Benefits At A Glance

Transcription

1 Benefits At A Glance In-Network Out-Network Annual Deductibles and Out-of-Pocket Maximums Deductible Individual An upfront $1,500 deductible per covered member will apply An upfront $3,000 deductible per covered member will apply Deductible Family An upfront $3,000 deductible per family will apply An upfront $6,000 deductible per family will apply Individual Out-of-Pocket Maximum $2,500 per year for Employees with annualized base pay of $50,000 or less; $4,000 per year $8,000 for Employees with annualized base pay of more than $50,000. Family Out-of-Pocket Maximum $5,000 per year for Employees with annualized base pay of $50,000 or less; $8,000 per family with a per individual max of $16,000 $6,850 for Employees with annualized base pay of more than $50,000. Lifetime Maximum None None Preventive Care Periodic physicals for adults Well-child care (including routine exams, injections and immunizations) Annual Preventive Mammograms, Prostate Screenings and Pap Smears Annual Preventive Colonoscopies, Endoscopies and Sigmoidoscopies Preventive Lab & X-ray Physician Office and Physician's Staff Services Primary Care Office Visit Waived if preventive. - Specialist Office Visit Waived if preventive. Office or home visits (including allergy injections) plan plan plan

2 X-ray and Laboratory Services Diagnostic X-ray and laboratory, including CAT Scan, MRI Preventive X-ray and laboratory Inpatient Hospital Services Anesthesiologist Inpatient physical, occupational and speech therapy Other Necessary Services and Supplies Physician/Surgeon Services Semi-private Room and Board Outpatient Hospital Services Chemotherapy Colonoscopy, Endoscopy and Sigmoidoscopy Dialysis Infusion Therapy speech therapy to treat developmental delay is not covered. Waived if preventive. plan plan plan speech therapy to treat developmental delay is not covered. plan plan plan plan plan plan plan

3 Other Medically Necessary Services and Supplies Physicians' and Surgeons' Charges Pre-Admission Testing Surgery (including services and supplies) Emergency Care Emergency Care for a lifethreatening condition See Covered Services & Supplies Section for an explanation of what constitutes Emergency Care. Non-Emergency Care Ambulance for emergencies (to the nearest facility providing adequate care) Ambulance transportation from one facility to another if medically necessary Air Ambulance if medically necessary Maternity Care Office visits for Prenatal & Postnatal care if not medically necessary. Waived if preventive. plan plan plan plan All out-of-network Emergency claims will be paid at the in-network benefit level. plan All out-of-network Emergency claims will be paid at the in-network benefit level. plan If precertification is approved by both facilities then benefit is paid at the innetwork level. plan pays 80% after deductible; plan pays 100% if not medically necessary plan

4 Birth Center (including certified Nurse-Midwife), where available Delivery Other Services Blood and blood transfusions (including administrative fees for collection) Durable Medical Equipment Injury to sound, natural teeth by an external force Organ Transplants Orthogenetic Surgery Overseas Coverage Prosthetics If the health plans network transplant program is utilized the deductible applies; then the plan pays 100%. If the health plans network transplant program is not utilized, the deductible applies; then the plan pays 80%. After deductible; plan pays 100% after out-of-pocket is Plan pays travel & lodging benefits up to $10,000. plan pays 80% after deductible to repair or correct a severe facial deformity or disfigurement that orthodontics alone cannot correct. Plan pays 100% after out-ofpocket See Section 5.B. for details. Emergency, Urgent Care and other conditions which require immediate treatment are covered at the In-network benefit level. Other covered services paid at Out-of- Network benefit level; preventive care is excluded. plan plan plan plan plan The deductible applies; then the plan pays 50%. After deductible; plan pays 100% after out-of-pocket is plan pays 50% after deductible to repair or correct a severe facial deformity or disfigurement that orthodontics alone cannot correct. Plan pays 100% after out-of-pocket See Section 5.B. for details. Emergency, Urgent Care and other conditions which require immediate treatment are covered at the In- network benefit level. Other covered services paid at Out-of-Network benefit level; preventive care is excluded. plan

5 Urgent Care Other Services - Limits combined for In-network and Out-of network Chiropractic Care Deductible applies; then plan pays 80% after deductible; plan pays 100% after out-of-pocket maximum is reached to a maximum of 30 visits per calendar year (on a combined in-network and out-ofnetwork basis). BCBS - Upfront deductible applies; then plan pays 80% after deductible; plan pays 100% after out-of-pocket To a maximum of 120 visits per calendar year. Home Health Care Cigna - Upfront deductible applies; then plan pays 80% after deductible; plan pays 100% after out-of-pocket To a maximum of 120 days per calendar year Hospice maximum is reached up to 180 days. Orthotics Outpatient Physical Therapy Outpatient speech and/or occupational therapy plan pays 80% after deductible; plan pays 100% reached to a maximum of one per calendar year (except for individuals with diabetes, in which case this limit will not be imposed). The following items are excluded: arch supports, lifts, inserts, wedges, soles, and those available over the counter. To a maximum of 30 visits per calendar year. Deductible applies; then plan pays 80% after deductible; plan pays 100% after out-of-pocket maximum is reached to a maximum of 30 visits per calendar year. Speech therapy to treat developmental delay is not covered. All out-of-network Emergency facility claims will be paid at the in-network benefit level.. plan 100% reached to a maximum of 30 visits per calendar year (on a combined innetwork and out-of-network basis). BCBS - Upfront deductible applies; then plan pays 50% after deductible; To a maximum of 40 visits per calendar year. Cigna - plan pays 50% after deductible; plan pays 100% after out-of-pocket To a maximum of 40 days per calendar year. plan 100% reached up to 180 days. plan pays 50% after deductible; plan pays 100% after out-of-pocket maximum is reached to a maximum of one per calendar year (except for individuals with diabetes, in which case this limit will not be imposed). The following items are excluded: arch supports, lifts, inserts, wedges, soles, and those available over the counter. plan 100% To a maximum of 30 visits per calendar year. Deductible applies; then plan pays 50% after deductible; plan pays 100% after out-of-pocket maximum is reached to a maximum of 30 visits per calendar year. Speech therapy to treat developmental delay is not covered.

6 Private Duty Nursing Skilled Nursing/Extended Care Facility TMJ (Temporomandibular Joint) Dysfunction Mental Health/Substance Abuse Inpatient Outpatient Prescription Drugs Prescription Drugs dispensed at network pharmacies Mail-Order Maintenance Prescription Drugs maximum is reached limited to outpatient care given by a licensed nurse (RN, LPN or LVN) for professional nursing services at the direction of a doctor. maximum is reached to a maximum of 120 days per calendar year. maximum is reached for services received in an Inpatient or Outpatient facility. All treatment must be pre-approved. Generic Preventive medications at mail order are provided at no cost. Generic Preventive medications at mail order are provided at no cost. Not Covered plan 100% reached to a maximum of 120 days per calendar year. plan 100% reached for services received in an Inpatient or Outpatient facility. plan plan plan No mail order available. plan No mail order available. Voluntary Family Planning (birth control, vasectomy, tubal ligation) Limits combined for In and Out-of- Network Office Visits maximum reversals of sterilization are not covered. Infertility treatments are limited to a total of $5,000 maximum per Covered Person per lifetime. Women s preventive services are covered at 100% plan 100% after out-of-pocket maximum reversals of sterilization are not covered. Infertility treatments are limited to a total of $5,000 maximum per Covered Person per lifetime.

7 Hospital Outpatient visit Vision Care Refer to the Vision Care Section for routine vision care coverage Hearing Care Office visit, audiometric exam, hearing aid evaluation Hearing aid, including mold maximum reversals of sterilization are not covered. Infertility treatments are limited to a total of $5,000 maximum per Covered Person per lifetime. Women s preventive services are covered at 100% Provided by Vision Service Plan. plan pays 100% plan pays 100%. Plan pays a maximum of $1,500 per hearing aid. plan 100% after out-of-pocket maximum reversals of sterilization are not covered. Infertility treatments are limited to a total of $5,000 maximum per Covered Person per lifetime. plan 100% plan pays 80% after deductible; plan pays 100%. Plan pays a maximum of $1,500 per hearing aid. This document summarizes the current terms of certain employee benefit plans and programs available to Honeywell employees. Honeywell's formal employee plan documents govern the terms and conditions of the plans. The information provided in this presentation and oral and written statements made by a supervisor or human resources representative cannot change the terms and condition of the written plans. Honeywell has reserved the right to modify, change, and revise the terms and conditions of the Company's employee benefits plans, as well as the right to terminate the plans (subject to applicable collective bargaining agreements). Honeywell has also reserved the right to change the premiums charged to employees and other cost sharing features of the Company's employee benefit plans (subject to applicable collective bargaining agreements). The information provided in this presentation is not a guarantee of the future availability or design of the Company's employee benefits.