MEDICAL & RX BENEFIT MATRIX
Perrysburg Exempted Village Schools
HDHP Plan
HSB Customer Service: 800-459-6571
EFFECTIVE DATE: 01-01-2017

BULLETIN PAGE

Date / Description
06-19-2017 Plan Change / Effective 08-01-2017
Group adding Teladoc. No copay for employees. Group will pay at 100%
01-01-2017 Plan Change / Effective 01-01-2017
Perrysburg Schools would like to start covering 3D mammograms
08-24-2016 Plan Change / Effective 01-01-2017
The specialty drug copays are the same as the retail copays. $5/$20/$35
08-23-2016 Plan Change / Effective 01-01-2017
Group is adding an HDHP Plan w/ HSA

CONSIDERATIONS

PLAN FEATURES
Benefit Options / Medical
Vision – VSP, 800-877-7195,
Benefit Period / Calendar Year (Jan – Dec)
COB / Normal
  • Children cannot be covered by both parents
  • Employee and spouse can not cover each other if both are employed by Perrysburg Exempted Village Schools (PEVS)

Dependent Child Limiting Age / All eligible dependent children covered to age 26. Coverage terminates at the end of the month in which Birthday occurs.
Incapacitated child – begin certification at age 26; recertification annually- except if dependent’s condition is such that they will never improve and will always be dependent and not ever able to live on their own, regular verification can be waived.
Dependent Eligibility / Covered – Spouse, Child, Grandchild (only covered if member has assumed legal guardianship)
Non Covered – Common law spouse, Domestic Partner, Same Gender Spouse
EAP / Refer to Harbor; 419-475-4449
Pre-existing condition waiting period / Does not apply
Subrogation / Pay and Pursue; administered by LNL, 800-345-4079
ERISA / Yes
Grandfathered / No
PRECERTIFICATION & CASE MANAGEMENT
Inetico877-885-2211 or warm transfer to 1488
Precertification Scheduled Hospital Admission / The following scheduled Inpatient services must be precertified:
  • Inpatient admissions
  • Inpatient Mental Health & Substance Abuse admissions, Detox or partial hospitalization
  • Maternity admissions exceeding 48 hours for vaginal delivery or 96 hours for C-section
  • Skilled Nursing Facility stays
  • Transplant Candidacy Evaluation and Transplant
No penalty but precertification is required for these scheduled services for in and out of network
Certification Non-Scheduled (Emergency) Hospital Admission / Emergency, non-scheduled, admissions must be certified within 48 hours after the admission.
No penalty but precertification is required for these services for in and out of network
Precertification Other Procedures / The following scheduled services must be precertified:
  • Chemotherapy (Group uses Biologics 800-983-1590)
  • Cancer-related Radiation Therapy (Group uses Biologics 800-983-1590)
No penalty but precertification is required for these services for in and out of network
Disease Management / Voluntary
Mandatory
Handled by Inetico 877-885-2211 or warm transfer to 1488
Case Management / Voluntary
Mandatory
Handled by Inetico 877-885-2211 or warm transfer to 1488
Referral / Not required
NETWORK INFORMATION
Network / Frontpath w/ PHCS Multiplan wrap
419-891-5206

Send medical claims to:
FrontpathRepricing
PO Box 5810
Troy, MI 48007-5810
EDI: 34171
Out of Network Exceptions
(Ology & Out of Area) / Ology – In Network benefits apply to Out of Network physician services when rendered at an In Network facility, Inpatient or Outpatient, for the following services:
  • Anesthesia
  • Laboratory
  • Pathology
  • Radiology
  • ER Physician

UCR / 90th percentile
PHARMACY BENEFITS MANAGER INFORMATION
Pharmacy Benefits Manager / Express Scripts
Customer Service: 800-451-6245
Pharmacy Help Desk: 800-824-0898

CLAIM INFORMATION
Appeal Address / PO Box 2860
Little Rock, AR 72203
Appeal Filing Timeframe / 180 days from receipt of claim denial
Claim Check Payment Cycle / Wednesday
Claim Filing Timeframe / 365 days from date of service
EOB / Monthly statement
ADDITIONAL ADMINISTRATIVE SERVICES
COBRA Administration / Administered by HSB; refer questions in regards to COBRA premiums to Benefits Administration at extension 1085
Employee ID Cards / HSB prints; request duplicates via Self Service
FSA / Not applicable
HIPAA Certificates / Send request via e-mail to Benefits Administration – see link on Resources tab of group matrix
Life Billing / Not applicable
Medicare Part D Notices / Send request via e-mail to Benefits Administration – see link on Resources tab of group matrix
Retiree Billing / Not applicable

PRESCRIPTION BENEFITS

30 Day Supply / GENERIC / PREFERRED BRAND / NON-PREFERRED
BRAND / SPECIALTY MEDICATIONS
$5 copay after deductible / $20 copay after deductible / $35 copay after deductible / Same as retail copay amounts
90 Day Supply – Mail Order / $5 copay after deductible / $20 copay after deductible / $35 copay after deductible / N/A
Mandated Drugs / $0 copay / $0 copay / $0 copay / N/A
  • Immunizations covered with no patient responsibility

MEDICAL & RX BENEFITS

SCHEDULE OF BENEFITS
MEDICAL BENEFITS
COVERED SERVICE/PLAN CATEGORY / IN-NETWORK / OUT-OF-NETWORK
Payment for in-network services is based on provider’s negotiated amount. Provider cannot balance bill charges in excess of negotiated amount.
Payment for out-of-network services is based on provider’s customary & reasonable amount. Provider can balance bill charges in excess of C & R amount.
GENERAL INFORMATION
Deductible
Includes Rx Amounts / Individual - $2,500
Family - $5,000 / Individual - $5,000
Family - $10,000
  1. Eligible Expenses applied toward the In-Network Deductible are also applied toward the Out-of-Network Deductible, and vice versa.
  2. Common accident – Family members injured in same accident need only satisfy 1 single deductible.
  3. Individual Deductible carry forward does apply- 4th quarter only
  4. Family accumulation – Eligible expenses incurred by all family members combined will be used to satisfy the family Deductible limit (aggregate).

Coinsurance / Plan pays: 100%
Patient pays: 0%
Unless otherwise specified / Plan pays: 70%
Patient pays: 30%
Unless otherwise specified
Coinsurance Out-of-Pocket Maximum
DOES NOT INCLUDE DEDUCTIBLE / Individual - $0
Family - $0 / Individual - $1,000
Family - $2,000
  • The Coinsurance Maximum is the maximum amount of coinsurance an individual will pay on benefits that are covered at 100% after deductible or 70% after deductible
  • Once the Coinsurance Maximum is met, benefits will process for that individual at 100%. Copays will still apply until the individual/family meets the Out-of-Pocket limit.
  • If the individual/family Out-of-Pocket limit is met before the Coinsurance Maximum is met, benefits will process at 100%.
  • In and Out of Network amounts accumulate separately and do not cross apply
  • The amount that has been applied to the Coinsurance Maximum is listed in the coinsurance bucket inHealthaxis

Out-of-Pocket Maximum
Includes Deductible, Copays, Coinsurance, and Prescription Copay amounts / Individual: $6,600
Family: $13,200
Thereafter, 100% until end of benefit period or maximum benefit reached / Individual: $13,200
Family: $26,400
Thereafter, 100% until end of benefit period or maximum benefit reached
  1. In and Out of Network amounts accumulate separately and do not cross apply
  2. Family accumulation – Eligible expenses incurred by all family members combined will be used to satisfy the family Deductible limit (aggregate).

Lifetime Maximum Benefit / Unlimited
COVERED SERVICES
Abortion Services / 100% after deductible / 70% after deductible
  • All female members covered

Acupuncture Services / Not Covered / Not Covered
Allergy Testing / 100% after deductible / 70% after deductible
Allergy Treatment & Serum / 100% after deductible / 70% after deductible
  • “Desensitization” treatments are covered

Allergy Office Visits / 100% after deductible / 70% after deductible
Ambulance Services
Ground or Air / 100% after deductible / 100% after INN deductible
  • Services provided by an ambulette or wheelchair van are not covered

Ambulatory Surgical Facility / 100% after deductible / 70% after deductible
Anesthesiologist Services / 100% after deductible / 70% after deductible
Birthing Center
Precert required for stays exceeding 48 or 96 hours / 100% after deductible / 70% after deductible
Birth Control / 100% no deductible / 70% after deductible
Covered services include:
  • Implantable contraceptives (i.e. Implanon)
  • Diaphragm or cervical cap
  • Depo Provera injections
  • Elective sterilization – tubal ligation
  • IUD insertion, surgical removal and equipment
Non Covered services include:
  • Reversal of sterilization

Birth Control Office Visit / 100% no deductible / 70% after deductible
Vasectomy / 100% after deductible / 70% after deductible
Breast Pumps
Can be ordered 2 months before or 2 months after giving birth / When the member calls to order a breast pump:
  • Confirm the type requested is the one the group made available:
  • Medela Pump In Style Advanced Breast Pump w/ Backpack- $243.99
  • Ameda Purely Yours Breast Pump- Carry All- $172.96
  • Lansinoh Double Electric Breast Pump - $149.99
  • Ameda Purely Yours Breast Pump- $136.25
  • Confirm the member's address and must advise the member that we cannot guarantee the model ordered will be the actual pump delivered. Depending on availability a similar model may be substituted.
  • Complete the highlighted sections on the Breast pump Invoice and email to Ashley Stokes.
  • Document in tracking that order form was emailed

Cardiac Rehabilitation / 100% after deductible / 70% after deductible
  • Phase 1 & 2 only covered

Chemotherapy
Group uses Biologics 800-983-1590 / 100% after deductible / 70% after deductible
Chiropractic Services / 100% after deductible / 70% after deductible
  • Limited to 10 visits per calendar year; additional visits require medical review

Cochlear Devices / 100% after deductible / 70% after deductible
  • Must be medically necessary

Cosmetic Surgery / Not covered / Not covered
Dental Services - Accident / 100% after deductible / 70% after deductible
Dental Services – Non Accident / 100% after deductible / 70% after deductible
Oral surgical services, including related x-rays and anesthesia, but limited to the following
procedures:
  • Surgical removal of full bony impacted teeth
  • Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof, and floor of the mouth
  • Surgical procedures to correct injuries to the jaw, cheeks, lips, tongue, roof, and floor of the mouth
  • Excision of extosis (bony outgrowth) of the jaws and hard palate
  • Maxillary or mandibular frenectomy (incision of the membrane connecting the tongue to the floor of the mouth)
  • Incision of drainage of cellulitis (tissue inflammation) of the mouth
  • Incision of accessory sinuses, salivary glands, or ducts

Diagnostic Lab & Radiology
Facility, includes preadmission testing / 100% after deductible / 70% after deductible
  • Independent laboratory expense paid at 100% no deductible
  • Radiology and Pathology interpretation covered at 100% no deductible

Durable Medical Equipment / 100% after deductible / 70% after deductible
  • Equipment must be prescribed by a Physician
Covered services include:
  • Rental or purchase, whichever is economically justified
  • Replacement covered, only if necessary due to the participant’s growth and development
  • TMJ appliances
Non-Covered Services include:
  • Routine periodic maintenance
  • Replacement of batteries

Education Services / 100% after deductible / 70% after deductible
  • Diabetic only
  • Nutrition Counseling covered under Home Health Care benefit, if provided or supervised by a registered dietician

Emergency Room
True Emergency
Non True Emergency / 100% after deductible
100% after deductible / 100% after INN deductible
70% after deductible
  • NOTE: ER services after 72 hours of an accidental injury are covered at 100% after deductible

Gender Dysphoria
Precert required / 100% after deductible / 70% after deductible
Coverage of gender dysphoria, including but not limited to:
  • prescription drugs,
  • hormone therapy,
  • psychotherapy
  • gender reassignment surgery.
  • Coverage will require pre-certification and be subject to certain eligibility criteria.
  • Limited to 1 per lifetime.
  • Certain cosmetic procedures related to gender reassignment surgery will continue to be excluded

Genetic Testing / Not covered / Not covered
  • Maternity related genetic testing (i.e. AFP, Amniocentesis) covered under Maternity services
  • BRCA testing covered under Health Maintenance benefits

Non Routine Hearing Exams & Hearing Aids / Not Covered / Not Covered
  • Refer to “Cochlear Devices” for benefits for Cochlear Implants

Hemodialysis
Group uses DCC
Request the start date of dialysis if available. Send open call to Claims supervisor with the start date. / 100% after deductible / 70% after deductible
  • If the provider is disputing the allowed amount, advise the caller: “Regardless of a provider’s network participation, the plan’s dialysis program pays outpatient dialysis service claims at the usual and reasonable charge which is based upon the average payment made for such services provided in the same market area during the prior year, adjusted for inflation.”

Home Health Care & Home Infusion Services / 100% after deductible / 70% after deductible
Covered services include:
  • 4 hours or less of non-custodial Home Health Aide services= 1 visit
  • Nutrition Counseling covered, if provided or supervised by a registered dietician
Non-Covered services include:
  • Custodial Care, rest care or care which is provided solely for someone’s convenience
  • Services rendered by a member of the Covered Person’s immediate family or a person residing in the Covered Person’s home
  • Transportation services
  • Services or supplies rendered during any period in which the Covered Person is not under the regular care of a Physician
  • Homemaker services
  • Food or home delivered meals

Hospice Services / 100% after deductible / 70% after deductible
Non-Covered services include:
  • Pre-death counseling and bereavement counseling not provided by or through the hospice
  • Bereavement counseling outside of what is provided by the hospice is not covered
  • Respite care is not covered
  • Services or supplies rendered during any period in which the Covered Person is notunder the regular care of a Physician
  • Services or supplies which might be considered as a covered expense under other sections of the Plan
  • Charges incurred during a remission period when the Covered Person is discharged from the Hospice Care program
  • Charges for services provided by a member of the Immediate Family
  • Pre-death counseling and bereavement counseling not provided by or through the Hospice
  • Chemotherapy or radiation therapy if other than to relieve the symptoms of a condition
  • Volunteer services
  • Spiritual counseling
  • Homemaker services
  • Food or home delivered meals
  • Custodial Care, rest care or care which is provided solely for someone’s convenience.

Hospital (Inpatient)
Precert required, including Maternity stays exceeding 48/96 hours / 100% after deductible / 70% after deductible
  • Private rooms allow at most common semi-private room rate
  • Hospitals with only Private rooms allow at most common semi-private room rate
  • Medically necessary Private rooms allow at hospital’s average semi-private room rate

Hospital (Outpatient)
Surgery / 100% after deductible / 70% after deductible
Hospital (Outpatient)
Non surgical/routine / 100% after deductible / 70% after deductible
Infertility Services / 100% after deductible / 70% after deductible
  • Plan only covers initial testing to diagnose infertility
  • Treatment not covered

Maternity Services
Physician Services
Refer to Hospital - Inpatient for facility benefits / Initial office visit- 100% after deductible
Preventive Prenatal – 100% no deductible
Global fee & all pregnancy office services- 100% after deductible / 70% after deductible
  • Preventative prenatal services covered at 100% no deductible no copay for all covered female members
  • Delivery & Post Partum care covered for all covered female members
  • Midwife services covered
  • Initial newborn services paid under mother

Massage Therapy / Not covered / Not covered
Medical and Surgical Supplies / 100% after deductible / 70% after deductible
  • Surgical/compression stockings covered

Mental Health & Substance Abuse
Inpatient
Precert required / 100% after deductible / 70% after deductible
Mental Health & Substance Abuse
Outpatient / 100% after deductible / 70% after deductible
Covered services include:
  • Family counseling
  • Group Therapy
Non Covered services include:
  • Marital counseling
  • Biofeedback
  • MILIEU/ situational therapy
  • Autism
  • ADD/ADHD

Morbid Obesity – Weight Control / Not covered / Not covered
Morbid Obesity – Surgical / 100% after deductible / 70% after deductible
  • Surgical treatment for obesity will not be covered unless patient meets ALL criteria
Surgical Treatment Criteria
Covered services include:
  • Initial Lap Band Placement
  • Lap Band Replacement
  • Lap Band removal
  • Lap Band adjustment
  • Gastric Bypass
Non Covered services include (but are not limited to):
  • Gastroplasty
  • Gastric Stapling
  • Panniculectomy
  • Abdominoplasty

Nutritional Therapy / 100% after deductible / 70% after deductible

Nutritional supplements and therapies are not covered except for enteral and parenteral nutrition therapies when medically necessary. Medical necessity is determined on a case by case basis and the treatment plan and a detailed explanation of the medical necessity must be submitted to HealthSCOPE Benefits for review and approval.

Non-covered services include:

Enteral tube feedings for individuals who are capable of adequate oral intake.

Food supplements, specialized infant formula, vitamins and/or minerals takenorally.

Parenteral nutrition for individuals with a functioning gastrointestinal tract whose

need for parenteral nutrition is only due to Swallowing disorder
  • Temporary defect in gastric emptying
  • Psychological disorder
  • Hemodialysis
  • Disorders inducing anorexia such as cancer
  • Peritoneal dialysis (introperitoneal amino acid (IPAA) supplementation for
individual on peritoneal dialysis may be considered if certain criteria are met
Outpatient Occupational Therapy / 100% after deductible / 70% after deductible
  • Limited to 10 visits per calendar year; additional visits require medical review

Orthotics (back, neck, knee, wrist, etc.) / 100% after deductible / 70% after deductible
  • Covered-
  • A rigid or semi-rigid supportive device which limits or stops motion of a weak or diseased body part, such as: splints, casts, strapping, orthopedic braces and crutches
  • Orthotic must be custom molded and prescribed by a Physician and not used only to improve comfort or appearance
  • Repair covered
  • Replacement only covered if necessary due to the participant’s growth and development

Orthopedic Shoes and Foot Orthotics / 100% after deductible / 70% after deductible
  • Orthotic must be custom molded and prescribed by a Physician and not used only to improve comfort or appearance
  • Special shoes not included, unless the device is a permanent part of an orthopedic brace
  • Repair covered
  • Replacement only covered if necessary due to the participant’s growth and development

Outpatient Physical Therapy / 100% after deductible / 70% after deductible
  • Limited to 10 visits per calendar year; additional visits require medical review
  • Must be medically necessary & non-maintenance
  • Covers treatment given to relieve pain, restore maximum function, and prevent disability following disease, injury or loss of body part.
  • Treatment should proceed according to written referral or treatment plan submitted by the attending Physician and/or therapist indicating the projected number of treatments and length of treatment program

Physician Office Visits for Non-Routine Care / 100% after deductible / 70% after deductible