RETIREE DEATH BENEFIT
(For Retirees only) |
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| Death Benefit Amount | $1,000 |
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| COMPREHENSIVE MEDICAL BENEFIT |
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Certain benefit reductions and exclusions apply when the precertification is not obtained.
All benefits and provisions are per person unless specifically stated otherwise. |
| Calendar year deductible per person | $500 |
Out-of-network hospital penalty
The out-of-network hospital penalty applies to each non-emergency hospital confinement and each occurrence of non-emergency outpatient treatment in an out-of-network hospital (some exceptions apply). Any such deductibles are in addition to the calendar year deductibles. | $250 |
Out-of-pocket limit per person
Only in-network covered medical expenses apply toward your out-of-pocket limit. The calendar year deductible also applies toward the out-of-pocket limit. | $2,500 |
Plan co-pay/payment percentages payable per person for covered medical expenses incurred during a calendar year, until out-of-pocket limit is met
Exceptions may apply. Those exceptions are noted in the “Special Benefits and Limitations” section below. | 80% |
Applied Behavior Analysis (ABA) Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care. | 50 visits |
Acupuncture
Must be pre-certified by Med-Care. Calendar year deductible does not apply. | 12 visits per calendar year |
Aqua Therapy subject to the medical necessity criteria
Must be pre-certified by Med-Care | No limit per calendar year |
Chair lift
Lifetime maximum benefit for purchase and installation of a chair lift that meets the requirements
Must be pre-certified by Med-Care. | $10,000 |
Chiropractic care
Calendar Year maximum benefit per person (includes adjustments and manipulations). (Physical therapy, acupuncture and massage therapy have separate limitations.)
Must be pre-certified by Med-Care. Calendar year deductible does not apply. | $2,500 |
| Hearing aids: | |
| Maximum benefit payable per person | $3,000 in a two-calendar year period |
Plan co-payment percentage
Calendar year deductible does not apply. | 50% |
Massage therapy, subject to the medical necessity criteria
Must be pre-certified by Med-Care. Calendar year deductible does not apply. | 12 visits per calendar year |
Nutrition Counseling, subject to the medical necessity criteria
Must be pre-certified by Med-Care. Calendar year deductible does not apply. | 12 visits per calendar year |
Occupational therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care. | 50 visits |
| Out-of-network surgical facility charges | Excluded |
Physical therapy – Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care. | 50 visits |
Podiatry – Calendar Year maximum benefit per person for all non-surgical podiatry fees
(professional fees only) Calendar year deductible does not apply. | $750 |
| Preventive care | |
| When provided by in-network providers | 100% deductible does not apply |
| When provided by out-of-network providers | 80% after deductible |
| Second or third surgical opinions recommended by Med-Care | 100% |
Speech therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care. | 50 visits |
TMJ
Lifetime maximum benefit for non-surgical treatment (professional fees only)
Must be pre-certified by Med-Care. Calendar year deductible does not apply.
Surgical TMJ is payable at 80%, subject to the deductible, and must be pre-certified by Med-Care. | $2,000 |
Travel Abroad
Maximum amount paid per participant per occurrence for medical ex-penses incurred while traveling abroad. Calendar year deductible does not apply. | $250 |
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| PRESCRIPTION DRUGS |
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| Your co-pays under the Sav-Rx drug card program for up to a 30-day supply of a covered prescription drug obtained from a participating pharmacy, and under the Sav-Rx mail-order and Walgreens walk-in programs, are based on a percentage of the negotiated price for the drug. |
| | Your Co-Pay |
| Generic Drugs | 10% |
| Formulary brand name drugs | 20% |
| Non-formulary brands | 30% |
| Lifestyle drugs | 40% |
| Proton pump inhibitors (such as Nexium, Prevacid and Prilosec) | Excluded* |
| Non-sedating antihistamines (such as prescription Claritin and Allegra) | Excluded* |
| There is a $5 minimum and $200 maximum on each co-pay. | |
Prescription Drug Out-of-Pocket Limit per person calendar year
If the total amount you paid in co-pay percentages reach $3,000 for a calendar year, the Plan will pay 100% for your covered prescription drug expenses during the remainder of that calendar year. | $3,000 |
Generic/Brand Differential (Card, Mail and Walk-In)
If you chose a brand name drug when a generic equiva-lent is available, you will be responsible for the difference in cost between the brand and the generic equiva-lent, in addition to your percentage co-pay. The cost difference that you pay does not apply to the Rx out-of-pocket limit. |
Prior Authorization and Clinical Review
Specialty drugs and other high-cost medications may require prior authorization by clinical personnel at Sav-Rx and/or Med-Care Management. The Plan has the right to exclude a high-cost drug if there are less expensive but clinically appropriate alternatives available.
Out-of-network prescriptions drugs are not covered.
* PPIs and NSAHs are only covered if Med-Care pre-authorizes your use of a prescription version. |
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