WellSpan Medical Plan WellSpan Plus Medical Plan Option. Summary Plan Description Material Modification

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1 Summary Plan Description Material Modification WellSpan Health has amended the effective January 1, If you have any questions about these changes, call the Human Resources Department at (717) or SOUTH CENTRAL Preferred s Customer Service Department at (800) or (717) Schedule of Benefits About The Modify on page MS-1 WellSpan Plus is a comprehensive Medical Plan Option (the Plan ) that provides you and your family with the flexibility to use healthcare providers from multiple networks. The benefit level you receive for each service will depend on which network your provider participates in. Or you may receive care from providers that do not participate in a network. Tier 1 WellSpan Provider Network: Includes WellSpan providers and facilities as well as other select providers. Tier 2 Aetna Signature Administrators (ASA) Network: Includes a nationwide network of providers and facilities when a service is not available in Tier 1. Tier 3 Out-Of-Network: Includes those providers and facilities who do not participate in the WellSpan Provider Network or ASA networks. WellSpan Plus Schedule of Benefits Modify on pages MS-2 through MS-26 TIER 1 WellSpan Provider Network TIER 2 Aetna Signature Administrators Network TIER 3 Out-Of-Network MEDICAL DEDUCTIBLE PER CALENDAR YEAR Per Covered Person None $250 $750 Deductibles do not accumulate across Tiers. Deductible carry-over months: October, November, December INJECTABLE DRUG DEDUCTIBLE PER CALENDAR YEAR Per Covered Person $100 $100 Deductible accumulates across Tier 1 and 2 only OUT-OF-POCKET MAXIMUM PER CALENDAR YEAR Per Covered Person $2,000 $10,000 Per Family Unit $4,000 None Out-of-pocket maximums accumulate across Tiers 1 and 2 only. Maximum includes Medical and Behavioral Health deductibles, coinsurance and co-payments. Pre-certification penalties, non-covered services, amounts over the usual, customary & reasonable charge (UC&R), etc. do not count toward the out-of-pocket maximum 1

2 TYPE OF EXPENSE TIER 1 WellSpan Provider Network TIER 2 Aetna Signature Administrators Network TIER 3 Out-Of-Network Urgent Care Services, Walk-In Clinics, Retail Clinics. Coverage is available for charges received in an urgent care center or a facility that sees patients for nonemergency, yet necessary, care. These facilities usually see patients for unscheduled walk-in care that is not through a hospital s Emergency Department. Prescription drugs that are dispensed, but not administered, are not covered under the medical or prescription drug benefits. $0 co-payment, then 100% for office visit with a PCP $20 co-payment, then 100% for office visit with a Specialist $20 co-payment, then 100% for office visit with a PCP $30 co-payment, then 100% for office visit with a Specialist 50% after the deductible subject to the UC&R limit Introduction to Your Medical Benefits Important Phone Numbers and Web Sites Modify on page IN-2 SOUTH CENTRAL Preferred (800) or (717) Quest Behavioral Health Services (800) WellSpan Health ( My WellSpan Benefits ) Aetna Signature Administrators Catamaran (Prescription Benefits Manager) (844) Participating in the Medical Plan Option Modify on page PA-1 through PA-30 Effective January 1, 2015, the will no longer provide eligibility for Plan participation to retired employees and their spouses/dependents. All references to retiree coverage is deleted from the Plan Document. Effective January 1, 2015, the will no longer consider domestic partners and their children eligible for participation in the Plan. Those domestic partners and their children who are currently covered (Plan Year 2014) may continue that same coverage for Plan Year No new domestic partners or their children can be added. This eligibility for Plan coverage will end December 31,

3 Your Dependents Eligibility Modify page PA-1 You may cover yourself, you and your spouse, you and your child(ren), or you and your entire family. These family members are called dependents. Your eligible dependents include: Your spouse; Your natural child(ren), legally adopted child(ren), stepchild(ren), a child for whom you are the legal guardian, a child who is the subject of a court order, or a child named in a qualified medical child support order: Until the end of the month in which they reach age 26; or Up to any age if physically or mentally disabled before age 26. They must be: o o Incapable of self-sustaining employment because of mental or physical disability, which can be expected to be of long-term or indefinite duration; and Age 26 and older, must be claimed as a dependent for federal tax purposes by the employee, or spouse. Both of these tests must be met to continue your child s eligibility under the Plan. If the child is, at any point, no longer disabled after their 26h birthday, they will thereafter be ineligible as a covered dependent even if a subsequent disability is a recurrence of a prior condition. The Plan Administrator may require initial and subsequent proof of the child s disability and dependency (but not more than once per year). The spouse of your dependent child, domestic partner of your dependent child, or the children of your dependent child are not eligible to be covered under this Plan. The About the Modify on pages WP-1 through WP-3 WellSpan Plus is a comprehensive medical plan that offers you three tiers of benefit coverage when you receive care from providers and facilities in the WellSpan Provider Network, the Aetna Signature Administrators (ASA) Network, or outside the networks; that is, out-of-network. This medical plan option combines important features such as low out-of-pocket costs, high benefit levels, and a wide choice of physicians and hospitals. You have the flexibility to use providers and facilities in any network at any time. However, the benefit you or your family receives will depend upon which network your provider participates in. When you use a network provider, that provider has agreed to accept the Plan s usual, customary & reasonable (UC&R) charge. In addition to each network, out-of-network benefits are also available at any time. WellSpan Plus is designed to provide the highest level of benefits when services are received by a WellSpan Provider Network provider or facility. Using WellSpan Provider Network providers, when possible, provides you and your family with an exceptional level of benefits through the WellSpan Provider Network. The Plan saves money when you use the WellSpan Provider Network and those savings are passed on to you as higher benefit levels. Network provider directories and updates can be found on the WellSpan Health web site at under My WellSpan Benefits. If you do not have access to the Internet or a printer, please contact the Human Resources Department or SOUTH CENTRAL Preferred to obtain a copy, free of charge. 3

4 It is important to understand that the benefit level you or your family receives will depend on which network and tier your provider participates in. A network may not always include the provider you need, which means you will receive the benefit level that includes the network in which the provider participates or receive the out-of-network benefit level if the provider does not participate with a network. WellSpan Provider Network providers and facilities may need to use Tier 2 or Tier 3 providers for some services. The WellSpan Provider Network Tier 1 When you use a WellSpan Provider Network provider or facility, you will receive the highest benefit level under Tier 1. Generally, benefits are paid at 100%, with some office co-payments. There is no calendar year deductible, except for the calendar year injectable drug deductible. To find a WellSpan Provider Network provider, go to the WellSpan Health web site, and search under My WellSpan Benefits or call SOUTH CENTRAL Preferred for assistance in finding a participating provider. Remember, only WellSpan Provider Network providers and facilities will receive the Tier 1 level of benefits, except for emergency hospital observation or admissions. Claims for emergency hospital observation or admissions that occur at WellSpan Provider Network or non-wellspan facilities will be covered at the Tier 1 WellSpan Provider Network benefit level (subject to usual, customary & reasonable limits) and any per-admission co-payment will not apply. This includes all services you or your dependent receives while in observation or inpatient.. Aetna Signature Administrators Tier 2 Aetna Signature Administrators (ASA) is a national network. When you use an ASA provider, you receive the Tier 2 benefit level. Generally, benefits are paid at 80% after the calendar year deductible and the injectable drug deductible. There are also office and facility co-payments. Your expenses are limited with an out-of-pocket maximum. Visit the ASA web site at or call SOUTH CENTRAL Preferred for information about participating providers. Out-Of-Network Tier 3 Providers and facilities who do not participate with any of the networks receive the Tier 3 level of benefits. Generally, benefits are paid at 50% after the calendar year deductible and injectable drug deductible as well as facility co-payments. Your expenses are limited with an out-of-pocket maximum. Remember, you will also be responsible for any amounts in excess of the usual, customary & reasonable charge. Medical Management Services Utilization Review and Pre-Certification Modify page WP-8 and WP-9 Utilization review is a program designed to help you and your covered dependents receive necessary, appropriate, and cost-efficient health care. For certain inpatient care and outpatient procedures, you or your provider will need to notify the Plan. How this is done depends upon your circumstances. There are two Medical Management organizations that will work together to manage your care - SOUTH CENTRAL 4

5 Preferred s Medical Management Department and Active Health. Active Health is the Medical Management organization for Aetna Signature Administrators. Contact phone numbers are listed on the back of your medical identification card. If you live in Pennsylvania and the service is at a WellSpan Provider Network or a WellSpan-owned service location, your provider is responsible for calling SOUTH CENTRAL Preferred with your precertification information. If you live in Pennsylvania and the service is at an Aetna Signature Administrator provider or out-ofnetwork service location, you are responsible for calling Active Health with your pre-certification information. Depending where you are receiving care, Active Health may assist you in contacting SOUTH CENTRAL Preferred to complete your pre-certification. If you do not live in Pennsylvania, regardless of your provider choice, you are responsible for calling Active Health with your pre-certification information. Regardless of where you live, if you need an injectable drug that requires pre-certification from a WellSpan Provider Network or WellSpan-owned provider, your provider is responsible for calling SOUTH CENTRAL Preferred with your pre-certification information. If you choose an Aetna Signature Administrator or out-of-network provider for your injectable drug, you are responsible for calling SOUTH CENTRAL Preferred with your pre-certification information. If you, your Aetna Signature Administrator provider, or out-of-network provider fail to call when required, you will not receive the highest level of benefits under the Plan. It is important to discuss this with your provider when you need one the services listed below. Pre-Certification and Utilization Review Is Required for all Non-Emergency: Inpatient Admissions Medical/Surgical Inpatient Hospice Skilled Nursing Facility Inpatient Rehabilitation program Procedures Abdominoplasty Arthroscopic Surgery (excludes knee & shoulder) Bariatric Surgery Blepharoplasty Cardiac CT Angiography Esophagogastroduodenoscopy (EGD) Colonoscopies (under age 50) MRI of Spine (cervical, thoracic, lumbar) Nuclear Stress Test Orthognathic Surgery Perinatology Consultation PET Scans/PET CT Scans Reduction Mammoplasty Referral to a Transplant Center Rhinoplasty/Septoplasty Temporomandibular Joint Dysfunction (TMJ) Surgery Uvulopalatoplasty MRI of Brain Pre-Notifications All maternity cases, as soon as a diagnosis of pregnancy has been established All genetic testing All outpatient clinical trials Home Health Care Aide Care Hospice Infusion Therapy Skilled Nursing Private Duty Nursing Durable Medical Equipment & Orthotics Apnea Monitor Bone Growth Stimulator CPAP/BIPAP Hospital Bed Insulin Pump Wheelchair/Scooter Lymphedema Pump Muscle Stimulator Oxygen Therapy Patient Lift/Stair Chair UV Light Therapy Wound Vac Injectable Drugs Certain Injectable drugs. You or your provider must call SCP s Customer Service Department to pre-certify. 5

6 Prescription Drug Benefits Prescription Drugs Through the Prescription Benefit Manager (PBM) Modify on page PA-1 The has contracted with a Prescription Benefit Manager (PBM) to administer the prescription drug benefits. The Prescription Benefit Manager takes advantage of a network of participating pharmacies, allowing you to purchase prescription drugs for a per-prescription copayment or co-insurance. There is no deductible for the prescription drug benefits. There is an out-of-pocket maximum. Mail order prescription benefits are also included in the prescription drug benefit program. It is also important to remember that certain prescription drugs must be pre-authorized and that certain specialty drug prescriptions can only be filled at a WellSpan Pharmacy! Specialty Prescription Drug Benefit Modify on page PD-2 The PBM and Claims Administrator for the WellSpan Health prescription drug benefits is Catamaran. The Plan uses the Catamaran Value Formulary. As this formulary is subject to change throughout the year, copies of the formulary may be requested by calling (844) or by visiting the Catamaran web site at A select group of specialty drugs may only be obtained through a WellSpan Pharmacy. This does not include drugs supplied or administered by your physician in his/her office. WellSpan Pharmacy will fill your prescription through its WellSpan Infusion Service. A one-time emergency fill of these medications is allowed at a non-wellspan pharmacy for emergency situations when dispensing by a WellSpan Pharmacy is not possible. Call SOUTH CENTRAL Preferred s Customer Service Department at (800) or (717) for the list of specialty prescription drugs or go to under My WellSpan benefits for a list of the drugs. To have your prescription drug filled at WellSpan Infusion Services, take your prescription to any WellSpan Pharmacy. For more information call WellSpan Infusion Services at (877) and your specialty support team will assist you. Specialty prescription drugs treat chronic and complex conditions such as hepatitis C, multiple sclerosis and rheumatoid arthritis. These drugs require frequent dosing adjustments, intensive clinical monitoring, patient training, and specialized handling. They may also require specialized administration, such as an injection. Your PBM, Catamaran, also includes a specialty drug pharmacy, called BriovaRX. You can contact them at (855) or visit their web site at if you require a specialty prescription drug and a WellSpan Health pharmacy is unable to fill your prescription. Remember, some specialty prescription drugs may only be filled through WellSpan Pharmacy! 6

7 Prescription Drug Benefits Modification to page PD-8 Prescription Drug Schedule of Benefits TYPE OF EXPENSE Tier 1 NETWORK BENEFITS WellSpan Health Pharmacy Tier 2 NETWORK BENEFITS Prescription Benefit Manager Tier 3 OUT-OF-NETWORK BENEFITS CO-PAYMENT/COINSURANCE LIMIT PER CALENDAR YEAR Per Covered Person $2,000 None Per Family Unit $4,000 None Only Prescription Drug co-payments and coinsurance counts towards this limit. Once met, the Plan pays 100% coinsurance of covered charges for the rest of the Plan Year. RETAIL (UP TO 34-DAY SUPPLY) Some Specialty Drugs are only covered if obtained from WellSpan Infusion Services. Specialty Drugs may be limited to a 30 day fill. When a generic is available, you will be responsible for any amount over the generic drug cost, even if the prescription states dispense as written or brand medically necessary. Generic Drugs $10 co-payment, 20% with a $10 minimum coinsurance, insurance, then 20% with a $10 minimum co- 100% Brand-Name Formulary Drugs Brand-Name Non- Formulary Drugs $25 co-payment, 25% with a $25 minimum coinsurance, $50 co-payment, 45% with a $50 minimum coinsurance, 25% with a $25 minimum coinsurance, 45% with a $50 minimum coinsurance, RETAIL (UP TO 100-DAY SUPPLY) Only available at a WellSpan Pharmacy. Some Specialty Drugs are only covered if obtained from WellSpan Infusion Services. Specialty Drugs may be limited to a 30 day fill. When a generic is available, you will be responsible for any amount over the generic drug cost, even if the prescription states dispense as written or brand medically necessary. Generic Drugs $20 co-payment, Brand-Name Formulary Drugs $50 co-payment, Brand-Name Non- Formulary Drugs $100 co-payment, WELLSPAN PHARMACY MAIL ORDER (UP TO 100-DAY SUPPLY) Some Specialty Drugs are only covered if obtained from WellSpan Infusion Services. Specialty Drugs may be limited to a 30 day fill When a generic is available, you will be responsible for any amount over the generic drug cost, even if the prescription states dispense as written or brand medically necessary. Generic Drugs Brand-Name Formulary Drugs Brand-Name Non- Formulary Drugs $20 co-payment, then 100% $50 co-payment, then 100% $100 co-payment, then 100% 7

8 TYPE OF EXPENSE Tier 1 NETWORK BENEFITS WellSpan Health Pharmacy Tier 2 NETWORK BENEFITS Prescription Benefit Manager Tier 3 OUT-OF-NETWORK BENEFITS PREVENTIVE DRUGS Requires a Physician s prescription Pediatric Fluoride $0 co-payment $0 co-payment Tamoxifen and Raloxifene* $0 co-payment $0 co-payment Breast cancer preventive medication Vitamin D Age 65+ and at risk for falls Iron Supplements Under age 1 Generic Tobacco Cessation Drugs and Aids* Brand-name formulary or brand-name nonformulary if a generic does not exist or the generic would be medically inadvisable according to the prescribing physician Contraceptives Drugs and Devices* $0 co-payment $0 co-payment $0 co-payment $0 co-payment $0 co-payment $0 co-payment $0 co-payment $0 co-payment *Catamaran cannot process some drugs, devices or aids - or cannot process it with a $0 co-payment. In those cases, a claim for an item or a claim for the Plan s Prescription Drug Plan co-payment/coinsurance must be submitted to the Medical Plan along with a physician prescription. See the section Covered Prescription Drugs for more information about this Plan benefit. Mental Health and Chemical Dependency Benefits Your Out-Of-Pocket Costs Modify on pages MH-4 Out-Of-Pocket Maximum To protect you and your family from the cost of catastrophic claims, the Plan has calendar year out-ofpocket maximums. This means the amount you pay each calendar year for covered expenses is limited. Your out-of-pocket is the amount for which you are responsible after the Plan pays its normal coinsurance. Amounts applied to your out-of-pocket maximums accumulate across the WellSpan and Quest Networks. Services received from WellSpan Provider Network providers and Quest Network providers both are credited towards the same out-of-pocket maximum. The out-of-pocket maximum for out-of-network services is separate and does not accumulate with the network out-of-pocket. 8

9 Once an annual out-of-pocket maximum has been reached within the calendar year, the Plan will pay 100% of covered charges for the remainder of the calendar year, under that benefit level, subject to any limitations. Certain expenses do not count toward an out-of-pocket maximum, including: Your Plan contributions Expenses over the usual, customary & reasonable limits Any penalties for not following pre-certification requirements; and Services that the Plan does not cover. Out-of-pocket maximums accrued under the medical benefits and mental health and chemical dependency benefits are combined, according to each benefit tier. Terms You Should Know Terms You Should Know Modify on page TM-18 Usual and Customary Charge (UC&R) (WellSpan Plus Only) Defined: For a network provider (WellSpan Provider Network or Aetna Signature Administrators) the contracted fee schedule; or For an out-of-network provider it will be the fee assessed by a provider that will not exceed the general level of charges made by others rendering or furnishing such services within the area where the charge is incurred and is comparable in severity and nature to the sickness or injury. Due consideration will be given to any medical complications or unusual circumstances which require additional time, skill, or experience. The usual and customary charge is determined from a statistical review and analysis of the charges for a given procedure or service in a given area. The term area as it would apply to any particular services means a zip code area or such greater area as is necessary to obtain a representative cross-section of the level of charges. If a provider submits a charge that is lower than the UC&R charge for a service, the Plan will reimburse the provider for the actual amount of the charge. The Plan Administrator has discretionary authority to decide whether a charge is usual and customary. This means the Plan may use other methodologies and accepted sources (such as Medicare), to determine the usual and customary charge. 9