2011 011 Ordinance - Laserfiche WebLink

Home Browse Search

o2/ls/2o11 Mayfield Village/chamber & life discount Proposed Effective Date: 04/01/2011 BGS ASSOCS LLC tiea[th Lnsurance ojjered by C,'ommunity Lnsurance (.'ompany Blue Access Option 1 with Rx Option B Network Non-Network Calendar Year Deductible (individual/family) $0 / $0 $300 / $900 Annual Out-Of-Pocket Maximum (individual/family) $0 / $0 $1,000 / $2,000 Physician Home and Office Services (per visit)(PCP/SCP) $15 / $ls 30% Allergy injections $s 30% Emergency Room Services: Facility/Other Covered Services $200 $200 Urgent Care Center $7s 30% Inpatient/Outpatient Professional Services No Cost Share 30% Inpatient Facility Services (per admission) No Cost Share 30% Outpatient HospitaUAlteruative Care Fac: Surgery (per visit) No Cost Share 30% Outpatient Services: Other (per visit) No Cost Share 30% Ambulance Services No Cost Share No Cost Share Hospice Services No Cost Share No Cost Share (PCP) means Primary Care Physician. (SCP) means Specialty Care Physician. Flat dollar copayments are excluded from the Out-of-pocket limits. Also Prescription Drug deductibles/copayments/coinsurance and Non-network Human Organ and Tissue Transplants are excluded from the Out-of-pocket limits. Network and Non-network deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other. Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance. However, the deductible does not apply to Emergency Room Services @ Hospital where a copayment & (%) coinsurance applies. No Copay means no deductible%opayment/coinsurance up to the maximum allowable amount. 0% coinsurance means no coinsurance up to the maximum allowable amount. Other Network Services: Durable Medical Equipment, Orthotics, and Prosthetics Behavioral Health (Mental Health and Substance Abuse) Outpatient Therapies -Benefits provided in accordance with Federal Mental - Physical Therapy: 20 visit limit Health Parity - Occupational Therapy: 20 visit limit - Manipulation Therapy: 12 visit limit - Speech Therapy: 20 visit limit - Cardiac Rehabilitation: 36 visit limit - Pulmonary Rehabilitation: 20 visit limit - Accidental Dental: $3,000 limit Human Organ /Tissue Transplants No CopaymenbCoinsurance BenefitID:152647 Home Care Services - 90 visits excludes Private Duty Nursing and IV Therapy Private Duty Nursing - $s0,000 annuaU$100,000 Lifetime Maximum Prescription Drugs (Network Pharmacy) - Retail (30-day Supply) $10 / $25 / $40 - Mail Service (90-day Supply) $10/$6s/$120 - Specialty medications are limited to a 30 day supply regardless of whether they are retail or mail service. - Member may be responsible for additional cost when not selecting the available generic drug. - Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits. * For groups size 100+ -refill by mail, if requested, requires special pricing from Underwriting. Please note: as we receive addilional guidance and clarification from the U.S. Department of Health and Human Services, we may be required to make additional changes to your benefits. This coverage has been selected for employees and eligible dependents; subject to the terms and conditions of this proposal and the application to which this is attached. Signature Date Anthem: 113130 -Blue 5.0 Page: 1 EXHIBIT A