ASCENSION PARISH SCHOOL BOARD SCHEDULE OF BENEFITS PLAN NAME Ascension Parish School Board PPO Plan - Option 2 GROUP NUMBER 78J79ERC PLAN'S ORIGINAL BENEFIT PLAN DATE PLAN'S AMENDED BENEFIT PLAN DATE PLAN'S ANNIVERSARY DATE February 1, 2016 November 1, 2018 November 1 st BENEFIT PERIOD: November 1 through October 31 BENEFIT PERIOD DEDUCTIBLE AMOUNTS: NETWORK ALL OTHER PROVIDERS Individual Deductible Amount: $1,000 $1,000 Family Deductible Amount*: $2,000 $3,000 * A Plan Participant does not have to meet the Individual Benefit Period Deductible Amount to be eligible for the Family Deductible Amount. SPECIAL NOTES: Benefits for services of Network Providers that accrue to the Deductible Amount for Network Providers WILL NOT accrue to the Deductible Amount for Non-Network Providers. Benefits for services of Non-Network Providers that accrue to the Deductible Amount for Non-Network Providers WILL NOT accrue to the Deductible Amount for Network Providers. Benefits for Emergency Services of Network and Non-Network Providers WILL accrue to the Deductible Amount for Network Providers. The Benefit Period Deductible Amount does not apply to the following services when performed by Network Providers: Preventive or Wellness Care Allergy Testing, Injections, Serums and Vials of Medication Spinal manipulations performed by a Chiropractor Services for which a Copayment is applicable such as Office Visits, Emergency Room, Skilled Nursing Facility, Inpatient Facility, Outpatient Surgical Facility, Physical Therapy, Occupational Therapy and Speech Therapy 40HR2293 R11/18 1.
OUT-OF-POCKET AMOUNT Includes the Deductible Amount, Coinsurance and Copayments. Network Providers Individual: $3,500 Family: $7,000 All Other Providers (Non-Network) Individual: $4,000 Family: $12,000 SPECIAL NOTES: Benefits for services of Network Providers that accrue to the Out-of-Pocket Amount for Network Providers WILL NOT accrue to the Out-of-Pocket Amount for Non-Network Providers. Benefits for services of Non-Network Providers that accrue to the Out-of-Pocket Amount for Non-Network Providers WILL NOT accrue to the Out-of-Pocket Amount for Network Providers. Benefits for Emergency Services of Network and Non-Network Providers WILL accrue to the Out-of-Pocket Amount for Network Providers. MEDICAL BENEFITS COPAYMENTS AND COINSURANCE: NETWORK PROVIDERS ALL OTHER PROVIDERS Deductible applies unless otherwise stated. Coinsurance is shown as Company - Plan Participant responsibility. Copayments shown are the Plan Participant's responsibility. Primary Care Provider (PCP) Office Visits for the following: $30.00 per visit 70% - 30% Family Practice General Practice Internal Medicine Geriatrics Pediatrics Nurse Practitioner Obstetrician / Gynecologist Certified Mid-Wife Physician Assistant Retail Health Clinic Specialists Office Visits for all other Providers: $45.00 per visit 70% - 30% Allergy Testing, Injections, Serums and Vials of Medication: 100% 70% - 30% 40HR2293 R11/18 2.
Chiropractic Services: Office Visits $30.00 per visit 70% - 30% Spinal Manipulations 80% - 20% 70% - 30% Urgent Care: $45.00 per visit 70% - 30% Emergency Ambulance Services: 80% - 20% 80% - 20% Emergency Medical Services performed in the Emergency Department of a Hospital: Includes Facility and Professional/Physician Services. Copayment waived if admitted. $150.00 per visit then 100% $150.00 per visit then 100% Inpatient Hospital Admission Includes Inpatient Hospital Facility Services and Professional / Physician Charges. Outpatient Surgical Services Facility Charges: $150.00 per visit then 100% 70% - 30% Outpatient Surgical Services Professional / Physician Charges: Hearing Aids: See the Other Covered Services, Supplies or Equipment Article for more details and limitations on Hearing Aids Benefits. Home Healthcare: Limited to 150 visits per Plan Participant each Benefit Period. Hospice Care: Mental Health and Substance Use Disorder: Office visit for Mental Health and Substance Use Disorder $45.00 per visit 70% - 30% All Other Mental Health and Substance Abuse Services Organ, Tissue, and Bone Marrow Transplants: Authorization required prior to services being performed. See Travel, Lodging, and Meal Expenses for details. Prenatal Care for an Employee, Spouse or Dependent Child: $30.00 per visit 70% - 30% Includes Physician services performed in an office visit only. Pregnancy Care services received from other Providers (such as a Hospital, Emergency Room, Urgent Care Center or Ambulatory Surgical Center), are subject to the applicable Copayments, Deductible and Coinsurance shown for each. 40HR2293 R11/18 3.
Preventive or Wellness Care: See the Preventive or Wellness Care Article for more details on Preventive or Wellness Care Benefits. 100% Not Covered Low-Tech Imaging and High-Tech Imaging: Low-Tech Imaging such as x-rays, lab tests and machine tests. Performed within the office or clinic of a Network Provider that is subject to the applicable Office Visit Copayment. 100% 70% - 30% Performed within a Network Independent Lab / Facility. High-Tech Imaging such as CT, MRI, MRA, PET Scans or Nuclear Cardiology. Rehabilitative Care Services: Physical Therapy Occupational Therapy Speech Therapy, including developmental speech therapy $45.00 per visit 70% - 30% Skilled Nursing Facility: Temporomandibular / Craniomandibular Joint Dysfunction (TMJ): Limited to $600.00 of Allowable Charges per Plan Participant per Lifetime for splint therapy and initial panorex x-ray only. Surgical treatment will only be eligible following a demonstrated failure of split therapy. Authorization required prior to services being performed. Vision Exam: Limited to one per 12 month period per Plan Participant. $30.00 per visit Not Covered TRAVEL, LODGING, AND MEAL EXPENSES Coverage is available for the patient and companions during treatment for the following: Organ, Tissue and Bone Marrow Transplants Cancer Treatment Congenital Heart Disease Services Combined expenses are limited to: $10,000.00 maximum per patient per Lifetime $50 per day for patient $100 per day for patient and companions 40HR2293 R11/18 4.
PRESCRIPTION DRUG COVERAGE BLUE CROSS AND BLUE SHIELD OF LOUISIANA DOES NOT PROVIDE CLAIMS PAYMENT SERVICES FOR PRESCRIPTION DRUGS EXCEPT FOR THOSE PRESCRIPTION DRUGS ADMINISTERED DURING AN INPATIENT OR OUTPATIENT STAY OR THOSE REQUIRING ADMINISTRATION BY A HEALTHCARE PROFESSIONAL IN A PHYSICIAN S OFFICE. Therapeutic/Treatment Vaccines are subject to payment of Deductible and Coinsurance. Examples include, but are not limited to vaccines to treat the following conditions: Allergic Rhinitis, Alzheimer s Disease, Cancers, Multiple Sclerosis, and Substance Use Disorder. CARE MANAGEMENT Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-376-7973. If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically Necessary. If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided based on the participating status of the Provider rendering the services. AUTHORIZATION OF INPATIENT AND EMERGENCY ADMISSIONS: Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions for Concurrent Review of an Admission in progress must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-523-6435. If a Network Provider or a Participating Provider fails to obtain a required Authorization, We will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract with Us or with another Blue Cross and Blue Shield plan. This penalty applies to all covered Inpatient charges. The Network Provider or Participating Provider is responsible for the penalty and all charges not covered. The Plan Participant remains responsible for the applicable Copayment Amount, Deductible Amount and Coinsurance percentage. NOTE: Benefits for Participating Providers will be paid at the lower Non-Network level shown on this Schedule of Benefits. If a Non-Participating Provider fails to obtain a required Authorization, the Claims Administrator will reduce the Allowable Charge by the amount shown below. This penalty applies to all covered Inpatient charges. The Plan Participant is responsible for all charges not covered, the penalty amount and the Deductible Amount and Coinsurance percentage. Additional Plan Participant responsibility if Authorization is not requested for an Inpatient Admission to a Non- Participating Provider / Facility: fifty percent (50%) reduction of the Allowable Charges. AUTHORIZATION OF OUTPATIENT SERVICES AND SUPPLIES: If a Network Provider fails to obtain a required Authorization, We will reduce Allowable Charges by the amount shown below. This penalty applies to all services and supplies requiring an Authorization. The Network Provider is responsi ble for the penalty and all charges not covered. The Plan Participant remains responsible for the applicable Copayment Amount, Deductible Amount and Coinsurance percentage. Additional Network Provider responsibility if Authorization is not requested for Outpatient services and supplies: fifty percent (50%) reduction of the Allowable Charges. 40HR2293 R11/18 5.
If a Non-Network Provider fails to obtain a required Authorization, We will reduce Allowable Charges by the amount shown below. This penalty applies to all services and supplies requiring an Authorization. Benefits will also be paid at the lower Non-Network level shown on this Schedule of Benefits. The Plan Participant is responsible for all charges not covered for the penalty amount and the Deductible Amount and Coinsurance percentage. Additional Plan Participant responsibility if Authorization is not requested for Outpatient services and supplies from a Non-Network Provider: fifty percent (50%) reduction of the Allowable Charges. SERVICES THAT REQUIRE PRIOR AUTHORIZATION: The following services and supplies require Authorization prior to the services being rendered or supplies being received. Air Ambulance (Non-Emergency) Applied Behavior Analysis Bone growth stimulator CT Scans Day Rehabilitation Programs Durable Medical Equipment (Greater than $300.00) Electric & Custom Wheelchairs Home Healthcare Hospice Care Hyperbarics Implantable Medical Devices over $2000.00 (such as Implantable Defibrillator and Insulin Pump) Intensive Outpatient Programs MRI / MRA Partial Hospitalization Programs PET Scans Prosthetic Appliances Residential Treatment Centers Sleep Studies (except those performed as a home sleep study) Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Temporomandibular Joint Dysfunction (TMJ) Surgical Treatment Transplant Evaluation & Transplants Vacuum Assisted Wound Closure Therapy ELIGIBILITY WAITING PERIOD The Plan Administrator will determine the Eligibility Waiting Period and Effective Date of coverage for all eligible Employees and their Dependents. Under no circumstances will the initial Eligibility Waiting Period ever exceed ninety (90) days following the date of hire. Eligibility Periods are designated by the Group and defined in the Benefit Plan. 40HR2293 R11/18 6.