections involving the bones, nerves, muscles or tendons of the foot or ankle Cutting or removal of corns, calluses or toenails covered only if done in connection with an underlying medical condition such as diabetes or peripheral vascular disease 4
Prosthetic Appliances Covered Repair Replacement if necessary due to the participant s growth and development or device otherwise is not in working order or cannot be repaired Not Covered Dental prosthesis Penile prosthesis due to sexual dysfunction or impotency Routine maintenance Respiratory Therapy Routine Health Maintenance Age 19 and older Routine physical exam Routine OB/GYN exam Routine mammogram o 1 Baseline: ages 35 39 o Annually age 40+ Routine pap smear Routine lab/pathology Routine bone density Routine prostate exam Flu shot Flu mist (age 25 months 49 years) Routine immunizations Gardasil immunization Routine vision exam Routine hearing exam HPV testing Routine colonoscopy Routine sigmoidoscopy Routine Well Baby & Child Care Birth to age 19 Routine exam Routine immunizations Routine lab/pathology Routine radiology Gardasil immunization Routine hearing exam covered Routine vision exam covered Radiation Therapy Routine Nursery Care of Newborn Infant Second and Third Surgical Opinion Skilled Nursing Precert required Must follow hospital confinement of 3 consecutive days and begin no later than 14 days after discharge a the end of hospital confinement Sleep Disorders Smoking Cessation Outpatient Speech Therapy 5
Surgeon 20 visits per calendar year, additional visits available with medical necessity review TMJ Treatment Physician s office 100% no deductible, after $25 OV copay Transplants Includes surgical treatment and splints Transportation, meal & lodging covered no limitations Procurement covered no limitations Urgent Care 456, 516, 526 Physician place of service 20 Vision Services Donor services If donor and recipient are both participants under the plan, donor charges are paid under the Recipient If donor is a participant under the plan and the recipient is not, the donor s charges are covered Transportation, meals & lodging covered no limitations $50 copay, 100% no deductible $50 copay, 100% no deductible Medical condition Covers first pair of contacts or glasses after cataract surgery Wigs Covered if hair loss due to chemotherapy or radiation 1 per calendar year 6
EXCLUSIONS 7