Sjschools.org

St. Joseph Public Schools, G-778
PPO Plan Option
Benefit Description
In-Network
Out-of-Network
*Includes benefit percentage only. Does not include deductibles, in-network co-payments, prescription drug co-payments, or expenses that constitute a penalty for non-compliance, exceed the usual and customary charge, exceed the limits of the Plan, or are otherwise excluded. Annual Maximum Paid per Covered Person per Benefit Year (Includes $5,000,000 for in-network and out-of-network services combined Prescription Drugs Purchased Through the Prescription Drug Card Program or the Prescription Drug Mail Service Program) Outpatient Physician Services (Includes Office Visits, Immediate Care Center Visits, and Second Surgical Opinions) All Other Charges Billed in Connection with the Examination Paid the same as any other Paid the same as any other Illness; benefit percentage depends upon the type of service depends upon the type of service rendered Intrauterine Contraceptive Device Insertion/Removal Special Note about Acupuncture / Acupressure Treatment:
Only eligible charges for acupuncture or acupressure performed as preoperative anesthesia or as treatment for chronic pain; post-operative, chemotherapy-related, or
pregnancy-related nausea or vomiting; post-operative dental pain (if the dental procedure was covered under the Plan); migraines; and temporomandibular disorders are
covered under this benefit. Services must be performed by an individual who is duly licensed by the state or regulatory agency responsible for licensing in the state in
which the individual practices.
Flu Shots and Other Routine Immunizations Mammograms, Colonoscopies, and Other Routine Services Physician’s Fee for an Examination in the Emergency Room for the for an accidental injury or if admitted inpatient), then 100% Physician’s Fee for an Examination in the Emergency Room for the Third and All Subsequent Visits in the Benefit Year All Other Charges Billed by the Physician in Connection with the Hospital’s Fee for the Use of the Emergency Room All Other Services Billed by the Hospital in Connection with the Emergency Treatment at a Outpatient Hospital Required for all inpatient hospital admissions and observational Room and Board, Surgical Services, and Ancillary Services Hospital Visits, Surgical Procedures, and Anesthesiology This brochure represents only a summary of your group health benefits plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding plan provisions. PPO Plan Option
Benefit Description
In-Network
Out-of-Network
Surgery and Surgery-Related Services Chemotherapy and Radiation Therapy Hemodialysis Diagnostic X-ray and Lab Services $2,000 Maximum Paid per Covered Person per Benefit Year for All Chiropractic Care (In-Network and Out-of-Network Services Combined) Physical Therapy, Speech Therapy, and Occupational Therapy Durable Medical Equipment, Prosthetics, and Orthotics Behavioral Care (includes Mental Health Care and Addictions Treatment) Inpatient/Partial Hospitalization Services Outpatient/Intensive Outpatient Services Diagnostic Infertility Testing Treatment Special Note about Diagnostic Infertility Testing Treatment
Prescription drugs prescribed for the treatment of infertility are not eligible for Plan coverage.
120 Treatment Days per Covered Person per Benefit Year (In-Network Temporomandibular Joint Dysfunction (TMJ) Treatment $1,400 maximum Paid per Covered Person per Ear for a Hearing Aid in any Three-Year Period. One Audiometric Exam, Hearing Aid Evaluation, and Conformity Test per Covered Person per Ear in any Three-Year Period. Services Requiring Authorization:
Coordination with Other Coverage for Injuries Arising out of Automobile Accidents
1. Inpatient hospital confinements and observational stays
In the event that a covered person is injured in an accident involving an automobile, this Plan
shall be the primary plan for purposes of paying benefits and the covered person’s automobile
Services Suggested for Voluntary Outpatient Service Certification
insurance shall pay as secondary.
1. Home and outpatient occupational and speech rehabilitative therapies
2. Rental and purchase of durable medical equipment
3. Home health care
Special Provision for Dependent Spouses Employed Full-Time with Other Available Employer-
4. Purchase of custom-made orthotic or prosthetic appliances
Based Coverage
5. Oncology treatment
A PARTICIPANT’S SPOUSE WHO IS ELIGIBLE FOR COVERAGE UNDER HIS OR HER OWN
EMPLOYER’S GROUP MEDICAL PLAN AS A FULL-TIME EMPLOYEE MUST ENROLL FOR THAT
COVERAGE AT HIS OR HER NEXT AVAILABLE ENROLLMENT OPPORTUNITY FOLLOWING THE
If a covered person receives eligible treatment at an in-network facility, any anesthesiology,
DATE ON WHICH THIS PROVISION WAS INITIALLY ENACTED. Coverage under the spouse’s
pathology, or radiology charges will be paid at the in-network benefit percentage, even if out-of-
own employer’s group medical plan will be considered his or her primary coverage, and this
network providers performed those services.
Plan will be the secondary coverage.
The participant is obligated to immediately report to the Plan Administrator any change that
If a covered person receives treatment from an out-of network provider and the Plan
would affect his or her spouse’s eligibility under this Plan (i.e., the spouse changes employers
Administrator determines that the sole reason treatment was not provided by an In-Network
or the spouse’s employer offers its employees a medical plan for the first time). If the Plan
provider was because a covered person traveled to a place where he/she could not reasonably
Administrator determines that a spouse who is eligible for coverage under his or her own
be expected to know the location of the nearest in-network provider (if available), the Plan
employer’s group health plan as a full-time employee has not enrolled in his or her own
Administrator may request the claim be adjusted to yield in-network-level benefits.
employer’s group health plan for primary coverage as required by this provision, a $500
monthly surcharge shall be charged to the participant in order to maintain Plan coverage for the
spouse. This surcharge shall be assessed retroactive to the date that the spouse was eligible to
If a dependent child receives treatment from an out-of-network provider while attending a
enroll for coverage under his or her own employer’s group health plan and failed to do so, and
secondary school, college, university, or vocational/technical school, the Plan Administrator
shall continue to be charged until the spouse enrolls for his or her own employer’s group health
may request that the claim be adjusted to yield in-network-level benefits.
plan for primary coverage. The purpose of this surcharge is only to serve as a short-term
bridge so that the spouse may continue to have medical coverage. Such a spouse must still
enroll for his or her own employer’s group medical plan for primary coverage at the next
available enrollment opportunity in order to continue to participate in the Plan.
See the Plan Document or Summary Plan Description for details about spouses exempted from
the provision or the special provision for spouses that are not given an opportunity to enroll in
their own employer’s group health plan.
This brochure represents only a summary of your group health benefits plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding plan provisions. Prescription Drugs
Retail Prescription Drug Co-payments (34-Day Supply)
Prilosec, Claritin, Allegra, Zyrtec, and Prevacid OTC Generic Prescription Drugs and Diabetic Lancets, Test Strips, and $7.50 co-payment until the maximum out-of-pocket for prescription drugs is satisfied, then $-0- to the end of the benefit year Co-payment per Brand-Name Prescription Drug if 1) there is no $30 co-payment until the maximum out-of-pocket for prescription drugs generic equivalent available; or 2) a generic equivalent is available, is satisfied, then $-0- to the end of the benefit year but the prescribing Physician has requested “Dispense as Written” (DAW) and that request has been approved by the Claim Co-payment per Brand-Name Prescription Drug if a generic $50 co-payment until the maximum out-of-pocket for prescription drugs equivalent is available and either the prescribing Physician has not is satisfied, then $-0- to the end of the benefit year requested DAW or the Physician has requested DAW and that request has been denied by the Claim Administrator Co-payment per High Utilization Prescription Drug (Ambien CR, $50 co-payment until the maximum out-of-pocket for prescription drugs Celebrex, Clarinex, Cymbalta, Lexapro, Lipitor, Nasonex, Nexium, is satisfied, then $-0- to the end of the benefit year Mail-Order Prescription Drug Co-payments (90-Day Supply)
Prilosec, Claritin, Allegra, Zyrtec, and Prevacid OTC Generic Prescription Drugs and Diabetic Lancets, Test Strips, and $7.50 co-payment until the maximum out-of-pocket for prescription drugs is satisfied, then $-0- to the end of the benefit year Co-payment per Brand-Name Prescription Drug if 1) there is no $30 co-payment until the maximum out-of-pocket for prescription drugs generic equivalent available; or 2) a generic equivalent is available, is satisfied, then $-0- to the end of the benefit year but the prescribing Physician has requested “Dispense as Written” (DAW) and that request has been approved by the Claim Co-payment per Brand-Name Prescription Drug if a generic $50 co-payment until the maximum out-of-pocket for prescription drugs equivalent is available and either the prescribing Physician has not is satisfied, then $-0- to the end of the benefit year requested DAW or the Physician has requested DAW and that request has been denied by the Claim Administrator Co-payment per High Utilization Prescription Drug (Ambien CR, $50 co-payment until the maximum out-of-pocket for prescription drugs Celebrex, Clarinex, Cymbalta, Lexapro, Lipitor, Nasonex, Nexium, is satisfied, then $-0- to the end of the benefit year Maximum Out-of-Pocket per Benefit Year for all eligible
prescription drugs purchased though the Prescription Drug Card
Program and the Mail Service Program
Special Notes about Prescription Drug Coverage:
1. The pharmacy will dispense generic drugs unless a generic equivalent is not available. If the covered person refuses an available generic equivalent, the covered
person must pay the applicable co-payment plus the difference in price between the brand-name drug and its generic equivalent. If the prescribing physician requests
DAW for the prescription and this request has been approved by the Claim Administrator, this penalty shall be waived.
2. Claims filled at an out-of network retail pharmacy will be paid at 75% of the approved amount, less the applicable co-payment.
3. The High Utilization Prescription Drug co-payment may be reduced to $30 until the Maximum Out-of-Pocket for Prescription Drugs is satisfied if the prescribing
physician requests DAW for the prescription and this request has been approved by the Claim Administrator. After the Maximum Out-of-Pocket for Prescription Drugs is
satisfied, no co-payment shall apply to these drugs for the rest of the benefit year.
Vision Plan
Benefit Description
Eyeglass Lenses(Including scratch-resistant coating, anti-reflective coating, transitional lenses, progressive lenses, faceted lenses, polycarbonate lenses, high-index lens material, and no-line bifocals) Maximum Benefit Paid per Covered Person per Benefit Year for All Claims for routine vision examinations incurred by covered persons under age 18 are not subject to the Benefit Year dollar maximum. This brochure represents only a summary of your group health benefits plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding plan provisions. Dental Plan
Benefit Description
Type II - Minor Restorative Dental Services Type III - Major Restorative Dental Services Type IV - Orthodontic Services (for Dependent children under age 19 Maximum Benefit Paid per Covered Person per Benefit Year for Types I, II Claims for Type I Preventive Dental Services incurred by covered persons under age 18 are not subject to the Benefit Year dollar maximum. Lifetime Maximum Benefit Paid per Dependent Child for Type IV This brochure represents only a summary of your group health benefits plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding plan provisions.

Source: http://www.sjschools.org/cms/lib7/MI01000643/Centricity/Domain/5/Teachers_Benefit_Summary_-_PPO.pdf