BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address Remit claims to: Gilsbar, Inc., P.O. Box 2947, Covington, LA 70434; 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 (800) 643 4416. Must precertify services listed 2 days prior to admission, Emergency admissions within 48 hours or 1 business day following admission. Inpatient confinements Transplants Penalty: Additional $200 for covered expenses ANNUAL MAXIMUM BENEFIT DEDUCTIBLE, PER CALENDAR YEAR Unlimited Per Participant $1,500 Per Family $3,000 MAXIMUM OUT OF POCKET EXPENSES, PER CALENDAR YEAR Per Participant $4,000 Per Family $12,000 NOTE: The following charges do not apply toward the out of pocket expense amount and are never paid at 100%: Utilization Management Penalties HEALTH BENEFITS: COPAYMENTS AND BENEFIT PERCENTAGES Accident Benefit Acupuncture Ambulance Bariatric Surgery Behavioral/Mental Health and Substance Use Disorders Inpatient Precertification required Includes Residential Treatment Behavioral/Mental Health and Substance Use Disorders Outpatient Includes Partial Hospitalization Blood Convenience Care Clinic Chemotherapy & Radiation Therapy Chiropractic Treatment Dental $250 copay per day up to 5 days, then $25 copay then, $25 copay then, Refer to Non Surgical Treatment of the Spine Covered under Separate Dental plan Page 1 of 6
Impacted Wisdom Teeth Diabetes Self management Training 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 All outpatient drug testing will be subject to a medical necessity review X ray Covered under Medical, refer to Physician Services Surgeon for physician benefit (Facility charges will follow facility benefits). $45 copay then, Lab Diagnostic Testing (X ray, Blood work) Stand Alone Facility All outpatient drug testing will be subject to a medical necessity review X ray $45 copay then, Lab Diagnostic Testing (X ray, Blood work) Office All outpatient drug testing will be subject to a medical necessity review X ray Refer to Physician s Services Office Visits Lab Durable Medical Equipment Replacement allowed only after 5 years Emergency Room Copay waived if admitted directly to Hospital from Emergency room Extended Care/Skilled Nursing Facility (100 days Calendar Year maximum) Foot Conditions Routine foot care and foot orthotics are not covered 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 Gastric Bypass Hearing Aid Hearing Exam Home Health Care (120 visits Calendar Year maximum) $150 copay then, $250 copay per day up to 5 days, then Refer to Bariatric Surgery 100%, no Page 2 of 6
Hospice Care Inpatient $250 copay per day for the first 5 days then 100%, no Outpatient Bereavement Counseling by Hospice provider. For other bereavement counseling services refer to Behavioral/Mental Health and Substance Use Disorders Outpatient Hospital / Facility Inpatient Precertification required Room and Board is limited to the semiprivate room rate, or if the Hospital has private rooms only, the private room rate billed. ICU as billed. Hospital / Facility Outpatient Infertility/Sterility Covered up to diagnosis only Maternity Physician s Office Services Maternity related expenses for a dependent Child are covered $250 copay per day up to 5 days, then Services not in the office Newborn Care (routine inpatient) Non Surgical Treatment of the Spine (60 visits Calendar Year maximum) OV & X ray not included in the maximum. Please refer to those benefit sections for applicable benefits Obesity Coverage includes preventive counseling visits and/or risk factor reduction intervention; nutrition counseling; and healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet related chronic disease. All other obesity related services are excluded Organ Transplants Precertification required Donor charges are covered. Refer to plan document for further limitations & exclusions Organ Transplant Travel & Accommodation Orthotics / Prosthetics Foot orthotics is not covered 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) $45 copay then, Page 3 of 6
Physician Services Office Visits Copay per provider and applies only to office visit charge, x ray, allergy testing and allergy treatment. Primary Care Physicians $25 copay then 100%, no Specialist $45 copay then 100%, no All other eligible expenses not covered under copay and not specifically listed elsewhere Primary Care Physicians are: Family Practice, General Practice, Internal Medicine, and Pediatrician. 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. Physician Services In office Surgeon Prescription Drugs Inpatient Prescription Drugs Outpatient Preventive Care Benefit Preventive care includes the following once annually: routine office visit and physical exam, prostatic/testicular exam, hearing screening and audiometric hearing exam (limited to 1 per 2 calendar years and hearing testing up to age 2), and vision exam (once every 2 calendar years including refraction and glaucoma test) Breast pumps are limited to one per calendar year 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 (Limited to Inpatient only and 70 eight hour shifts per Calendar Year maximum. Each period of private duty nursing of up to 8 hours will be deemed one private duty nursing shift) Rehabilitation Services (Cardiac Rehab, Pulmonary Rehab, Occupational, Physical, Speech and Vision Therapies) Provider must send letter of medical necessity and all applicable notes Cardiac rehab therapies limited to phase I & II Pulmonary Rehab (36 visits Calendar Year maximum) 100%, no Refer to Hospital / Facility Inpatient Refer to Prescription Drug Benefits schedule and section 100%, no Occupational, Physical and Speech Therapy (60 visits Calendar Year maximum combined) Vision Therapy Page 4 of 6
Sleep Disorder Sleep Study Other eligible expenses Sterilization Vasectomy Female Sterilization Temporomandibular Joint Syndrome Urgent Care Facility (includes all covered charges billed by facility) Vision Exam Wig After Chemotherapy (Limited to 1 per covered person up to $300 lifetime) Refer to Preventive Care $50 copay then, Refer to Preventive Care 100% after Page 5 of 6
PRESCRIPTION DRUG CARD INFORMATION MaxorPlus 800 687 0707: RxBIN: 005377, RxPCN: 10000019, Rx Grp: S2855 UNIVERSITY OF THE INCARNATE WORD, S2855 Prescriptions purchased from a participating pharmacy, but the drug card is not used must be filed with the prescription drug company Prescriptions that are purchased from a non participating pharmacy must be filed with the prescription drug company. Out of Network is 30% of submitted cost after applicable copay. Out of Network mail order is not covered If a participant chooses a name brand drug when the Physician authorizes use of a generic drug the participant must pay the difference between the actual cost of the generic and brand name in addition to the brand name copayment Prescription Drug Card Options Copayment Benefit Percentage Retail Pharmacy Option (30 day supply) Prescribed Preventive Medications and Contraceptives as recommended by the USPSTF. Immunizations as recommended by the CDC Subject to existing brand costs if a generic both exists and is allowed by the physician. $0 100% Generic drug $10 100% Preferred Brand Name drug $25 100% Non Preferred Brand Name drug $50 100% Specialty Drugs Mail Order Option (90 day supply) Prescribed Preventive Medications and Contraceptives as recommended by the USPSTF. Subject to existing brand costs if a generic both exists and is allowed by the physician. Copay follows above tiers $0 100% Generic drug $15 100% Preferred Brand Name drug $37.50 100% Non Preferred Brand Name drug $75 100% Page 6 of 6