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Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1 Effective January 1, 2016 GENERAL FEATURES SERVICES PROVIDED BY, OR PERFORMED AT, STANISLAUS SURGICAL HOSPITAL SERVICES PROVIDED BY MEMBER OF EXCLUSIVE PROVIDER NETWORK (EPO) SERVICES PROVIDED BY MEMBER OF PARTICIPATING PROVIDER NETWORK (PPO) Individual: $500.00 Family: $1,000.00 Calendar Year Deductible SERVICES PROVIDED BY OUT-OF-NETWORK PROVIDER (NON-PARTICIPATING) Individual: $5,000.00 Family: $10,000.00 If an employee has completed the Health Risk Analysis, the individual deductible will be reduced to $300.00 and the family deductible will be reduced to $600.00. Current plan participants have until January 31st to complete a new Health Risk Analysis. New plan participants have 30 days from their effective date to complete the HRA. Unlimited Unlimited Annual Maximum Lifetime Maximum Calendar Year Out-of-Pocket Maximum The following will not be applied to the Out-of-Pocket Maximum: Reduced benefits for nonprecertification; Amounts applied to the deductible; co-payments; Noncovered Expenses; Prescription services; Amounts in excess of Plan limits; Patient balances for bariatric surgery HOSPITAL / FACILITY EXPENSES Inpatient Care - Includes Room & board, Ancillary Charges, and Intensive Care Requires Pre-Certification Maternity Inpatient Care - Employee, Spouse/Domestic Partner, dependent Individual: $3,500.00 Family: $10,500.00 STANISLAUS SURGICAL EPO PPO HOSPITAL Deductible applies to all services unless otherwise indicated. **See provision for completing the Health Risk Analysis** 100% of Negotiated Contract Rate 70% of Negotiated Contract Rate Without Pre-Certification: $1,000.00 patient copayment per admission, and benefits will be reduced by 50% Without Pre-Certification: $1,000.00 patient copayment per admission, and benefits will be reduced by 50% Not Available Outpatient Care - Emergency Room, including ER Physician Copayment is waived if admitted to the hospital or if services are within 48 hours of an accident Urgent Care Facility Individual: $15,000.00 Family: $45,000.00 OUT-OF-NETWORK Deductible applies to all services Billed Charges reduced by 50%; Reimbursement at 50% of reduced rate; Without Pre-Certification: $1,000.00 patient Without PreCertification: $1,000.00 copayment per admission, and benefits will be patient copayment per reduced by 50% admission, and benefits **See provisions for will be reduced by 50% emergency conditions 70% of Negotiated Contract Rate $1,000.00 patient copayment, $1,000.00 patient then 100% of Negotiated copayment, then 100% of Contract Rate Negotiated Contract rate Billed Charges reduced by 50%; $1,000.00 patient copayment, then 100% of reduced rate Not Available $200.00 patient copayment, then 85% of Negotiated Contract Rate $200.00 patient copayment, then 85% of Negotiated Contract rate Billed Charges reduced by 50%; $200.00 patient copayment, then 85% of reduced rate **See provisions for emergency conditions Not Available $30.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible $30.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible 50% of Stanislaus Foundation allowable Page 1 of 5 Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1 Effective January 1, 2016 Surgery Centers - Including surgeries performed in the outpatient hospital setting Requires Pre-Certification MEDICAL SERVICES 100% of Negotiated Contract Rate 70% of Negotiated Contract Rate Without Pre-Certification: Without Pre-Certification: $250.00 patient copayment $250.00 patient copayment per occurrence per occurrence SERVICES PROVIDED BY, OR PERFORMED AT, STANISLAUS SURGICAL HOSPITAL EPO 70% of Negotiated Contract Rate Without PreCertification: $250.00 patient copayment per occurrence PPO Deductible applies to all services unless otherwise indicated. **See provision for completing the Health Risk Analysis** Bariatric Surgery: Surgical procedure only; must be performed by an EPO provider and must be PreCertified; patient balances not applied to annual out-of-pocket maximum Surgeon and covered inpatient MD visits Pre-Certification required for surgery provided at a hospital or any surgical facility Assistant Surgeon Anesthesia Not Available 50% of Negotiated Contract Rate No coverage without precertification 100% of Negotiated Contract 85% of Negotiated Rate Contract Rate Without Pre-Certification: Without Pre-Certification: $250.00 patient copayment $250.00 patient copayment per occurrence per occurrence OUT-OF-NETWORK Deductible applies to all services Not Covered Not Covered 70% of Negotiated Contract Rate Without PreCertification: $250.00 patient copayment per occurrence 50% of Stanislaus Foundation Allowable Without Pre-Certification: $250.00 patient copayment per occurrence 70% of Negotiated 85% of Negotiated Contract 100% of Negotiated Contract Contract Rate for Assistant Rate for Assistant Surgeons rate for Assistant Surgeons Surgeons 100% of Negotiated Contract Rate Billed Charges reduced by 50%; Reimbursement at 50% of reduced rate; Without Pre-Certification: $250.00 patient copayment per occurrence 50% of Stanislaus Foundation Allowable for Assistant Surgeons 85% of Negotiated Contract Rate 70% of Negotiated Contract Rate 50% of Stanislaus Foundation Allowable Routine Well Baby Care - Includes Initial Hospital Confinement, Nursery Care, Physician Visits, Circumcision Not Available 85% of Negotiated Contract Rate 70% of Negotiated Contract Rate 50% of Stanislaus Foundation allowable Preventive Care - Well baby and Well Child (through age 17) - includes Office Visits, Routine Lab, X-rays & Immunizations Not Available 100% of Negotiated Contract Rate Not subject to deductible 100% of Negotiated Contract Rate Not subject to deductible 50% of Stanislaus Foundation allowable Preventive Care / Annual Routine Physical Exams (age 18 and over) One per calendar year; Guidelines from nationally validated recommendations of US Preventive Services Task Force Not Available 100% of Negotiated Contract Rate Not subject to deductible 70% of Negotiated Contract Rate 50% of Stanislaus Foundation allowable Not Available $20.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible $30.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible Specialist Doctor Visit (Home or Office) Not Available $20.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible $30.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible Injectables (Billed Separately) Not Available 85% of Negotiated Contract Rate 70% of Negotiated Contract Rate Doctor Visit (Home or Office) Page 2 of 5 50% of Stanislaus Foundation Allowable 50% of Stanislaus Foundation Allowable 50% of Stanislaus Foundation Allowable Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1 Effective January 1, 2016 Allergy Injections and Testing Diagnostic Tests and Services (including pre-admission testing) Cat Scans, MRIs, Bone Density Requires Pre-Certification MEDICAL SERVICES Nuclear Medicine Facility Requires Pre-Certification Chemotherapy and Radiation Therapy Ambulance Durable Medical Equipment and Medical Supplies-- $3,000.00 calendar year maximum Pre-Certification is required for Durable Medical Equipment over $1,000.00 or monthly rental exceeding $250.00 Orthotics Only if Medically Necessary and are custom made for the feet Physical, Occupational, and Speech Therapy - Combined Maximum of 24 visits per calendar year Requires Pre-Certification Home Health Care, Hospice, and Outpatient Private Duty Nursing Combined maximum of 100 visits per calendar year Requires Pre-Certification Chiropractic Care - Including x-rays Maximum $750.00 per calendar year Not Available 85% of Negotiated Contract Rate 70% of Negotiated Contract Rate 50% of Stanislaus Foundation Allowable 100% of Negotiated Contract Rate; (Quest Diagnostic and Yosemite Pathology ) 85% of Negotiated Contract Rate 70% of Negotiated Contract Rate 50% of Stanislaus Foundation allowable 70% of Negotiated Contract Rate Without PreCertification: $250.00 patient copayment per occurrence 50% of Stanislaus Foundation allowable Without Pre-Certification: $250.00 patient copayment per occurrence 100% of Negotiated 85% of Negotiated Contract Rate; Contract Rate Without Pre-Certification: Without Pre-Certification: $250.00 patient copayment $250.00 patient copayment per occurrence per occurrence SERVICES PROVIDED BY, OR PERFORMED AT, EPO PPO STANISLAUS SURGICAL HOSPITAL Deductible applies to all services unless otherwise indicated. **See provision for completing the Health Risk Analysis** 100% of Negotiated Contract Rate 85% of Negotiated Contract Rate Without pre-certification: Without Pre-Certification: $250.00 patient copayment $250.00 patient copayment per occurrence per occurrence 100% of Negotiated Contract Rate 85% of Negotiated Contract Rate 85% of Negotiated 85% of Negotiated Contract Rate Contract Rate Without Pre-Certification: Without Pre-Certification: $250.00 patient copayment $250.00 patient copayment per occurrence per occurrence 85% of Negotiated Contract Rate 85% of Negotiated Contract Rate $20.00 patient copayment, $20.00 patient copayment, then 100% of Negotiated then 100% of Negotiated Contract Rate Contract Rate Without Pre-Certification: Without Pre-Certification: $250.00 patient copayment $250.00 patient copayment per occurrence per occurrence Not Available 70% of Negotiated Contract Rate Without Pre-Certification: $500.00 patient copayment per admission, and benefits will be reduced by 50% Not Available $20.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible Page 3 of 5 70% of Negotiated Contract Rate Without PreCertification: $250.00 patient copayment per occurrence OUT-OF-NETWORK Deductible applies to all services Billed Charges reduced by 50%; Reimbursement at 50% of reduced rate Without Pre-Certification: $250.00 patient copayment per occurrence 70% of Negotiated Contract Rate 80% of Billed Charges 50% of Stanislaus Foundation allowable Paid as a PPO benefit 70% of Negotiated Contract Rate Without PreCertification: $250.00 patient copayment per occurrence 50% of Stanislaus Foundation allowable Without Pre-Certification: $250.00 patient copayment per occurrence 70% of Negotiated Contract Rate 50% of Stanislaus Foundation allowable 70% of Negotiated Contract Rate Without PreCertification: $250.00 patient copayment per occurrence 50% of Stanislaus Foundation allowable Without Pre-Certification: $250.00 patient copayment per occurrence 70% of Negotiated 50% of Stanislaus Contract Rate Foundation allowable Without PreWithout Pre-Certification: Certification: $500.00 $500.00 patient copayment patient copayment per per admission, and admission, and benefits benefits will be reduced by will be reduced by 50% 50% $30.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible 50% of Stanislaus Foundation allowable Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1 Effective January 1, 2016 Acupuncture Care - Pain Management Only Maximum $750.00 per calendar year Infertility - Only services to determine a diagnosis will be considered. Covered Expenses and benefits are limited to $2,500.00 per lifetime Temporomandibular Joint Dysfunction Syndrome (TMJ) / Jaw Treatment $3,000.00 Lifetime Maximum Transplants Mandatory Case Management and Pre-Certification OTHER COVERED SERVICES Skilled Nursing Facility- Maximum of 60 days per calendar year Requires Pre-Certification Mental Illness - Inpatient Requires Pre-Certification Mental and Nervous Conditions Outpatient Chemical Dependency and Substance Abuse, Inpatient Care Requires Pre-Certification Chemical Dependency and Substance Abuse Outpatient Care Requires Pre-Certification Not Available $30.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible $30.00 patient copayment, then 100% of Negotiated Contract Rate Not subject to deductible 50% of Stanislaus Foundation allowable 85% of Negotiated Contract Rate 50% of Negotiated Contract Rate 50% of Negotiated Contract Rate Not Covered Not Available 70% of Negotiated Contract Rate 70% of Negotiated Contract Rate Not Covered Not Available 70% of Negotiated Contract Rate Without Pre-Certification: $500.00 patient copayment per admission, and benefits reduced 50% 70% of Negotiated Contract Rate Without PreCertification: $500.00 patient copayment per admission, and benefits reduced 50% SERVICES PROVIDED BY, OR PERFORMED AT, EPO PPO STANISLAUS SURGICAL HOSPITAL Deductible applies to all services unless otherwise indicated. **See provision for completing the Health Risk Analysis** 70% of Negotiated Contract Rate Not Available Without pre-cert, $500.00 copayment and benefits reduced by 50% Not Covered OUT-OF-NETWORK Deductible applies to all services 70% of Negotiated Contract Rate Billed Charges reduced by 50%; Reimbursement at 50% of reduced rate Without Without pre-cert, $500.00 pre-cert, $500.00 copayment and benefits copayment and benefits reduced by 50% reduced by 50% 70% of Negotiated Billed Charges reduced by Contract Rate 50%; Reimbursement at 50% Without Preof reduced rate; Certification: $500.00 Without Pre-Certification: patient copayment per $500.00 patient copayment admission, and benefits per admission and benefits reduced 50% reduced 50% Not Available 70% of Negotiated Contract Rate Without Pre-Certification: $500.00 patient copayment per admission, and benefits reduced 50% $20.00 patient copayment, then 100% of Negotiated Contract Rate $20.00 patient copayment, then 100% of Negotiated Contract Rate Not Available 70% of Negotiated Contract Rate Without Pre-Certification: $500.00 patient copayment per admission, and benefits reduced 50% 70% of Negotiated Billed Charges reduced by Contract Rate 50%; Reimbursement at 50% Without Preof reduced rate Certification: $500.00 Without Pre-Certification: patient copayment per $500.00 patient copayment admission, and benefits per admission, and reduced 50% benefits reduced 50% $20.00 patient copayment, $20.00 patient copayment, then 100% of Negotiated then 100% of Negotiated Contract Rate Contract Rate Without Pre-Certification: Without Pre-Certification: $250.00 patient copayment $250.00 patient copayment per occurrence per occurrence $30.00 patient copayment, Billed Charges reduced by then 100% of 50%; Reimbursement at 50% Negotiated Contract Rate of reduced rate Without PreWithout Pre-Certification: Certification: $250.00 $250.00 patient copayment patient copayment per per occurrence occurrence Page 4 of 5 $30.00 patient copayment, then 100% of Negotiated Contract Rate 50% of Stanislaus Foundation allowable Stanislaus Surgical Hospital Medical Plan Summary for Group #8410, Option 1 Effective January 1, 2016 Smoking Cessation Programs Requires Pre-Certification $250.00 Lifetime Benefit 85% of Negotiated Contract Rate 70% of Negotiated Contract Rate Without Pre-Certification: $250.00 patient copayment per occurrence 70% of Negotiated Contract Rate Without PreCertification: $250.00 patient copayment per occurrence Not Covered **If a participant receives inpatient care or outpatient emergency room care from an out-of-network provider due to an emergency medical condition as defined in the Stanislaus Surgical Hospital Plan Document, and due to the emergent nature of the condition, the patient is unable to convey the need to utilize network providers from their health plan, the initial 50% reduction off billed charges will be eliminated. Services will still be subject to the out-of-network deductible, and the applicable outof-network reimbursement percentage. UTILIZATION MANAGEMENT / PRE-CERTIFICATION: INETICARE (877) 608-2200 inetico.com, click on PRE-CERTIFICATION WITH INETIPASS Requires Pre-Admission review of at least 3 working days for non-emergency hospital admissions and / or within 48 hours of an emergency. Failure to obtain approval results in a $1,000.00 patient copayment per admission, and benefits will be reduced by 50% Inpatient Admissions Surgery (inpatient and outpatient) and Surgery Centers Requires prior certification at least 3 working days in advance. Failure to obtain approval results in an additional $250.00 patient copayment per occurrence. All Other Services Requiring Pre-Certification Requires prior certification at least 3 working days in advance. Failure to obtain approval results in either an additional $250.00 or an additional $500.00 patient copayment per occurrence. Prescription Drugs: Prior Authorizations: (877) 526-9906 RESTAT Prescription Services: (800) 248-1062 Client #8410 Group #001 Participating RESTAT Pharmacies Mandatory Generic Substitution. Maximum 30-day supply. Generic: $5.00 copayment Brand Name: $250.00 Annual Deductible; $40.00 copayment Non-formulary: $250.00 Annual Deductible; 50% copayment with a maximum copayment of $60.00 Mail Order Program Approved Maintenance Medications Only. Maximum 90-day supply. Generic: $10.00 copayment Brand Name: $250.00 Annual Deductible; $80.00 copayment Non-formulary: $250.00 Annual Deductible; 50% copayment with a maximum copayment of $120.00 Page 5 of 5