BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB The Plan will cover all dependent Dependents children up to age 26 Filing Limit 12 months from date of service Mailing Address & PPO Company. Remit claims to: Gilsbar 360 Alliance Hospitals & Physicians (with PHCS Healthy Directions for travel outside of LA): Gilsbar, Inc., P.O. Box 2947, Covington, LA, 70433; Emdeon Payor ID# 07205 CIGNA Physicians & Hospitals PPO & NonPPO: Mail claims to Cigna, PO Box 188061 Chattanooga, TN 37422-8061. Electronic Payer ID 62308 NonPPO: Gilsbar, Inc., P.O. Box 2947, Covington, LA, 70433; Emdeon Payor ID# 07205 Don t forget to get a copy of the Patient s ID Card for claim filing directions in order to expedite claims processing Pre-Existing Does not apply Utilization Review: MedCom Care Management Inc., 1-800-643-4416. Must precertify services listed 7 days prior to admission, Emergency admissions within 48 hours or 1 st business day. Outpatient testing and surgery should call for review/guidance. No penalty will apply if not precertified. Inpatient confinements, Bariatric Surgery, and Obesity Penalty: Eligible room and board charges, Bariatric Surgery, and Obesity payment reduced to 50% BENEFIT DESCRIPTION- PPO NON-PPO ANNUAL MAXIMUM BENEFIT Unlimited DEDUCTIBLE, PER CALENDAR YEAR Deductibles are combined, that is, expenses applied toward the satisfaction of the PPO will be applied toward satisfaction of the Non-PPO, and vice versa. Individual Coverage $3,100 $3,100 Family Coverage $6,000 $6,000 MAXIMUM OUT-OF-POCKET EXPENSES, PER CALENDAR YEAR Out-of-Pocket expense amounts are combined, that is, expenses applied toward the satisfaction of the PPO out-of-pocket amount will be applied toward satisfaction of the Non-PPO out-of-pocket amount, and vice versa. On the family plan, no individual will have to meet more than a $7,150 individual out of pocket maximum. This applies to the PPO level only. Individual Coverage $5,000 $7,950 Family Coverage $9,900 $20,800 NOTE: The following charges do not apply toward the out-of-pocket expense amount and are never paid at 100%: N/A HEALTH BENEFITS: COPAYMENTS AND BENEFIT PERCENTAGES Accident Benefit Acupuncture/Massage (12 visits Calendar Year maximum) Ambulance Bariatric Surgery Page 1 of 5
BENEFIT DESCRIPTION- PPO NON-PPO (Precertification Required) Behavioral Health and Substance Use Disorders Inpatient Includes Residential Treatment Behavioral Health and Substance Use Disorders Outpatient Includes Partial Hospitalization Blood Blood and blood derivatives that are not donated or replaced are covered. Chemotherapy & Radiation Therapy Clinical Trials (as defined by this Plan for cancer or other life-threatening diseases or conditions) Includes coverage for routine patient costs associated with participation in approved Clinical Trials only. If one or more PPO providers are participating in a Clinical Trial, the Plan may require that the qualified individual participate in the Clinical Trial with the PPO provider. The Plan will cover Non-PPO providers outside the state in which the qualified individual resides only if there is not a PPO provider conducting the same trial in state. Chiropractic Treatment Dental Impacted Wisdom Teeth Diagnostic Testing (Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Diagnostic Testing (X-ray, lab) Inpatient Diagnostic Testing (X-ray, Blood work) Outpatient Hospital Diagnostic Testing (X-ray, Blood work) Stand Alone Facility Diagnostic Testing (X-ray, Blood work) Office Durable Medical Equipment Emergency Services in an Emergency Room Extended Care / Skilled Nursing Facility Foot Conditions Physicians' services in connection with corns, calluses or toenails are excluded, unless the charges are for the partial or complete removal of the nail roots Routine foot care and foot orthotics are not covered Gastric Bypass Hearing Aids Hearing Screening Home Health Care Hospice Care Refer to applicable service for benefits Refer to Non-Surgical Treatment of the Spine Covered under Separate Dental plan Covered under Medical. Refer to Surgeon Benefit (Facility charges will follow facility benefits). Refer to Bariatric Surgery Not Covered Bereavement Counseling by Hospice provider. For other bereavement counseling services refer to Behavioral/Mental Health and Substance Use Disorders Outpatient Hospital / Facility- Inpatient Room and Board is limited to the semiprivate room rate, or if the Hospital has private rooms only, 90% of the lowest private room rate. ICU as billed. Hospital / Facility- Outpatient Page 2 of 5
BENEFIT DESCRIPTION- PPO NON-PPO Infertility / Sterility Maternity Maternity-related expenses for a dependent Child are not covered except as required by law for prenatal care. Prenatal care as required by federal law. All other eligible expenses including but not limited to delivery fee. Newborn Care (routine inpatient) Non-Surgical Treatment of the Spine Obesity (Precertification Required) Organ Transplants Provider should notify Customer Contact Center prior to starting any transplant services, including initial evaluation. Case Management is strongly suggested. Refer to plan document for further limitations & exclusions. Orthotics / Prosthetics Foot orthotics are not covered Organ Transplant Travel & Accommodation Physician Services- Inpatient Visits Physician Services- Inpatient Surgeon Physician Services- Outpatient Visits (services other than in a Physician's office) Physician Services- Outpatient Surgeon (services other than in a Physician's office) Physician Services- Office Visits Physician Services- MDLive Call 877-953-4955, visit www.mdlive.com/gilsbar, or use the mobile app to receive general health care and pediatric care information for a member s condition. The MDLIVE program is available 24/7/365. See the Medical Benefits section for more details about this benefit. *Standard billed charge is $40 per consultation Physician Services- In-office Surgeon Prescription Drugs Inpatient Prescription Drugs Outpatient Preventive Care Benefit Adult Wellness benefit includes routine physical exam, x-ray/lab, gynecological exam, pap smear, mammogram, prostatic/testicular exam, smoking cessation programs and products, weight loss programs, routine vision exam (at any age), immunizations (up to age 18), flu shots and colonoscopies. Breast pumps are limited to one per calendar year. Not Covered * Refer to Hospital / Facility Inpatient Refer to Prescription Drug Benefits schedule and section 100%, no Services are also covered as recommended by the United States Preventive Services Task Force (USPSTF) and immunizations will be covered as recommended by the Centers for Disease Control (CDC). All services are limited to no more than once annually or as recommended by the USPSTF. Private Duty Nursing Page 3 of 5
BENEFIT DESCRIPTION- PPO NON-PPO (Limited to Outpatient only and $10,000 Lifetime maximum) Rehabilitation Services (Physical, Occupational, Speech, Cardiac Rehab Therapies) Provider must send letter of medical necessity and all applicable notes Cardiac rehab therapies limited to phase I & II Speech Therapy limited to 30 visits Calendar Year maximum Sleep Disorders Must be medically necessary Sleep Study Other eligible expenses Sterilization Vasectomy Female Sterilization as required by federal law Temporomandibular Joint Syndrome ($2,500 Lifetime maximum) Urgent Care Facility (includes all covered charges billed by facility) Vision Screening Vision Therapy Wig After Chemotherapy (1 wig Lifetime maximum) Refer to applicable service for benefits Refer to applicable service for benefits See Preventive benefit Page 4 of 5
PRESCRIPTION DRUG CARD OPTION Cigna (800)-325-1404 RxBIN: 017010 RxPCN: 05190000 RxGRP: 0716971 (Preauthorization is required for prescriptions over $1,000 for a 30 day supply.) Expenses for a prescription drug not purchased through the prescription drug card program are not covered under the Plan. If the drug is not available through the prescription drug card program, but is covered under the medical portion of the Plan, then the expense will be covered. Each time you present your prescription drug card when purchasing a prescription drug from a participating retail pharmacy, the price you pay will be a discounted amount. Prescription Drug Card Options Retail Pharmacy Option (30 day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. Generic drug Preferred Brand Name drug Non-Preferred Brand Name drug Mail Order Option (90 day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. Generic drug Preferred Brand Name drug Non-Preferred Brand Name drug Benefit Percentage 100% no 100% no Page 5 of 5