Download Schedule of Benefits…

Schedule of Benefits…
Specially Designed for Tee Jaye's Country Place Restaurants
Calendar Year Deductible
Amount Employee pays before coshare percentages
Single: $ 3,000
Single: $ 3,000
Family: $ 5,000
Family: $ 5,000
Coshare Percentage
0% Plan Coshare
Hospital Charges:
Inpatient/Outpatient
0% Plan Coshare
Coshare max doubles per family
Emergency Room Charge
Copay is waived if admitted to the hospital
Sickness/Injury – Physician Charges
– Office Visit
WellCare – Provider Services
– Office Visit
Other Covered Expenses
Example: Supplies, lab & X-ray, Durable Medical
Equipment, injections, etc.
Retail Prescription Drug
(Network provider for prescription services is Caremark)
Mail-Order Prescription Drug
(Network provider for prescription services is Caremark)
(Outpatient & Inpatient)
Care Advocacy Pathway (CAP)
Care Advocacy Pathway is often referred to as
Chronic Care or Disease Management
THEN 0 % FOR
BALANCE OF YEAR
20% Plan Coshare
AFTER $ 200 PER
OCCURANCE DED.
$ 200.00 Copay
20% Plan Coshare
0% of Plan Coshare
0% of Target Prices
$ 30.00 Per Visit
0% of Target Prices
0% Plan Coshare
0% of Target Prices
Deductible Waived
$ 30 o.v. COPAY
0% of Target Prices
0% Plan Coshare
0% of Target Prices
GENERIC : $ 10.00
PREFERRED : $ 30.00
NON-PREFERRED : $ 50.00
GENERIC : $ 20.00
PREFERRED : $ 60.00
NON-PREFERRED : $ 100.00
INPATIENT
Mental and Nervous, Alcohol
and Drug Disorders
20% of 1st $ 10,000
0% for 30 days
per year
OUTPATIENT
0% for 30 visits
per year
20% Plan Coshare
ALL DEDUCTIBLES
APPLY
20% Plan Coshare
ALL DEDUCTIBLES
APPLY
INPATIENT
20% for 10 days
per year
OUTPATIENT
20% for 10 visits
per year
0% Plan Coshare
0% of Target Prices
DEDUCTIBLE WAIVED
DEDUCTIBLE WAIVED
• L
ifetime Maximum for all Benefits paid under this plan is $1,000,000.
***This is a summary in outline form of the Benefits. Eligible persons who choose to participate should review the SUMMARY
PLAN DESCRIPTION and PLAN DOCUMENT (Benefit Booklet) for information about; participation, benefits, limitations, and
exclusions. This is not a contract, policy or guarantee of coverage.***
Schedule of Benefits…
Specially Designed for Tee Jaye's Country PlaceRestaurants
Out-of-area Benefits will be paid the same as in-network except:
1.The annual Benefit for Mental & nervous, alcohol & drug disorders is limited to 10 days inpatient
and 10 visits outpatient.
Target Prices – are used as the maximum allowable payment for out-of-network (nonparticipating) providers. The Target Price fee schedule applies to provider procedure codes
(called CPT-4’s) and will cover most charges made by a Physician. The Target fee schedule
is 115% of the Medicare reimbursement rate, which means that reimbursement is set at 15%
more under this Plan than is paid for providing the same service to a Medicare patient. Any
provider charge in excess of the Target Price will not be a covered expense under the terms of
this Plan and will be the responsibility of the Covered Person.
If you choose to see an out-of-network Physician, you should ask prior to treatment if he or she
will accept Target Price (115% of the Medicare reimbursement) as payment-in-full. If the
Physician agrees you will not be responsible for any excess charge. Therefore, it is important
that you obtain written verification. If not, you will be responsible for paying the balance of the
charges.
Out-of-network provider charges that are not based upon CPT-4 codes, which include most
Hospitals and other facilities and charges for which there are no Target Prices, will be paid at
the in-network Coshare percentage minus twenty (20) percentage points.
Other Coverage Notes:
• Second Surgical Opinion requested by BAC, Hospice, Centers of Excellence, and Pre-Admission
Testing recommended by BAC, and Optional Benefits are paid by the Plan at 100% (0% member
out of pocket) of covered expenses.
• Deductible waived for Maternity Care (if treatment begins within 1st trimester)
•Lifetime Maximum for substance abuse disorders paid is $15,000. Increased coshare does not
apply to substance abuse disorders.
• Annual Maximum for Tempomandibular Joint Dysfunction Syndrome (TMJ ) is $1,500.
•Chiropractic Services limited to a maximum benefit of $ 500.00 per year.
Available PPO Networks:
• Ohio – SuperMedPlus www.supermednetwork.com
***This is a summary in outline form of the Benefits. Eligible persons who choose to participate should review the SUMMARY
PLAN DESCRIPTION and PLAN DOCUMENT (Benefit Booklet) for information about; participation, benefits, limitations, and
exclusions. This is not a contract, policy or guarantee of coverage.***