Coverage Period 7/1/2013 6-30-2014 For Questions - call 1-888-321-4433 This is only a summary. If you want more detail about your coverage costs, you can get the complete terms in the policy or plan document at www.pennbehavioralhealth.org/ Employee Services or by calling 1-888-321-4433! Important Questions Answers Why this Matters: What is the overall deductible? $0 The EAP is a preventive care program for which no deductible is applicable. Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-ofpocket limit? Is there an overall annual limit on what the plan pays? Does the plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan does not cover? This plan has no out-of- pocket limit Yes, For a list of EAP counselors call 1-888-321-4433 Yes. The EAP is a preventive care program. You don t have to meet any deductibles for EAP services. There are no charges for EAP services obtained from a network EAP provider. As a result, there is no need for an out-of-pocket limit on your expenses for these services. Not applicable because there is no out-of-pocket limit on your expenses. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use a network EAP provider, this plan will pay all of the costs of the covered services. See the cha5rt starting on page 2 for how this plan pays different kinds of providers. The EAP does not cover specialists. If the EAP provider determines that you need treatment from a specialist, the EAP provider will refer you to your group health plan, or give you information about treatment resources in your community. Some of the services this plan does not cover are listed on page 4. See your policy or plan document for additional information about excluded services. 1 of 7
Coverage Period 7/1/2013 6-30-2014 For Questions call 1-888-321-4433 > Copayments are fixed dollar amounts (for example, $15) you pay for covered healthcare, usually when you receive the service. > Coinsurance is your share of the costs of a covered service, calculated as a percentage of the allowed amount for the service. For example, if the plan s allowed amount for `! an overnight hospital stay is $1000, your coinsurance payment of 20% would be $200. This may change if you have not met your deductible. > The amount the plan pays for covered services is based on the allowed amount. If an out of network provider charges more than the allowed amount you may have to pay the difference. For example, if an out of network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. > This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. If you visit a healthcare provider s office or clinic If you have a test If you need drugs to treat your illness or condition Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care $0 Not covered Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Brief counseling, limited to 8 face to face sessions per problem (individually or as a group) Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs 2 of 7
If you have outpatient surgery If you need immediate medical attention Services You May Need Facility fee (e.g., ambulatory surgery enter Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care If you have a hospital stay If you have mental health, behavioral health or substance abuse needs If you are pregnant Facility fee (e.g., hospital room) Physician/surgeon fees Mental/Behavioral health outpatient or Substance use disorder outpatient or Prenatal and postnatal care Delivery and all 3 of 7
Services You May Need Home health care If you need help recovering or have special health needs If your child needs dental or eye care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service Eye exam Glasses Dental check-up Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric surgery Chiropractic care Cosmetic surgery Emergency care when traveling outside the United States Hearing aids Infertility treatment Long-term care Non-emergency care when traveling outside the United States Private-duty nursing Routine dental care Routine eye care Routine foot care Weight loss programs Other Covered Services ( This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) 4 of 7
Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration. Other limitations on your rights to continue coverage may also apply For more information on your rights to continue coverage, contract the plan at 1-800-424-4103. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration(EBSA) at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x 61565 or www.cclio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact the Penn Behavioral Health EAP at 1-888-321-4433. Additionally, a benefits advisor from EBSA may be able to assist you. To find your local EBSA office, call 1-866-444-3272 or go to www.dol.gov/ebsa. 5 of 7