GENERALI WORLDCHOICE DEDUCTIBLE OPTIONS

Transcription

1 GENERALI WORLDCHOICE DEDUCTIBLE OPTIONS Group Health Plan Benefit Summary Comprehensive Major Medical Benefit Pre-Authorization through Generali Worldwide is required for certain Medical Services (1) otherwise coverage may be reduced. Lifetime Maximum Inpatient Mental Health & Substance Abuse Premature Babies & Congenital Abnormality PLAN MAXIMUMS $2,400,000 per person CO-INSURANCE MAXIMUM $30,000 per person per Lifetime $500,000 per member until exhausted then $120,000 per member per calendar year. No more than $500,000 will be paid in the first calendar year in which the child is born or covered. In subsequent years, we will pay the greater of (a) the balance remaining of the $500,000 or (b) $120,000 Annual Co-Insurance Maximum (3), per Calendar Year (Co-Insurance Maximum does not apply to Out of Network in the U.S.A.) Individual $1,200 Annual (combined with dental if applicable) Individual $350, $350, $500 Family $350, $700, $1,000 Hospital - Inpatient Admissions for Medical, Surgical, Maternity (Pre-Authorization Required (1) ) Inpatient Admissions (1) Facility Charges (including Room & Board) Delivery & Newborn Care (1) (First 30 days of life covered under Mother until other or alternate coverage is arranged) Organ Transplants (1) Laboratory (1) Imaging, including MRI and CT (1) Inpatient Pharmacy Ancillary Services Inpatient Chemotherapy & Radiation (1) Inpatient Professional Fees (1) (e.g. Surgeons, Anesthesiologist, Consultations, and Therapists) at Generali Advantage Network Facilities (2) & Plan pays 90% at all other in-network hospitals until You have Plan pays 100% Plan pays 90% until you have reached Your Co- Insurance IN Individual $1,000, $1,000, $1,000 Family $1,000, $2,000, $2,000 Hospital or Other Facility Outpatient Procedures and Surgery (Pre-Authorization required (1) ) Outpatient Surgery (1) Facility Fees All other Outpatient Procedures and Services, including Pharmacy, Laboratory, routine and high tech imaging (including MRI, PET and CT Scans) (1) Professional Fees (1) (e.g. Surgeons & Anesthesiologist) Outpatient Chemotherapy & Radiation (1) Physician Office Surgery (1) at Generali Advantage Network Facilities (2) & Plan pays 90% at all other in-network facilities until You have reached Your Co-Insurance Maximum, then, Plan pays 80%

2 Preventative Care IN Routine Physical Exams Immunizations Mammogram, Prostate Exams and Pap Smears Routine Dental Schedule of Care Colorectal Cancer Screening Digital Rectal Exam (DRE) and related lab fees Immunizations Lead Poisoning Screening Mammograms Pap Smears and related lab fees Prostate Cancer Screening (PSA) Routine Physical Exams for Adults Routine Physical Exams for children Routine Dental Nutritional Counselling Plan pays $600 per person per Calendar Year at 100% does not apply. See Schedule of Care Below. For individuals aged 50 or older or any person deemed to be at high risk of colon cancer due to family history, ethnic or lifestyle background 1 routine exam per 24 months. 1 exam per calendar year. For infectious disease, and testing for tuberculosis for adults and children. For children from birth to age 18 this includes immunizations based on the World Health Organization guidelines according to the country in which the child is residing. For children at or around 12 months old and children under age 6 who are considered high risk. For women ages baseline exam. Ages exam per calendar year for asymptomatic women, but no sooner than 2 years after a woman s baseline. Age 50 or older 1 exam per calendar year. 1 exam per calendar year. For males aged 45 or older 1 exam per calendar year. Age 18 or older - 1 exam per calendar year. Birth to 1 year old 7 exams per calendar year. 1 to 3 years old 2 exams per calendar year. 3 to 18 years old 1 exam per calendar year. 1 Dental exam and 1 Dental cleaning per calendar year under Preventative Care unless your Employer has opted for additional Dental Coverage. In that case this benefit will be paid under Your dental plan. Covered when medically necessary in conjunction with a medical diagnosis and with MD referral. Not covered solely for the purpose of weight loss or weight management. Physician Office and Other Non-Hospital Care (Pre-Authorization Required for certain services (1) ) Primary Care Physician Office Visits Plan pays first $500 per person per Plan pays100% after You pay a Calendar year at 100%, then after $20 Co-pay per office visit. Specialist Physician Office Visits meeting your, Plan pays Pre-Admission Diagnostic Tests (1) 80% until You have reached Your Co-Insurance maximum, then Laboratory (1) Imaging (1) (Including Professional Fees) Chemotherapy & Radiation Therapy (1) Maternity - Prenatal Care, reached your Co-Insurance of the first $600 per pregnancy, then after meeting Your : Plan Pays 90% until You have (Note: For MD visits You only pay a $20 Co-pay per office visit) Durable Medical Equipment (DME) (1) (Includes hearing aids up to $3,000 per person per Lifetime), Plan pays 80% until You have reached, Acupuncture / Chiropractic Therapy (4) Initial visit does not require Pre-Authorization Outpatient Physical Therapy (4) First 6 visits do not require Pre-Authorization up to $120 per visit. (Note: provider must submit a plan of treatment for Pre-Authorization beyond the first visit or sixth visit for cover to apply for additional visits). A combined Maximum of 25 visits per year for all services (Co-Insurance Maximum does not apply) No coverage

3 IN Physician Office and Other Non-Hospital Care (Pre-Authorization Required for certain services (1) ) Outpatient Therapy (5) Includes Speech, Occupational Therapy and Outpatient Rehabilitation Services. (Note: provider must submit a plan of treatment for Pre-Authorization before the first visit for cover to apply) A combined Maximum of 25 visits per year for all services (Co-Insurance Maximum does not apply),. Prior authorization is needed before any visits. A combined Maximum of 25 visits per year for all services Emergency Room Care & Emergency Transportation (Pre-Authorization Required for certain Services (1) ) Emergency Room (1) of first $5,000,, Plan (sudden onset threat to then until You pays 90% until You have reached loss of life or limb) have Must be authorized within 24 hours if. hospital admission results. does not apply Emergency Ground Ambulance Non-Emergency Services provided at a Hospital Emergency Room (1) (6) Emergency Air Ambulance Plan First $500 at 100% per Calendar Year under Physician Office & Other Non-Hospital Care if not exhausted. until You have reached Your Co- Insurance Plan pays 100%, Plan pays 50% (Co-Insurance Maximum does not apply), Plan pays 50% pays 100% up to the Lifetime Maximum. Use of an Air Ambulance is only Covered in a life threatening situation. Any use of an Air Ambulance or other air transportation must be authorized and coordinated by Generali Worldwide for cover to apply. (Note: In the Cayman Islands, Emergency Services Benefit applies). Mental Health & Substance Abuse Care (Pre-Authorization Required for Inpatient care (1) ) Outpatient Care, up to $1,000 per calendar year, Plan pays 90% until You have reached up to $1,000 per calendar year up to $1,000 per calendar year Inpatient Care (1) up to $30,000 per Lifetime up to $30,000 per Lifetime up to $30,000 per Lifetime Miscellaneous Care (Pre-Authorization Required for certain services (1) ) Home Health (1), (Maximum 120 days per confinement) Private Duty Nursing (Maximum 70 days per calendar year),, Plan pays 90% until You have reached Inpatient Convalescent Facility (1) & Inpatient Rehabilitation Services (1) (Maximum 30 days per calendar year (7) ) Hospice Care Facility (Maximum 30 days per lifetime for facility charges and $3,000 per lifetime for all other charges)

4 Miscellaneous Care (Pre-Authorization Required for certain services (1) ) IN Haemodialysis Alternate Emergency Transport (1) Companion Air Travel (6) Repatriation of Mortal Remains In the event the medical emergency requires air transportation, but in Our opinion not at the level of an air ambulance, and only if associated with a hospital admission, we may provide cover only for roundtrip air transportation to the destination via regularly scheduled or chartered air service on an economy class ticket. We will provide cover for one companion to the location where the covered patient is receiving an Emergency hospital admission. This cover for one friend/family member will be either inside the Air Ambulance or via an economy roundtrip plane ticket, up to a maximum round-trip airfare of $500. Plan will Pay 100% up to $10,000 for the transportation costs of returning Home Your Mortal Remains (including cremation expenses) from the country or island where death occurs. ( does not apply.) Pharmacy Plan pays 90% for generic drugs and 80% for brand name drugs ( and Co-Insurance maximum do not apply) Not Covered Pre-Authorization is required for all hospital admissions; outpatient surgery; rehabilitation services; chemotherapy; radiation therapy; Alternate Emergency Transport, MRI s C-T and PET scans; laboratory and x-ray / imaging services in excess of $1,000; Durable Medical Equipment (DME); air ambulance; home health; and obstetrical ultrasounds exceeding three per pregnancy. You MUST notify Us at least 5 business days prior to a scheduled or elective admission or treatment plan. If advance notice cannot be provided due to an Emergency, we must receive notification from You or Your representative within the later of 48 hours or the end of the first business day following the beginning of the service. If Pre-Authorization is not obtained, cover for services received may be subject to a denial or a reduction in Your Benefits to 50%. The Generali Advantage Network is a network of leading facilities and physicians. Hospitals and other providers included in the Generali Advantage Network can be found at Annual Out of Pocket/Co-Insurance Maximum does not apply to Co-Pays, Pharmacy Co-Insurance, out-of-network services, deductibles, benefit penalties for non-authorized services and 50% Co-Insurance items. Chiropractic and acupuncture therapy after your initial visit and outpatient physical therapy after your sixth visit must be Pre-Authorized in advance, otherwise additional treatment may be subject to denial of, or a reduction in, your benefits to 50%. Outpatient Therapy must be Pre-Authorized in advance otherwise treatment may be subject to denial of, or a reduction in, your Benefits to 50%. Air Ambulance: If Air Ambulance is required, the patient will be taken to the nearest appropriate facility. In the event the medical emergency requires air transportation, but in our opinion not at the level of an Air Ambulance, and only if associated with a hospital admission, we may provide cover only for round-trip air transportation to the destination via regularly scheduled or chartered air service on an economy class ticket. We will provide cover for one companion to travel to the location where the covered patient is receiving an emergency hospital admission. This cover for one friend/family member will either be inside the Air Ambulance or via an economy return trip plane ticket, up to a maximum of $500. We will provide cover for the member to return to their country of residence by economy trip plane ticket, up to a maximum of $500. This cover will apply only in the event of the member having been evacuated by Air Ambulance in order to receive emergency inpatient treatment. Where the Chief Medical Officer/Medical Director and one other registered medical practitioner other than the attending medical practitioner certify that a patient must receive the inpatient benefit for more than thirty days maximum, such patient may claim payment for the cost or part of the cost of the benefit in excess of thirty days. This Benefit Summary should be read in conjunction with the Plan document and the Policy Record and all other auxiliary documents which constitutes the contract. In case of any discrepancy between published documents or in case of any legal action, the terms set forth in the Plan Document which is part of the group insurance contract issued by Generali Worldwide will prevail.

5 Generali WorldChoice Health Plan Supplemental Benefits Dental Effective June 1, 2016 WORLDWIDE COVERAGE Provides benefits for charges for dental services and supplies incurred for treatment of a dental disease or injury. These benefits apply separately to each covered person. For medical conditions or injury to the mouth, jaws and teeth requiring dental surgery the medical plan benefits apply. Calendar Year Maximum Preventative Expenses Restorative Expenses Reconstructive Expenses Waiting Period Combined with Medical $1,000 or $2,000 per person (One option for all employees) 80% with no deductible (oral exams, cleanings every 6 months, x-rays) 80% after deductible (fillings, root canals, inlays, crowns) 50% after deductible (fixed bridgework, dentures) for teeth lost while covered or for replacement of existing nonserviceable dental work 5+ years old. Orthodontia for all members. A twelve (12) month waiting period applies for Reconstruction and Orthodontic expenses. The waiting period is waived for all members enrolled on the initial Plan Sponsor effective date with prior Dental coverage where satisfactory proof is provided to us. It is also waived for Plan Sponsors who have purchased non-underwritten plans. Members with effective dates after the initial Plan Sponsor effective date are subject to the waiting periods above. Vision WORLDWIDE COVERAGE Provides a benefit equal to 100% up to $400 per calendar year of the covered vision expenses per person. Services must be furnished or prescribed by a legally qualified ophthalmologist or optometrist. No waiting period applies. Payments based upon Reasonable and Customary parameters. Calendar Year Maximum Covered Vision Expenses Exclusions None $400 per person Eye Exams, Frames and Single Vision Lenses, Bifocal Vision Lenses, Trifocal Vision Lenses, Lentricular Vision Lenses and Contact Lenses.* 1. Sunglasses of any kind, including prescription sunglasses. 2. Services or supplies which are cosmetic in nature. This includes cosmetic contact lenses. *2 Lenses: to correct acuity to 20/40 or better in the better eye or following cataract surgery, maximum benefit payable during an insured s lifetime for all such contact and aphakic lenses is $100. Life and AD&D CLASSIFICATION AMOUNT All Employees $10,000 or $50,000 (One option for all employees)