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1000 Plan

By Elaine Reyes,2014-12-03 15:58
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1000 Plan

     PPO ASO Standard Network Deductible

    BlueChoice Network BENEFIT HIGHLIGHTS Prepared

     for Alvin ISD #015626 $1,000 Plan

    This is a general summary of your benefits. Please refer to your benefit booklet for additional details and a description of the plan requirements and benefit design. This plan does not cover all health care expenses. Upon receipt of your benefit booklet, carefully review the plan’s limitations and exclusions.

     Deductibles

     Per-admission Deductible None $500

    Plan Year Deductible $1,000 Individual / $2,000 Individual /

    Applies to all Eligible Expenses except Inpatient Hospital Expenses (unless $3,000 Family $6,000 Family

    otherwise indicated)

    Three-month Deductible carryover applies No No

    Deductible credit from prior carrier (Applied on initial group enrollment only) No No CoShare Stoploss Maximum

    Deductibles are not applied to the Coshare Stoploss Maximum. Copayment $2,000 Individual / $4,000 Individual / Amounts are applied but will continue to be required after the benefit $6,000 Family $12,000 Family

    percentages increase to 100%. Your benefit booklet will provide more details.

     Network Deductible & Coshare Out-of-Network Deductible & Coshare

     Stoploss will only apply toward Stoploss will also apply toward

    Network Deductible & Coshare Network Deductible & Coshare Stoploss Maximum Stoploss Maximum

    Credit for Coshare Stoploss Maximum from prior carrier (Applied on initial No No

    group enrollment only)

    Copayment Amounts Required

     Physician office visit/consultation:

    Primary Care Copayment Amount for office visit/consultation when $35 Primary Care Copayment

    services rendered by a Family Practitioner, OB/GYN, Pediatrician, Behavioral

    Health Practitioner, or Internist and Physician Assistant or Advanced Practice

    Nurse who works under the supervision of one of these listed physicians

    Specialty Care Copayment Amount for office visit/consultation when services $60 Specialty Care Copayment

    rendered by a Specialty Care Provider

     Refer to Medical/Surgical Expenses section for more information

    Urgent Care center visit $60 Copayment Amount

    Refer to Urgent Care Services section for more information

    Outpatient Hospital Emergency Room/Treatment Room visit $250 Copayment Amount $250 Per Visit

    Refer to Emergency Room/Treatment Room section for more information

    Inpatient Hospital Admissions $200 per day-limited to first five None

    days per admission

    Maximum Lifetime Benefits

     Per Participant Unlimited Inpatient Hospital Expenses All services must be preauthorized

     All usual Hospital services and supplies, including semiprivate room, intensive 100% of Allowable Amount after 70% of Allowable Amount after per-

    care, and coronary care units Inpatient Hospital Admission admission Deductible

    Copayment and Plan Year

    Deductible

    Penalty for failure to preauthorize services None $250

    A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+ business-PPO-ASO-Standard-with Network Deductible, Split Copay effective 1/1/2012 (rev. 11/22/11) Page 1 of 5

     PPO ASO Standard Network Deductible

     Medical / Surgical Expenses

     Services performed during the office visit/consultation when rendered by 100% of Allowable Amount after $35 70% of Allowable Amount after Plan a Primary Care Provider, including lab and x-ray (does not include Certain Primary Care Copayment** Year Deductible Diagnostic Procedures and surgical services)

    Allergy Shots with Office Visit 100% of Allowable Amount after 70% of Allowable Amount after Plan

    $35/$60 Copayment Per Visit Year Deductible Allergy Shots without Office Visit 100% of Allowable Amount after $5 70% of Allowable Amount after Plan

    Copayment Per Visit Year Deductible Services performed during the office visit/consultation when services 100% of Allowable Amount after $60 70% of Allowable Amount after Plan rendered by a Specialty Care Provider, including lab & x-ray (does not Specialty Care Copayment Year Deductible include Certain Diagnostic Procedures and surgical services)

    Lab & x-ray in other outpatient facilities (excluding Certain Diagnostic 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan Procedures) Year Deductible Year Deductible -Physician surgical services performed in any setting 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan

    Year Deductible Year Deductible -Physician inpatient hospital visits 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan

    Year Deductible Year Deductible -Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan CT -Scan (with or without contrast), MRI, Myelogram, PET Scan. Year Deductible Year Deductible -Home Infusion Therapy (Services must be preauthorized) 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan

    Year Deductible Year Deductible -All other outpatient services and supplies 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan

    Year Deductible Year Deductible In Vitro Fertilization Services Not Covered

     Extended Care Expenses All services must be preauthorized

    100% of Allowable Amount 70% of Allowable Amount after Plan Year Deductible

     Skilled Nursing Facility Limited to 25 day maximum each Plan Year* Home Health Care Limited to 60 visit maximum each Plan Year* Hospice Care Unlimited

     Serious Mental Illness

    Mental Health Care

    Treatment of Chemical Dependency

    Inpatient Services (All services must be preauthorized)

     -Hospital services (facility) 100% of Allowable Amount after 70% of Allowable Amount after per-(Inpatient Chemical Dependency treatment must be provided in a Inpatient Hospital Admission Copayment admission Deductible Chemical Dependency Treatment Center)and Plan Year Deductible

     -Physician services 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan

    Year Deductible Year Deductible Outpatient Services (Certain services must be preauthorized; refer to benefit booklet for more details) 100% of Allowable Amount after $35 70% of Allowable Amount after Plan

     -Services performed during office visit/consultation when rendered by Primary Care Copayment Amount Year Deductible

     a Primary Care Provider (does not include psychological testing)

     -All outpatient services and psychological testing 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan

    Year Deductible Year Deductible

    * Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated ** Primary Care/Specialty Care copayments are defined in the Overall Payment Provisions section in this document.

    ***Benefits used In-Network at the physicians office are limited to $400; After $400 is exhausted benefit pays at Plan Year Deductible and Coinsurance; This does not include Chiropractic, Immunizations or Preventive Care, Mental Health or Chemical Dependency Care, Organ Transplants, RX benefits.

    A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+ business-PPO-ASO-Standard-with Network Deductible, Split Copay effective 1/1/2012 (rev. 11/22/11) Page 2 of 5

     PPO ASO Standard Network Deductible

     Emergency Room/Treatment Room

    Accidental Injury & Emergency Care -Facility charges 100% of Allowable Amount after $250 Copayment Amount (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply)

     -Physician charges 80% of Allowable Amount after Plan Year Deductible

    Non-Emergency Care (If it is Not a True Emergency) -Facility charges 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan Year Deductible Year Deductible

     -Physician charges 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan

    Year Deductible Year Deductible

     Urgent Care Services

    Urgent Care center visit, including lab & x-ray services (does not include 100% of Allowable Amount after $60 70% of Allowable Amount after Plan Certain Diagnostic Procedures and surgical services) Copayment Amount Year Deductible

     Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, 80% of Allowable Amount after Plan 50% of Allowable Amount after Plan CT -Scan (with or without contrast), MRI, Myelogram, PET Scan, surgical Year Deductible Year Deductible procedures and all other services and supplies.

     Ground and Air Ambulance Services

    80% of Allowable Amount after Plan Year Deductible

     Preventive Care

    Routine annual physical examinations, well-baby care exams, 100% of Allowable Amount 70% of Allowable Amount after Plan immunizations 6 years of age & over, and any other preventive health Year Deductible services as determined by USPSTF

     thImmunizations for Dependent children through the date of the child’s 6 100% of Allowable Amount 100% of Allowable Amount birthday

     Speech and Hearing Services

    Services to restore loss of or correct an impaired speech or hearing function Covered same as any other sickness Covered same as any other sickness Hearing Aid Maximum Hearing aids are subject to a $1,000 maximum amount each 36-month period*

    * Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated

     Physical Medicine Services Chiropractic Care-Office Services 100% of Allowable Amount after Plan 100% of Allowable Amount after Plan

     Year Deductible Year Deductible Plan Year Maximum Limited to 15 visits each Plan Year*

     All other Physical Medicine Services rendered by any other eligible Provider will

    be allowed on the same basis as any other sickness.

    * Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated

    A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+ business-PPO-ASO-Standard-with Network Deductible, Split Copay effective 1/1/2012 (rev. 11/22/11) Page 3 of 5

     PPO ASO Standard Network Deductible

     Drug List** Preferred Drug List 1

     Retail Pharmacy

    (Copayment amounts are based on a 30-day supply. With appropriate

    prescription order, up to a 90-day supply is available. Copayment amounts will not apply to Coshare Stoploss Maximum.)

    Generic Drug $15 Copayment Amount 50% of Allowable Amount minus

    Copayment Amount Preferred Brand Name Drug $35 Copayment Amount 50% of Allowable Amount minus

     Copayment Amount Non-Preferred Brand Name $55 Copayment Amount 50% of Allowable Amount minus

    Copayment Amount Nexium $200 Copayment Amount

     Non-Preferred Specialty Drug Up to 60 Day Supply $200 Copayment Amount

     Specialty Drugs Available at the participating pharmacy benefit level through Triessent only. All other

    pharmacies payable at the non-participating pharmacy benefit level.

     Mail Order Program Yes

    (Copayment amounts are based on a 90-day supply. Copayment

    amounts will not apply to Coshare Stoploss Maximum.)

    Generic Drug $15 Copayment Amount

    Preferred Brand Name Drug $35 Copayment Amount

    Non-Preferred Brand Name Drug $55 Copayment Amount

    Nexium $200 Copayment Amount

    Generic Incentive-Members who purchase Preferred/Non-Preferred Brand Name Drugs when a Generic equivalent exists will be required to pay the

    difference between the cost of the Generic and Preferred/Non-Preferred Brand Name Drug, plus the Preferred Brand Name Copayment Amount. All medications with over-the-counter (OTC) equivalents are excluded from coverage except for Omeprazole 20 mg.

    * To locate a participating pharmacy in your area go to myprime.com or contact customer service at the phone number on the back of your identification card. **The preferred drug list is available at: bcbstx.com/member/rx_drugs.html

    *** Three-month Deductible carryover does not apply to prescription drug deductible.

    For more information on the specialty drug program, call Triessent Specialty Drugs at (888) 216-6710.

    Diabetes Supplies are available under the Prescription Drug benefits of your plan. Diabetic Supplies include insulin and insulin analog preparations, insulin

    syringes necessary for self-administration, prescriptive and non-prescriptive oral agents, all required test strips and tablets which test for glucose, ketones, and

    protein, lancets and lancet devices, biohazard disposable containers, glucagon emergency kits, and other injection aids. All provisions of this portion of the plan

    will apply including Copayment Amounts and any pricing differences that may apply to the items dispensed.

    A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+ business-PPO-ASO-Standard-with Network Deductible, Split Copay effective 1/1/2012 (rev. 11/22/11) Page 4 of 5

     PPO ASO Standard Network Deductible

    EMPLOYEE INFORMATION

This is a general Summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions.

The following benefits apply to dependent coverage:

    ; Dependent children are covered to age 26.

    ; Automatic coverage for newborns for the first 31 days following birth. Infants not enrolled for coverage within the first 31 days after birth will not be eligible for

    coverage until the following open enrollment period or special enrollment event.

    Payments: Network providers agree to accept amounts negotiated with BCBSTX and are paid according to this BCBSTX-determined Allowable Amount. Covered individuals are responsible for any required Deductibles, Coinsurance Amounts, and Copayments. Plan benefits paid to Out-of-Network providers are also based on the BCBSTX-determined Allowable Amount. Covered individuals will be responsible for charges in excess of the Allowable Amount in addition to any applicable Deductibles, Coinsurance Amounts, and Copayments. For cost savings information, refer to the section on ParPlan Providers and the definition of Allowable Amount in the benefit

    booklet.

    Preexisting conditions Provision: Benefits for Eligible Expenses incurred for treatment of a Preexisting Condition will not be available during the twelve-month period following the individual’s initial Effective Date, or if a Waiting Period applies, the first day of the Waiting Period. In accordance with state and federal law, certain conditions will not be considered Preexisting Conditions and the Preexisting Condition exclusion will not apply to certain individuals. Details are provided in the benefit

    booklet.

    Replacement of Medical Coverage: In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the following provisions apply to each eligible participant who has health coverage under the employer’s plan immediately prior to the effective date of the health contract between the employer and BCBSTX (the contract date):

    ; Benefits for eligible expenses incurred for any service or supplies prior to the contract date, are not covered under the contract.

    ; Eligible expenses for services or supplies incurred on or after the effective date will be considered for benefits subject to all applicable contract provisions.

Members residing in other states may use that state's network through the BlueCard program. To locate a participating provider in your state, please contact ?1-800-810-BLUE or visit our web site at bcbstx.com to use our Provider Finder tool.

This benefit plan design includes provisions mandated by the Affordable Care Act of 2010, and is subject to change upon direction by federal and state agencies.

    ____________________________________ ________________________________ _____________

    Group Executive Name and Title Signature Date

    (Please type or print)

    ____________________________________ _______________________________ _____________

    Agent of Record Name Signature Date

    (Please print or type)

    _____________________________________ _______________________________ _____________

    BCBSTX Representative Name Signature Date

    (Please print or type)

    A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+ business-PPO-ASO-Standard-with Network Deductible, Split Copay effective 1/1/2012 (rev. 11/22/11) Page 5 of 5

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