Medical

Your Summary of Benefits

Mahoning County School Employees Insurance Consortium
Blue Access (PPO)
Effective 07/01/2018


Covered benefits Network Non-Network

Deductible (Single/Family)

$300/$600 $600/$1,200
Coinsurance Limit (Single/Family) $500/$1000 $1,250/$2,500

Out-of-Pocket Limit (Single/Family) (includes deductible, medical & Rx copayments and coinsurance)

$7,350/$14,700 Unlimited
Physician Home and Office Services (PCP/SCP) $10/$25 30%
Primary Care Physician (PCP)/ Specialty Care Physician (SCP)

Including Office Surgeries and allergy serum:

  • allergy injections (PCP and SCP)
10% 30%
  • allergy testing
10% 30%
  • MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-maternity related Ultrasounds and pharmaceutical products
10% 30%
Preventive Care Services
  • Services included but not limited to: Routine medical exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, and Hearing screenings.
No cost share 30%
Emergency and Urgent Care
Emergency Room Services $100/10% $100/10%
  • Facility/other covered services
    (copayment waived if admitted)
Urgent Care Center Services $25 30%
  • MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, Non-maternity related Ultrasounds and pharmaceutical products
10% 30%
  • Allergy testing
10% 30%
Inpatient and Outpatient Professional Services 10% 30%

Include but are not limited to:

  • Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams

Inpatient Facility Services (Network/Non-Network combined) Unlimited days except for:

10% 30%
  • Unlimited days for physical medicine/rehab (limit includes Days Rehabilitation Therapy Services on an outpatient basis)
  • 120 days for skilled nursing facility
Outpatient Surgery Hospital/Alternative Care Facility 10% 30%
  • Surgery and administration of general anesthesia

Other Outpatient Services including but not limited to:

10% 30%
  • Non Surgical Outpatient Services for example: MRIs, C-Scans, Chemotherapy, Ultrasounds, and other diagnostic outpatient services.
  • Home Care Services 90 visits (excludes IV Therapy) (Network/Non-Network combined)
  • Durable Medical Equipment
  • Physical Medicine Therapy Day Rehabilitation programs
  • Hospice Care
10% 30%
  • Ambulance Services
10% 10%
Outpatient Therapy Services

(Combined Network & Non-Network limits)

  • Physician Home and Office Visits (PCP/SCP)
10% 30%
  • Other Outpatient Services @ Hospital/Alternative Care Facility
10% 30%

Limits apply to:

  • Cardiac Rehabilitation Unlimited
  • Pulmonary Rehabilitation Unlimited
  • Physical Therapy: 30 visits
  • Occupational Therapy: 30 visits
  • Manipulation Therapy: 36 visits
  • Speech therapy: 20 visits

Accidental Dental: Unlimited per accident (Network and Non-network combined)

Copayments/Coinsurance based on setting where covered services are received

30%

Behavioral Health:

Benefits provided in accordance with Federal Mental Health Parity
Mental Illness and Substance Abuse 1
  • Inpatient Facility Services
30%
  • Physician Home and Office Visits (PCP/SCP)
  • Other Outpatient Services. Outpatient Facility @ Hospital/Alternative Care Facility, Outpatient Professional
Human Organs and Tissue Transplants 10% 30%
  • Acquisition and transplant procedures, harvest and storage.

Prescription Drugs

Network Tier structure equals-
(Generic, Brand Formulary, Brand Non formulary, Specialty)

Network Retail Pharmacies:

Up to 30 days

$5/$25/$50/$100 (Specialty) 25%

Up to 90 days

$12.50/$62.50/$125/Specialty N/A
Home Delivery Service: $12.50/$62.50/$125 Not covered

(90-day supply)

$100 (Specialty)

** Member may be responsible for additional cost when not selecting the available generic drug

** Prilosec OTC/omeprazole

** Medicare Rx - Wrap

No cost share


Notes:

  • All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum.
  • Deductible(s) apply to covered medical services listed with a percentage (%) coinsurance, including 0%.
  • Network and Non-network deductibles, copayments, coinsurance and out-of-pocket maximums do accumulate toward each other.
  • Dependent Age: to end of the month which the child attains age 26
  • Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OB/GYNs and Geriatrics or any other Network Provider as allowed by the plan.
  • No cost share (NCS) means no deductible/copayment/coinsurance up to the maximum allowable amount. 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for any balance due after the plan payment.
  • PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan.
  • SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
  • Live Health Online (LHO) is covered at the PCP costshare.
  • Benefit period = calendar year
  • Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity.
  • Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered.
  • Private Duty Nursing – unlimited visits/Calendar Year
  • Plan to cover surgical treatment of morbid obesity, medical, $30,000 Lifetime.
  • Plan to cover Rx for surgical treatment of morbid obesity.
  • Plan to cover sexual dysfunction, medical and Rx.
  • Exclude elective abortions
  • 4th qtr. Deductible carryover applies.

1 We encourage you to review the Schedule of Benefits for limitations.

Precertification:

Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help the member know if the services are considered not medically necessary.

Pre-existing Exclusion Period: none

This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.

This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Benefit Booklet, and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

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