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Health Fund

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Other Medical Services

MEDICAL, MENTAL HEALTH AND CHEMICAL DEPENDENCY
  REGULAR PLAN PPO LOW OPTION PLAN 1
  NETWORK PROVIDER 2 NON-
NETWORK PROVIDER 3
OUT OF AREA (For participants
who live over 25
miles outside the
PPO service area
of 2 providers)
3 4
NETWORK PROVIDER 2 NON-
NETWORK PROVIDER 3

Alternative Medicine

85% of $60 allowable/visit;
one monthly
re-exam to
monitor progress

70% of $60 allowable/visit;
one monthly
re-exam to
monitor progress

80% of $60 allowable/visit;
one monthly
re-exam to
monitor progress

70% of $60 allowable/visit;
one monthly
re-exam to
monitor progress

60% of $60 allowable/visit;
one monthly
re-exam to
monitor progress

Ambulance 80%
(emergency only)
80%
(emergency only)
80%
(emergency only)
70%
(emergency only)
60%
(emergency only)
Air or Sea Ambulance 85%

(emergency only)
70%

(emergency only)
80%

(emergency only)
70%

(emergency only)
60%

(emergency only)
Ambulatory Surgery Center A freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It must also be Medicare-approved or meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care. 85% 70%
$1,500/incident maximum
80%
$1,500/incident maximum
70% 60%
$1,500/incident maximum
Electro- Convulsive Therapy (ECT) 85% 70% 80% 70% 60%
Enhanced External Counterpulsation Therapy (EECP) 85% 70% 80% 70% 60%
Hearing Aids 50% 22 50% 22 50% 22 50% 22 50% 22
Home Health Care A program for care and treatment of a sick or injured person in that person's home by a home health care agency. The program must be ordered by the sick or injured person's attending physician and approved by case management intervention. 23 and Home Infusion Therapy Preauthorization
Required - 85%
Preauthorization
Required - 70%
Preauthorization
Required - 80%
Preauthorization
Required - 70%
Preauthorization
Required - 60%
Hospice Care 23 Preauthorization
Required - 85%
Preauthorization
Required - 70%
Preauthorization
Required - 80%
Preauthorization
Required - 70%
Preauthorization
Required - 60%
Infertility Treatment Not covered Not covered Not covered Not covered Not covered
Preventive Care Services 100% of certain Preventive charges as identified by Federal Law Not available Not available 100% of certain Preventive charges as identified by Federal Law Not available
Routine Mammograms: Covered under Preventive
Care 11
Covered under Wellness Benefits 10, 24 Covered under Wellness Benefits 10, 24 Covered under Preventive Care11 60%
  • Under 35
Not covered Not covered Not covered Not covered Not covered
  • Ages 35-39
1 every 5 years 1 every 5 years 1 every 5 years 1 every 5 years 1 every 5 years
  • Age 40 & Over
1 every year 1 every year 1 every year 1 every year 1 every year
Speech Therapy The evaluation and treatment of communication and swallowing disorders by a person acting within the scope of licensed practice. Services provided may involve measurement, testing, identification, prognosis, counseling or instruction related to the development and disorders of speech, voice or language for the purpose of identifying, preventing and rehabilitating such disorders. Services may include evaluation of patients for augmentative/alternative communication systems, evaluation of verbal and written language reception and expression and evaluation of cognitive processing of language.
(subject to plan restrictions) 20
85%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's school. Any sessions covered through school program will reduce visits, on a one-for-one basis.
70%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's school. Any sessions covered through school program will reduce visits, on a one-for-one basis.
80%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's school. Any sessions covered through school program will reduce visits, on a one-for-one basis.
70%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's school. Any sessions covered through school program will reduce visits, on a one-for-one basis.
60%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's school. Any sessions covered through school program will reduce visits, on a one-for-one basis.
Transplant Services 23 Preauthorization
Required - 85%
Preauthorization
Required - 70%
Preauthorization
Required - 80%
Preauthorization
Required - 70%
Preauthorization
Required - 60%
Treatment of TMJ Dysfunction 85% for X-rays and 6 physiotherapy visits 70% for X-rays and 6 physiotherapy visits 80% for X-rays and 6 physiotherapy visits 70% for X-rays and 6 physiotherapy visits 60% for X-rays and 6 physiotherapy visits
Wellness
Benefits 24, 10
(Ages 7 and older; refer to SPD for covered services)
$500/person or $1,500/ family/
calendar year for specific wellness care expenses covered at 100% up to this limit 10
$500/person or $1,500/ family/
calendar year for specific wellness care expenses covered at 100% up to this limit
$500/person or $1,500/ family/
calendar year for specific wellness care expenses covered at 100% up to this limit
Not covered 11 Not covered

IMPORTANT!
Note: All services are subject to review for medical necessity at the time of payment.

1. Manipulation of the musculoskeletal system.

2. If Wellness Benefit Maximum is met, routine mammogram and pap smear will be considered under the medical plan, subject to annual deductible and plan limitations (this doesn't apply to the Low Option plan, which does not have the Wellness Benefit).

3. Covers one device per ear every three years, up to an allowable charge of $2,000 per device.

4. The participant must contact the Fund office to determine if the provider qualifies for the out-of-area benefit. If the provider is approved, the participant is responsible for filing claims with the Fund to receive benefit reimbursement.

10. See Wellness Benefits, page 12.

11. See Preventive Care Benefits Services, page 10. Some or all of the services in this section may be covered under the Preventive Care Service Benefits, payable at 100%, no deductible, when seen by a network provider.

19. For chronic pain control only.

20. A referral is required from a doctor of medicine (M.D.).

21. Manipulation of the musculoskeletal system.


IMPORTANT!
Inpatient, outpatient facility, Home Health Care, Hospice, Home Infusion Therapy, Skilled Nursing Facility and Transplant Services must be preauthorized through Anthem Blue Cross. Network services that are considered Preventive Care Services as identified by the Federal Law are not subject to a copay or annual deductible. Effective 1/1/13 this includes Women's Preventive Care: For additional details, see pages 69-72 or http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html.


22. Covers up to a maximum allowable charge of $2,000 per device. A prescription from a doctor of medicine (M.D.) is required. Does not go towards the coinsurance only the out-of-pocket maximum. However, eligible for the ACA's $6,350/$12,700 family out-of-pocket maximum which includes the deductible, coinsurance and copays.

23. Please have your provider contact the Fund's Utilization Administrator (Anthem Blue Cross) to facilitate your care through Case Management Intervention. On the backside of your Medical ID card, you will find the phone number for Preauthorization or Pre-Service Review.

24. If the Wellness Benefit maximum is exhausted, wellness care expenses will be considered under the medical plan, subject to the annual deductible, medical necessity review and plan cost sharing requirements. (Doesn't apply to Low Option Plan and Preventive Care Service benefits.)

25. The per-person annual dollar limit will not apply to essential pediatric vision care for dependent children under the age of 18.