2012 HealthPartners Distinctions Customer Service Medical: or

Transcription

1 2012 HealthPartners Distinctions Customer Service Medical: or Web-Site Address Service Area Pharmacy: Medco Medical: - to find in-network providers select either Find a Doctor/Dentist or Find a Clinic/Hospital under Search the Distinctions II network. Pharmacy: Minnesota counties: Aitkin, Anoka, Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Clearwater, Cook, Cottonwood, Crow Wing, Dakota, Dodge, Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Hubbard, Isanti, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching, Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Pipestone, Polk, Pope, Ramsey, Red Lake, Redwood, Renville, Rice, Rock, Roseau, Scott, Sherburne, Sibley, St. Louis, Stearns, Steele, Stevens, Swift, Todd, Traverse, Wabasha, Wadena, Waseca, Washington, Watonwan, Wilkin, Winona, Wright, Yellow Medicine counties. Wisconsin counties: Adams, Ashland, Barron, Bayfield, Buffalo, Burnett, Chippewa, Clark, Crawford, Douglas, Dunn, Eau Claire, Grant, Iron, Jackson, Juneau, La Crosse, Lincoln, Marathon, Monroe, Oneida, Pepin, Pierce, Polk, Portage, Price, Richland, Rusk, Sauk, Sawyer, St. Croix, Taylor, Trempealeau, Vernon, Vilas, Washburn, Wood counties. Nurse Line CareLine or Primary Care Clinic Selection Deductible Annual Out-of-Pocket Maximum (medical) Lifetime Maximum Physician Services Office Visits, Preventive Care, Specialist Office Visits Prescription Drugs Retail Home Delivery Not required. Use any participating provider in the Distinctions Network. For medically necessary services provided by HealthPartners providers. None (except retail pharmacy). Copayments apply. $1,850 per individual, $3,700 per family. $1,500 per person prescription Out-of- Pocket maximum for home delivery is separate from medical Out-of-Pocket maximum. Unlimited lifetime maximum. $10,000 infertility maximum and $5,000 non-surgical TMJ maximum - combined both In and. Includes all medical and prescription claims for all company sponsored self-insured plans. Administered by Medco $15 copayment for generic drugs, $39 copayment for brand formulary drugs, $63 copayment brand non-formulary; up to a 30-day supply. $65 deductible per person per calendar year, $130 total family deductible per calendar year. Deductible applies to retail pharmacy only. $37 copayment for generic drugs, $97 copayment for brand formulary drugs, $157 copayment for brand non-formulary drugs; up to a 90-day supply. No deductible required on home delivery.. For medically necessary services provided by providers not associated with the Distinctions Network. Applies to eligible expenses. None Copayments apply. $5,000 per individual, $10,000 per family. Unlimited lifetime maximum. $10,000 infertility maximum and $5,000 non-surgical TMJ maximum - combined both In and. Includes all medical and prescription claims for all company sponsored self-insured plans. 50% of the Medco discounted price for the medication.

2 Prescription Drugs Maintenance Medications From the 4 th fill and on, copayment will be 50% of the cost of the medication if filled at a retail pharmacy (minimum of 1x retail copayment and a maximum of 2x the retail copayment for a 30 day supply). Maternity Hospital Office Visits Inpatient Services Hospital Outpatient Services Lab/X-ray Surgery Annual out-of-pocket limit: $1,500 per person applies to home delivery only and does not include the deductible. Prescription out-of-pocket maximum is separate from medical out-of-pocket. Generic Drug Incentive Program (applies to both the retail pharmacy and home delivery) - if you prefer a brand name drug when a generic drug is available, you will pay the brand name copayment of $39/$97 plus the difference in cost between the brand name drug and the generic drug. Copayment level 1: $500 copayment per day (separate copayment applies to mother and newborn); up to 3 days or $1,500 maximum per admission. Copayment level 2: $600 copayment per day (separate copayment applies to mother and newborn); up to 3 days or $1,800 maximum per admission. Copayment level 1: $30 copayment for initial visit; 100% thereafter for office visits. Copayment level 2: $45 copayment for initial visit; 100% thereafter for office visits. Copayment level 1: $500 copayment per day; up to 3 days or $1,500 maximum per admission. Copayment level 2: $600 copayment per day; up to 3 days or $1,800 maximum per admission. 100% coverage. $250 copayment for outpatient surgery performed in outpatient surgery facility or hospital. Level 1 and 2 copayments apply to outpatient services performed in a clinic setting. (separate copayment applies to mother and newborn) or $1,500 maximum per admission plus 70% coinsurance. or $1,500 maximum per admission plus 70% coinsurance. 70% coverage. 100% for Mental Health/Chemical Dependency diagnosis. $500 copayment plus 70% coinsurance for outpatient surgery performed in outpatient surgery facility or hospital. $60 copayment; 70% thereafter for outpatient services performed in a clinic setting.

3 Outpatient Services Therapy Physical, speech & occupational Physical, speech & occupational Mental Health Inpatient Outpatient Chemical Dependency Inpatient Maximum of 35 visits per calendar year per therapy for combined In and Out-of- Network services. $500 copayment per day; up to 3 days or $1,500 maximum per admission-unlimited number of days. $30 copayment; 100% thereafter per office visit-unlimited number of visits. $500 copayment per day; up to 3 days or $1,500 maximum per admission-unlimited number of days. Maximum of 35 visits per calendar year per therapy for combined In and Out-of- Network. or $1,500 maximum per admission plus 70% coinsurance-unlimited number of days. office visit-unlimited number of days. or $1,500 maximum per admission plus 70% coinsurance-unlimited number of days. Outpatient $30 copayment; 100% thereafter per office office visit-unlimited number of visits. visit-unlimited number of days. Emergency Services An emergency exists when there is reason to believe that a serious medical condition exists or the absence of medical attention would result in a threat to the person s life, limb, or sight and requires immediate medical Emergency Services Ambulance treatment. This includes the treatment of severe pain. 80% coverage for medical emergency if emergency criteria are met. 80% coverage for medical emergency if emergency criteria are met. Emergency Care Urgent/After Hours Care Vision/Hearing Exams Vision/Hearing Eyewear Hearing Aids Miscellaneous Services Chiropractic Durable Medical Equip $150 copayment, then 100% coverage; emergency copayment waived if admitted for the same condition within 24 hours and inpatient hospital copayment applies. $45 copayment; 100% thereafter per Discounts available. $45 copayment; 100% thereafter per Up to 20 visits per year combined In and. 80% coverage of eligible expenses up to a maximum of $10,000 per calendar year for each prosthesis or piece of durable medical equipment (DME). $150 copayment plus 70% coinsurance; emergency copayment waived if admitted for the same condition within 24 hours and inpatient hospital copayment applies. office visit. Up to 20 visits per year combined In and Out-of-network. 70% coverage of eligible expenses up to a maximum of $10,000 per calendar year for each prosthesis or piece of durable medical equipment (DME).

4 Miscellaneous Services Home Health Care 100% coverage. 70% coverage. Infertility Podiatrist Skilled Nursing Facility Dental Accidental TMJ Copayment level 1: 80% coverage of eligible expenses; up to $10,000 lifetime maximum.* Copayment level 2: 80% coverage of eligible expenses; up to $10,000 lifetime maximum.* *$10,000 lifetime combined In and (includes drugs). No coverage for maintenance care or routine foot care including over-thecounter orthotics. 100% coverage up to 180 days for each period of confinement for combined In and services when approved by plan manager. 80% coverage for treatment of accident related injury to natural teeth. All other dental treatment not covered. For all accidental dental services, treatment and repair must be initiated within 12 months of the date of injury and completed within 24 months of the date of injury. Surgical: Copayment level 1: $500 copayment per day; up to 3 days or $1,500 maximum per admission. Copayment level 2: $600 copayment per day; up to 3 days or $1,800 maximum per admission. No coverage for appliances or orthodontia. Non-Surgical: $45 copayment; then 100% of eligible expenses thereafter per office visit up to a $5,000 lifetime maximum for x-ray/lab, chiropractor, PT/OT, prescription medications, Behavioral Modifications and other non-surgical medical services. No coverage for appliances or orthodontia. 70% after specialist and facility copayments; up to $10,000 lifetime combined In network and Out-of- Network (includes drugs). 70% up to 180 days for each period of confinement for combined In and Outof-Network services when approved by plan manager. 80% coverage for the initial visit for treatment of accident related injury to natural teeth; 70% coverage thereafter of the charges incurred for subsequent visits. All other dental treatment not covered. For all accidental dental services, treatment and repair must be initiated within 12 months of the date of injury and completed within 24 months of the date of injury.

5 Coverage available. Coverage available. Same-sex Domestic Partners This is only a summary of coverage provided and is not intended to reflect all benefits, limitations, or exclusions. In the event there is a discrepancy between the information presented here and the actual plan document, the terms of the plan document will prevail. General Mills believes this plan is a grandfathered health plan under the Affordable Care Act. If you have questions regarding the grandfathered status of the health plan, please contact the HR Service Center at or Denotes change for 2012