AFSCME Local No. 113 4/12/2017 - Laserfiche WebLink

PPO Medical Plan Summary for January 1 , 2017 Appendix2 This document is for illustrative purposes only. It is not an SPD. 1/1/2017 Services PPO Plan Lifetime Benefit Maximum Unlimited Calendar Year Deductible (Applies to out-of-pocket maximum) (Copays do not apply toward the deductible.) -Per Individual $300 -Per Family $600 Out-of-Pocket Maximum -Per Individual $750($1,500 out of network) -Per Family $1,500($3,000 out of network) Office Visits $20 co-pay then 100%(deductible waived) Lab&X-Ray Services 90% Preventive Care 100%(deductible waived)Includes wellness exams,routine physicals,immunizations and ob/gyn visits,and related tests. Chiropractic (No out-of-network benefit) $20 co-pay then 80%(deductible waived) 24 visit max per calendar year Hospital Treatment(Semi-private room and board) In Network $100 co-pay then 90% Out-of-Network $200 co-pay then 80% Outpatient Surgery In Network $100 co-pay then 90% Out-of-Network $100 co-pay then 60% Organ Transplants 90% Rehabilitation -Inpatient $100 co-pay then 90% -Outpatient (36 visits combined with neurodevelopmental therapy per calendar 90% year,addt'I 36 visits for head injury,spinal injury,stroke) Emergency Room $100 co-pay(waived if admitted)then 90% Skilled Nursing (90 days per calendar year) 90% Mental Health Services -Inpatient $100 co-pay then 90% -Outpatient $20 co-pay then 100%(deductible waived) Substance Use Disorder Services -Inpatient $100 co-pay then 90% -Outpatient $20 co-pay then 100%(deductible waived) TMJ 80%(deductible waived) Home Health(130 visits per calendar year) 90%(deductible waived) Hos.ice limited to 6 months'er lifetime 90% deductible waived Out of Area Benefits Same level of benefits as in-network Out of Network Benefits 60%benefit up to allowed amounts plus applicable co pays and deductible,unless otherwise stated(does not apply to PPO/PAR OOP Max). Maintenance of Benefit(Secondary Coverage) When the COE health plan is secondary,and the primary plan reimburses at a lower level than the secondary COE plan,the sum of the reimbursement amounts of both the primary and secondary plans for any service,treatment,test,procedure or supply shall not exceed the amount covered by the City of Everett Health Plan. When the Primary health plan reimburses at an equivalent or higher level than the COE plan,there will be no additional reimbursement by the secondary COE plan. 24 hour Nurse Hotline Line is available at 1-800-807-1370 Prescription Drugs RX Out of Pocket Maximum $1,000 per individual/$2,000 per family Retail(in-network) 30 Day Supply Generic $10 co-pay Brand Formulary $25 co-pay Brand Non-Formulary 20%co-pay with a$50 out-of-pocket maximum per script Retail(out-of-network) Members utilizing out-of-network pharmacies will be required to submit a direct member reimbursement to CVS.This form can be obtained from www.Caremark.com Upon receipt,Caremark will reimburse the members the contracted rate currently in place with the City of Everett minus the members copay. Mail Order:90 Day Supply Generic $20 co-pay Brand Formulary $50 co-pay Brand Non-Formulary 20%co-pay with a$50 out-of-pocket maximum per script