GENERAL PROVISIONS Calendar Year Deductible Employee Employee + One Family HEALTH PLAN SCHEDULE OF BENEFITS HIGH PERFORMANCE PPO PLAN GROUP# 0180928001 HPN HIGH PERFORMANCE NETWORK $300 $450 $600 TIER 1 IN-NETWORK (Health Plan Network) $1,000 $1,500 $2,000 TIER 2 OUT-OF-NETWORK Eligible Expenses are limited to Usual and Customary Rates $3,000 $4,500 Coinsurance (employee portion of claim expense) Copayments/Copays Primary Care Visit Specialist Visit Urgent Care Center Hospital ER Inpatient Admission Out-of-Pocket Limit Includes all Deductibles, Coinsurance & Copays, including Rx Copays Employee Employee + One Family $3,000 $300 $6,850 $13,700 $13,700 $450 Lifetime Maximum Essential Health Benefits None None None PRESCRIPTION DRUG CO-PAYS Subject to drug limitations Retail 31-day supply Tier 1 - Generic drugs $20 $34 Tier 2 - Preferred Formulary brand Drugs $30 $52 Tier 3 - Non-Preferred Formulary brand drugs $40 $66 Tier 4 - Specialty drugs 30% Coinsurance or $300 (lesser of two) Mail Order 90-day supply Not Available Customer Service 888.816.3096 8:00 am 8:00 pm EST Pharmacy Customer Service 800.624.6961 ext. 7914 Available 24 hours a day, follow after hours prompts Nurse Information Line 304-639-8597 Available 24 hours a day To Find a High Performance Network Provider: Visit: wheelinghospital.org Click on Find A Doctor To Find a Tier One Health Plan Medical Provider: Visit: www.healthplan.org Step 1 Click on Find a Provider Step 2 Select Search for The Health Plan Providers Page 1 of 5 Benefits Medical Health Plan Schedule of Benefits
COINSURANCE PAID AFTER DEDUCTIBLE IS MET INPATIENT HOSPITAL SERVICES HPN TIER 1 TIER 2 Anesthesia Diagnosis and Treatment Laboratory, Therapeutic & diagnostic imaging & x-ray services Emergency Hospital Admission 100% after Copay 100% after Copay 100% after Copay up to the allowed amount Inpatient Treatment for Mental Health & Substance Use Disorders 90% and Copay per per Oral Surgery - Limited services Inpatient Physician Services Surgical/Medical Pre Testing Second Surgical Opinion Room and Board Limited to 365 days per confinement Semiprivate room; ICU/CCU; Maternity / birthing room; Nursery; Operating room; General nursing care Services and Supplies Drugs; Medicines; Injections; Intravenous therapy; Dressing & casts; Blood administration & related services Skilled Nursing Facility Limited to 120 days per Plan Year Therapy Chemotherapy, radiation therapy, physiotherapy; Oxygen & respiratory therapy; Physical, occupational & speech therapy, each limited to maintenance or 60 days per Plan Year; Short-term rehabilitation, limited to 60 days per Plan Year Transplant Surgery 90% and Copay per per 90% and Copay per per 90% and Copay per per OUTPATIENT SERVICES HPN TIER 1 TIER 2 Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.); Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology) Emergency Room Hospital ER services for Emergency 100% after Copay up 100% after Copay 100% after Copay Medical Conditions, including severe pain to allowed amount Injections & Immunizations Only for Recommended Preventive Services 100% 100% 50% and Copay Mental Health/ Psychiatric Care/ Substance Use Disorders Treatment 90% 70% and Copay 50% and Copay Ob-Gyn/Maternity Care Ob-Gyn services; Pre- and post-natal services Oral Surgery Limited services Outpatient Surgery At Physician s office, hospital, surgical center or outpatient clinic 90% 70% and Copay 50% and Copay Primary Care Physician Office Visit Including drugs administered at office 90% 70% and Copay 50% and Copay Specialist Physician Office Visit Including drugs administered at office 90% 70% and Copay 50% and Copay Preventive Care - Physical exam; Mammogram; Pap test 1 100% of Eligible each per Plan Year; Well Child Care Expenses 100% of Eligible Expenses 50% and Copay Recommended Preventive Services - Diagnostic screening services, counseling & procedures per ACA guidelines. Therapy Chemotherapy, radiation therapy, physiotherapy; Physical, occupational, respiratory, oxygen, or speech, each limited to lesser of 60 visits per Plan Year or maintenance; Cardiac and pulmonary, each limited to lesser of 12 weeks or 36 visits per Plan Year 100% of Eligible Expenses 100% of Eligible Expenses 50% and Copay for most services Urgent Care Center Visit 90% 70% and Copay 50% and Copay Page 2 of 5
COINSURANCE PAID AFTER DEDUCTIBLE IS MET OTHER SERVICES HPN TIER 1 TIER 2 Allergy Evaluation, Treatment, Injections 90% 70% and Copay 50% and Copay Ambulance Emergency transportation when Medically Necessary Autism Spectrum Disorders Children to age 21 Limited to,000 per Plan Year Chiropractic services/ Spinal manipulation Limited to 26 visits per Plan Year 90% 70% and Copay 50% and Copay Cosmetic Surgery Limited services 90% 70% and Copay 50% and Copay Dental Services for Accidental Injury 90% 70% and Copay 50% and Copay Diabetic Services Durable Medical Equipment Generally limited to standard model only, limited replacement Enteral Nutrition Therapy (ENT) Hearing tests and aids 1 exam per Plan Year; Replacements once every 3 Years Home Health Services Skilled care only Infertility Counseling, Testing and Treatment Limited to $7,500 per Plan Year IV Therapy Kidney Dialysis Orthotics Podiatry Prosthetic Appliances &Devices Limited to one device every 3 Years TMJ Services Limited to $5,000 lifetime maximum benefit Additional Information HPN TIER 1 TIER 2 Facilities Wheeling Hospital Full list on the Health Plan website www.healthplan.org Wheeling Clinic Network Plan = PPO *Please note that not all physicians at a facility are in the network. Be sure to confirm with the website or WJU Human Resources before seeking services if you are unsure. Belmont Community Hospital Harrison Community Hospital Bridgeport Health Center Bishop Hodges Continuous Care Center Colerain Health Center Powhatan Point Health Center Shadyside Health Center St. Clairsville Health Center Med Express (Urgent Care) Allegheny General Cleveland Clinic OVMC UPMC facilities: Children s Hospital Magee-Women s Hospital Community Medicine Community Specialty Med. Emergency Resource Mgt. UPMC Mercy UPMC Passavant UPMC Pittsburgh Physicians UPMC Presbyterian UPMC Shadyside Urgent Care WVU Hospitals Any other facility not included in the HPN or Health Plan networks. Page 3 of 5
SCHEDULE OF COVERED PREVENTIVE SERVICES PER ACA GUIDELINES Effective January 1, 2017 COVERED PREVENTIVE SERVICES FOR ADULTS Abdominal Aortic Aneurysm (One-time screening for men of specified ages who have ever smoked) Alcohol Misuse screening and counseling Aspirin use to prevent cardiovascular diseases for men and women of certain ages Blood Pressure screening for all adults Cholesterol screening for adults of certain ages or at higher risk, typically for the following: o Men age 35 and older o Men under age 35 who have heart disease or risk factors for heart disease o Women who have heart disease or risk factors for heart disease Colorectal Cancer screening for adults age 50 and over Depression screening for adults Diabetes (Type 2) screening for adults with high blood pressure Diet counseling for adults at higher risk for chronic disease Hepatitis B screening for people at high risk Hepatitis C screening for adults at increased risk and one-time screening for all adults born between 1945 and 1965 HIV screening for all adults age 15 to 65, and other ages at increased risk Immunization vaccines for adults. Recommended ages, doses and frequencies vary. o Hepatitis A and B o Meningococcal o Herpes Zoster (Shingles) age 50 or older o Pneumococcal o Human Papillomavirus (HPV) o Tetanus, Diphtheria, Pertussis (Whooping Cough) o Influenza (Flu Shot) (DTAP/TDAP) o Measles, Mumps, Rubella o Varicella (Chickenpox) Lung cancer screening for adults age 55 to 80 at high risk for lung cancer because they are heavy smokers or quit smoking within the past 15 years Obesity screening and counseling for all adults Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk Syphilis Screening for adults at higher risk Tobacco Use screening for all adults and cessation interventions for tobacco users COVERED PREVENTIVE SERVICES FOR WOMEN Anemia screening on a routine basis for pregnant women Breast or ovarian cancer genetic test (BRCA) and counseling for women at higher risk for breast cancer Breast Cancer Mammography screenings every 1 to 2 years for women over 40 Breast Cancer Chemoprevention counseling for women at higher risk Breastfeeding comprehensive support, supplies, and counseling for pregnant and nursing women o Includes costs for renting breastfeeding equipment Cervical Cancer screening (Pap Smears) for sexually active women Chlamydia Infection screening for younger women and other women at higher risk Contraception, including FDA-approved contraceptive methods and drugs (not including abortifacient drugs), sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity Domestic and interpersonal violence screening and counseling for all women Folic Acid supplements for women who may become pregnant Gestational Diabetes Screening for women between 24 and 28 weeks pregnant and those at high risk of developing gestational diabetes Gonorrhea screening for all women at higher risk Hepatitis B screening for pregnant women at their first prenatal visit HIV screening and counseling for sexually active women Human Papillomavirus (HPV) testing every 3 years for women with normal cytology results who are age 30 or older Osteoporosis (bone density) screening for women over age 60 depending on risk factors Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk Sexually Transmitted Infections counseling for sexually active women Syphilis screening for all pregnant women or other women at increased risk Tobacco Use screening and interventions for all women and expanded counseling for pregnant tobacco users Urinary tract or other infection screening for pregnant women Well-woman visits to obtain recommended preventive services Page 4 of 5
COVERED PREVENTIVE SERVICES FOR CHILDREN Alcohol and Drug Use assessments for adolescents Autism screening for children at 18 and 24 months Behavioral assessments for children at the following ages: 0 to 11 months; 1 to 4 years; 5 to 10 years; 11 to 14 years; 15 to 17 years Blood Pressure screening for children at the following ages: 0 to 11 months; 1 to 4 years; 5 to 10 years; 11 to 14 years; 15 to 17 years Cervical Dysplasia screening for sexually active females Depression screening for adolescents Developmental screening for children under age 3 Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years; 5 to 10 years; 11 to 14 years; 15 to 17 years Fluoride chemoprevention supplements for children without fluoride in their water source Gonorrhea preventive medication for the eyes of all newborns Hearing screening for all newborns Height, Weight and Body Mass index measurements for children (newborn to age 17) Hematocrit or Hemoglobin screening for children Hemoglobinopathies or sickle cell screening for newborns HIV screening for adolescents at higher risk Hypothyroidism screening for newborns Immunization vaccines for children from birth to age 18. Recommended ages, doses and frequencies vary. Vaccines include the following: o Diphtheria, Tetanus, Pertussis o Measles, Mumps, Rubella o Haemophilus Influenza Type B o Meningococcal o Hepatitis A and Hepatitis B o Pneumococcal o Human Papillomavirus o Rotavirus o Inactivated Poliovirus o Varicella o Influenza (Flu Shot) Iron supplements for children ages 6 to 12 months at risk for anemia Lead screening for children at risk of exposure Medical History for all children throughout development at the following ages: 0 to 11 months; 1 to 4 years; 5 to 10 years; 11 to 14 years; 15 to 17 years Obesity screening and counseling Oral health risk assessment for young children 0 to 11 months; 1 to 4 years; 5 to 10 years Phenylketonuria (PKU) screening for genetic disorder in newborns Routine well child exams (including hearing and vision screenings that are part of the routine exam) Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months; 1 to 4 years; 5 to 10 years; 11 to 14 years; 15 to 17 years Vision screening for all children Page 5 of 5