Microsoft word - 2010-2011 sfsd benefits at a glance.doc

Claims Administrator: UMR, Inc. (800) 826-9781 (www.umr.com) Patient Choice (877) 390-7632 (www.patientchoicehealthcare.com) • Sanford (Sioux Valley Hospital) (800) 601-5086 • Avera Tri State (McKennan Hospital) (605) 322-6300 Innoviant (877) 559-2955 (www.innoviant.com) 1Based on Full-time schedule. Part-time staff premiums are proportionally adjusted based on work schedule. Premiums for Part-time staff can be found in the back of this booklet. Summary of Medical Benefits OUT-OF-NETWORK
IN-NETWORK PROVIDERS
PROVIDERS
Member pays
Member pays
designated Care System, the provider will file claims on your behalf and has agreed charge and the allowed amount is your responsibility. In addition, you are notification for inpatient hospital admissions and prior authorization for certain medical procedures. Services Received in a Physician’s Office:
Office Visits for illness or injuries
Physician Office Services (laboratory, xray, 20% after the deductible up to the out-of- therapy services, surgical procedures, etc.) OUT-OF-NETWORK
IN-NETWORK PROVIDERS
PROVIDERS
Member pays
Member pays
Preventive Care (up to $1,000/plan year)
Routine Diagnostic Tests, Lab and X-rays Preventive Colonoscopy,
20% after the deductible up to the out-of- Sigmoidoscopy, and similar preventive
Therapy Services:
• Physical, Speech and Occupational
• 20% after the deductible up to the out- • 20% after the deductible up to the out- Outpatient Services Received in a Hospital or Other Outpatient Setting:
Outpatient Hospital Services
20% after the deductible up to the out-of- (Lab tests, x-rays, kidney dialysis, radiation 20% after the deductible up to the out-of- 20% after the deductible up to the out-of- Physician services for outpatient surgery, 20% after the deductible up to the out-of- Inpatient Hospital Care (semi-private room):
Inpatient Hospital Services
20% after the deductible up to the out-of- 100%.
Preadmission Notification required or
you may be responsible for an
additional portion of the bill.
OUT-OF-NETWORK
IN-NETWORK PROVIDERS
PROVIDERS
Member pays
Member pays
20% after the deductible up to the out-of- of-pocket maximum, then plan pays
100%.
Preadmission Notification required or
you may be responsible for an
additional portion of the bill.
20% after the deductible up to the out-of- At Designated Transplant Facility (URN or Avera/McKennan Hospital/University Health Center): Nothing At another Network Facility: 40% of total cost (deductible waived) Other Medical Services:
Durable Medical Equipment and Supplies
20% after the deductible up to the out-of- 20% after the deductible up to the out-of- Home Health Care (40 visits/plan year 20% after the deductible up to the out-of- 20% after the deductible up to the out-of- Hospice Care (Lifetime maximum: Lesser of 20% after the deductible up to the out-of- Prescription Drug Benefit:
At designated retail pharmacies
Over-the-counter non-sedating antihistamines [Alavert, loratadine (generic You pay your co-pay at time of purchase. Claritin), cetirazine (generic Zyrtec)] and ulcer drugs (Prilosec OTC) - $0 copay (Your co-pay applies to a maximum 30-day or 100-unit supply; insulin and diabetic Generic Anti-Cholesterol [lovastatin (generic Mevacor), pravastatin (generic Pravachol), simvastatin (generic Zocor)] and Ulcer [omeprazole (generic Prilosec)] medications - $0 copay Generic Products: Greater of $7/prescription or 10% Preferred Brand Products: Greater of $25/prescription or 25% (Maximum $100) Non-Preferred Brand Products: Greater of $50/prescription or 40% (Maximum $200) If you choose to take a brand-name drug when a generic equivalent is available, you pay the brand-name copay plus the difference in cost between the brand and generic medication. Mail pharmacy
medications through the Mail Order program. Preferred Brand: Greater of $62.50/Prescription or 25% Non-Preferred Brand: Greater of $125/Prescription or 40% (Maximum Specialty Medications (From Specialty
Pharmacy Vendor. Co-pay applies to a
30-day supply)

Source: http://www.nctq.org/docs/Sioux_Falls_Medical_Benefits_April_2012.pdf