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)
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