Medical Benefits for eligible Pension Members and their eligible dependents who are not Eligible for Medicare effective 1/1/2019. NOTE $50,000.00 lifetime major medical maximum effective 1/1/2013 Out-of-network medical deductible is $250.00 per calendar year OptumRX-$25.00 deductible with 20% co-payment. Maximum payable by the Fund per calendar year is a $1,000.00 Adoption Acupuncture visit All Scans Allergy Injections Allergy Treatment Ambulance True Emergent $40.00 co-payment $10,000.00 Calendar year max ; 16 visits per Calendar Year; 1 visit per day; Ambulance Non Emergent not covered not covered Ambulatory Surgery $50.00 co-payment Anesthesia Anesthesia Maternity Annual Physical Assistant Surgeon Birthing Center Breast Sonogram 75% of Fund's fee schedule; Cardiac Rehabilitation 36 visits per Calendar Year; Chemotherapy Chiro $15.00 co-payment schedule; 1 visit per day; 24 visits per Calendar Year; Chiro X-rays 4 x-rays per Calendar Year; Diabetic Supplies Diabetic Education with Dietician office visit Diagnostic Testing Office Diagnostic Independent lab / Professional charge Diagnostic Testing OP / Hospital Charge Diagnostic Testing OP in Free Standing Facility 100% of negotiated Pulmonary Function Test Tilt Table Testing Electrophysiological Study Page 1 of 5
Video EEG Mammogram Dialysis Office Dialysis OP Facility Dialysis OP Physician visit Dietician / Nutritionist office visit DME / Medical Equipment ER Non Emergent Facility ER Emergent Facility ER Non Emergent Physician ER Emergent Physician Gastric Bypass, Lap Band, Sleeve Surgery Gastric Assistant Surgery Genetic Testing -independent lab $200.00 co-payment / waived if admitted 75% of the Fund's Negotiated 6 visits per Calendar Year; Prior approval by the Fund is deductible waived $4000.00 Calendar year max combined physician ; charges; Prior approval $4000.00 Calendar year max combined physician charges; Prior approval. Genetic Counciling not covered. Genetic Testing-OP Hospital Genetic Counciling not covered. Halfway House Hearing Aid Right schedule; $2000.00 per Calendar year max ; Hearing Aid Left schedule; $2000.00 per Calendar year max ; Home Health Care schedule; ; 200 visits per Calendar Year; Combined with Private Duty Nursing; Hospice Care IP schedule; Hospice Care home schedule; Immunizations IUD supplies Infertility Anesthesia $5,000.00 Calendar year max ; combined all Infertility Facility $5,000.00 Calendar year max; combined all Page 2 of 5
Infertility Pathology / Lab Infertility RX OptumRX 20% co-payment, deductible applies infertility RX services; prior approval required for certain medication. (NOTE: not to exceed a Infertility Physician $100.00 per stay copayment Inpatient hospital Illness / / $250.00 max There may be a patient responsibility when using a Room & Board per calender year. non-participating facility that will not negotiate. $1,600.00 global allowance; prior approval Lasik Surgery Left eye $1,600.00 global allowance; prior approval Lasik Surgery Right eye Lithotripsy Physician Lithotripsy Facility $50.00 co-payment schedule; ; Maternity C Section $4,000 max per delivery Maternity Midwife Maternity Regular Delivery Medical Equipment / Rentals and Purchases schedule; ; $3,200 max per delivery schedule; ; $3,600 max per delivery schedule; See DME Medication Coverage Outside Of The RX Plan Abuse Inpatient Abuse Outpatient (MD) (PhD) only Abuse Outpatient Social Worker (LCSW) only Abuse Outpatient Group Therapy (MD) (PhD) (LCSW) only Abuse Outpatient Family Therapy (MD) (LCSW) only J codes for Hep C, Cancer, MS, HIV/AIDS, Epilepsy, Crohn's Disease and Diabetes; Arthritis; prior approval through the Fund is required. Prior approval through the fund is required $125.00 per visit; $85.00 per visit; $55.00 per visit; $55.00 per visit; MRI's and MRA's Newborn Hearing IP Physician charges Nerve Block Injections Neuropsychological Testing $40.00 co-payment up to 4 per Calendar Year; 12 units per test per Calendar Year; prior approval required Page 3 of 5
Occupational Therapy Physical Therapy Speech Therapy Visual Therapy Orthotics Orthotripsy Office visit Specialist Office visit General Practitioner $15.00 co-payment Office Surgery Physician charges Outpatient Surgical Facility / Ambulatory Surgery $50.00 co-payment Partial Hospitalization Inpatient or Out patient Pathology Physician IP Pathology Outpatient PEMG deductible waived Pharmocogenetic schedule; 30 visits per Calendar Year; prior approval required schedule; 30 visits per Calendar Year; prior approval required schedule; 30 visits per Calendar Year; prior approval required schedule; 30 visits per Calendar Year; prior approval required $1,000.00 Calendar Year maximum; prior approval required $4,000.00 Global Calendar year maximum; prior approval required Podiatry Private Duty Nursing Pre-Surgical Testing Prior approval through the fund is required for surgery. PT and strapping not covered. $10,000.00 per Calendar year; Prior approval Must be performed within seven days of the surgical procedure. Prescription RX (OptumRX) Prosthetics Pulmonary Rehab 20% co-payment, $25.00 deductible per person per Calendar year. Prior approval required for certain medications. NOTE: There is a Calendar year maximum of $5,000.00 combined for all infertility RX services, not to exceed a combined $10,000.00 yearly max Medical / RX. Prior approval 42 visits per Calendar year; Reconstructive Surgery Sclerotherapy Skilled Nursing Facility Sleep Study up to a maximum of $3,000.00 Surgical Center $50.00 co-payment Prior approval is required. $2,600 per Calendar year maximum both legs; Prior approval is required. 60 days per Calendar year; 75% of the Fund's negotiated ; up to a maximum of $3,000.00 $3,000 per Calendar year max; Page 4 of 5
Swift MD Synagis injections Ultrasound Pregnancy first three Ultrasound Pregnancy after the three limit Prior approval Urgent Care Clinics Wig Important Questions Answers Why this matters What is the Annual maximum $200,000.00 All services unless otherwise indicated apply to the annual maximum. Once the annual maximum has been exhausted no benefits are payable for that year. Other annual limits apply to certain benefits as specified in the Schedule of Benefits What is the overall deductible $100.00 The sum of out of pocket expenses that each participant must pay each calendar year before the Plan begins to pay benefits. The deductible is applied to all services unless otherwise indicated. Are there other deductibles for specific services N/A No, however there are certain services where the deductible does not apply Is there an out-of-pocket limit on my expenses No What is not included in the outof-pocket N/A Is there an overall limit on what the insurer pays Yes See the schedule of benefits. Does this plan use a network of providers? Yes EBCBS Do I need a referral to see a specialists No Is there a Prescription Drug Card Yes Prescriptions are handled through Caremark Are there services this plan doesn't cover Yes See Limitations and exclusions Page 5 of 5