PEIA PPB Plan A Benefits At a Glance

Transcription

1 PEIA PPB Plan A Benefits At a Glance Benefit Description PEIA PPB Plan A In-Network PEIA PPB Plan A Out-of-Network Annual deductible Varies by salary and employer type. See premium charts. Twice the in-network deductible Annual out-of-pocket maximum Varies by salary, employer type, and coverage tier. The out of pocket maximum for employee and child(ren), family, or family with employee spouse is 150% of the employee only amount. See premium charts. Lifetime maximum None None Twice the in-network out-ofpocket maximum Adult routine physical examinations $10 co-pay for office visit Deductible + 40% + amounts that Diagnostic x-ray, lab and testing Deductible + 20% Deductible + 40% + amounts that Mammograms, Pap smears, and prostate cancer screenings Covered in full Deductible + 40% + amounts that Physician inpatient visits Deductible + 20% Deductible + 40% + amounts that Physician office visits - primary care $15 co-pay office visit only Deductible + 40% + amounts that Physician office visits - specialty care $20 co-pay office visit only Deductible + 40% + amounts that Prenatal care Covered in full after deductible Deductible + 40% + amounts that Second surgical opinions $20 co-pay office visit only Deductible + 40% coinsurance (office visit only) + amounts that Voluntary sterilization Deductible + 20% Deductible + 40% + amounts that Well child exams Covered in full Covered in full Well child immunizations (birth through 16) Covered in full Covered in full Semiprivate room; ancillaries; therapy services, x- ray, lab, surgical services, and general nursing care Inpatient occupational, physical, or speech therapy* Maternity care (delivery) Deductible + 20% $500 + Deductible + 40% +

2 Rehabilitation* Deductible + 20% $500 + Deductible + 40% + Skilled nursing* Deductible + 20%. $500 + Deductible + 40% + Ambulatory/outpatient surgery $50 + deductible + 20% $100 + Deductible + 40% + Preadmission testing, diagnostic x-ray and lab Deductible + 20% Deductible + 40% + amounts that Outpatient chemical dependency* Deductible + 20% Deductible + 40% + amounts that Outpatient mental health* Deductible + 20% Deductible + 40% + amounts that Inpatient chemical dependency (including partial hospitalization) * Inpatient detoxification* Inpatient mental health (including partial hospitalization) * Acupuncture* Deductible + 20% Deductible + 40% + amounts that ; Chiropractic* Deductible + 20% Deductible + 40% + amounts that Massage Therapy* Deductible + 20% Deductible + 40% + amounts that Occupational therapy* Deductible + 20% Deductible + 40% + amounts that Physical therapy* Deductible + 20% Deductible + 40% + amounts that Speech therapy* Deductible + 20% Deductible + 40% + amounts that

3 Allergy testing and treatment Deductible + 20% Deductible + 40% + amounts that Cardiac rehabilitation* Deductible + 20% Deductible + 40% + amounts that Dental services - accident related* Deductible + 20% Deductible + 40% + amounts that Dental services - other* Diabetic supplies* Impacted teeth only; deductible + 20% Covered under Prescription drug Impacted teeth only; Deductible + 40% + amounts that exceed PEIA s fee Covered under Prescription drug Durable Medical Equipment (DME) * Deductible + 20% Deductible + 40% + amounts that Emergency ambulance (medically necessary) Deductible + 20% Deductible + 40% + amounts that Emergency Room Treatment (Non-emergency) $50 + deductible+ 20% $50 + Deductible + 40% + Emergency services (including supplies) * $25 + deductible + 20% $25 + deductible + 40% + Growth hormone* Covered under prescription drug Covered under prescription drug Hearing exam Covered under well child benefit only Covered under well child benefit only Home health services* Deductible + 20% Deductible + 40% + amounts that Home health supplies* Deductible + 20% Deductible + 40% + amounts that Hospice* Deductible + 20% Deductible + 40% + amounts that Infertility services* Deductible + 20% Deductible + 40% + amounts that No Prescription Coverage under any. Medical supplies* Deductible + 20% Deductible + 40% + amounts that Podiatry* $20; surgery- 20% Deductible + 40% + amounts that

4 Prosthetics * Deductible + 20%. Deductible + 40% + amounts that Pulmonary rehabilitation* Deductible + 20% Deductible + 40% + amounts that Radiation and chemotherapy Deductible + 20% Deductible + 40% + amounts that TMJ* Not covered Not Covered Transts (non-experimental) * Deductible + 20% Deductible + 40%; + amounts that additional $10,000 deductible Urgent Care Deductible + 20% Deductible + 40% + amounts that

5 PEIA PPB Plan A Prescription Benefits Prescriptions PEIA PPB Plan A In-Network PEIA PPB Plan A Out-of-Network Deductible $75 individual/ $150 family $75 individual/$150 family Annual out-of-pocket maximum $1,750 individual/ $3,500 family $1,750 individual/ $3,500 family Generic copayment $5 $5 (see other details below) Formulary brand $15 $15 (see other details below) Non-Formulary Brand $50 $50 (see other details below) Specialty Medications $50 Not covered Maintenance Medication discount program details 90-day supply for two months' co-pay No discount Annual benefit maximum (per member/year) Other details None None PEIA will reimburse Express Scripts allowed amount, less any member responsibility.