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Benefit and Information Grid

Insurance Plan
The following comparisons describe the In-Network and Out-of-Network benefit options for the Enhanced and Standard Benefit Plans.  See Health and Dental Insurance Rates for the cost of each plan.

Enhanced Plan In-Network PPO Benefits

Enhanced Plan Out-of-Network PPO Benefits

Standard Plan In-Network PPO Benefits

Standard Plan Out-of-Network PPO Benefits
Annual Deductible $200 per Covered Person,

$400 per Family Unit

 $200 per Covered Person,

$400 – Per Family Unit

 $200 per Covered Person,

$400 per Family Unit

 $200 per Covered Person,

$400 per Family Unit
Annual Out-of-Pocket Maximum
Including Annual Deductible 		$1,000 per Covered Person

$2,000 per Family Unit

 $2,000 per Covered Person

$4,000 per Family Unit

 $2,000 per Covered Person

$4,000 per Family Unit

 $4,000 per covered Person

$8,000 per Family Unit
Coinsurance After Deductible, 90% of contracted rate paid by Plan – unless otherwise noted. After Deductible, 70% of Usual and Customary paid by Plan – unless otherwise noted. After Deductible, 80% of contracted rate paid by Plan – unless otherwise noted. After Deductible, 60% of Usual and Customary paid by Plan.
Coinsurance for Covered Persons residing outside of Indiana and Network Unavailable Services After Deductible, 90% of Usual and Customary paid by Plan After Deductible, 80% of Usual and Customary paid by Plan.
Lifetime Plan Maximum

$2,500,000 per Covered Person

HOSPITAL/FACILITY SERVICES

Enhanced Plan In-Network PPO Benefits

Enhanced Plan Out-of-Network PPO Benefits

Standard Plan In-Network PPO Benefits

Standard Plan Out-of-Network PPO Benefits
Hospital Inpatient
Semi Private Room
Intensive Care Unit		 After Deductible, 90% paid by Plan;

 

 After Deductible, 70% of Usual and Customary paid by Plan. After Deductible, 80% paid by Plan. After Deductible,  60% of Usual and Customary paid by Plan.
Hospital Outpatient Surgery and Related Charges After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan. After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Outpatient Laboratory and X-ray charges After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan. After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.

PRE-CERTIFICATION

Pre-certification Services

Pre-certification is required for all Hospital Admissions and recommended for Durable Medical Equipment (including all Prosthetic, Orthotic, or Othopedic Devices), Home Health Care, Home IV Therapy and First Trimester Maternity.

Call ICM at (800) 521-4132
Authorization Penalties

$250 PER ADMISSION PENALTY

PHYSICIAN SERVICES

Enhanced Plan In-Network PPO Benefits

Enhanced Plan Out-of-Network PPO Benefits

Standard Plan In-Network PPO Benefits

Standard Plan Out-of-Network PPO Benefits
Outpatient Physician charges
(lab, x-ray & in-hospital physician visits)		 After Deductible 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan. After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Surgery and related charges (including anesthesia) After Deductible 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan. After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Primary Care Physician Office Visit (Illness or Injury) $10 Copayment paid by Covered Person, then 100% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan. $20 Copayment paid by Covered Person, then 100% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Specialist Office Visit (Illness or Injury) $10 Copayment paid by Covered Person, then 100% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan. $20 Copayment paid by Covered Person, then 100% paid by Plan After Deductible,  60% of Usual and Customary paid by Plan.
Other Physician Services in the office - labs, x-rays, minor surgery (received in the office and charged with the office visit) 100% paid by Plan after $10 office visit Copayment  

Not Covered

 100% paid by Plan after $20 office visit Copayment  

Not Covered
EMERGENCY SERVICES

Enhanced Plan In-Network PPO Benefits

Enhanced Plan Out-of-Network PPO Benefits

Standard Plan In-Network PPO Benefits

Standard Plan Out-of-Network PPO Benefits
Supplemental Accident Benefit

No Deductible and 100% of first $300 per Accident
Emergency Room
(In or Out of Area Medical Emergency)

Please Note: Any Non-Emergency ER visit will result in an additional $100 per visit penalty

 After Deductible,
90% paid by Plan		 After Deductible,
90% of Usual and Customary paid by Plan.

If Non-Medical Emergency, after Deductible, 70% of Usual & Customary paid by Plan.

 After Deductible,
80% paid by Plan		 After Deductible,
80% of Usual and Customary paid by Plan.

If Non-Medical Emergency, after Deductible, 60% of Usual & Customary paid by Plan.
PREVENTIVE CARE

Enhanced Plan In-Network PPO Benefits

Enhanced Plan Out-of-Network PPO Benefits

Standard Plan In-Network PPO Benefits

Standard Plan Out-of-Network PPO Benefits
Routine Physical Exams, Immunizations, Lab & X-ray

Adult and Child

$350 combined Calendar Year Maximum per Covered Person for all Routine services

(See section Covered Services for a List of Covered Routine Services)

$10 Physician Copayment paid by Covered Person, then 100% paid by Plan to the $350  Maximum.

(other services performed in the office the same day are included under the same copay)

  

 

Not Covered

 $20 Physician Copayment paid by Covered Person, then 100% paid by Plan to the $350  Maximum.

(other services performed in the office the same day are included under the same copay)

  

 

Not Covered
OTHER MEDICAL SERVICES

Enhanced Plan In-Network PPO Benefits

Enhanced Plan Out-of-Network PPO Benefits

Standard Plan In-Network PPO Benefits

Standard Plan Out-of-Network PPO Benefits
Ambulance

$1,000 per ground trip Maximum

$5,000 per Air trip Maximum

 After Deductible, 90% paid by Plan After Deductible, 90% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible, 80% of Usual and Customary paid by Plan.
Durable Medical Equipment, Prosthetic, Orthotic, and Orthopedic Devices

$30,000 combined Calendar Year Maximum with Rx only.

 After Deductible, 90% paid by Plan Person After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan Person After Deductible, 60% of Usual and Customary paid by Plan.
Extended Care Facility

Combined with Skilled Nursing Facility

90 day Calendar Year Maximum

 After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan

 

 After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Home Health Care

Combined with Private Duty Nursing

100 visit Calendar Year Maximum

 After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Hospice
 
6 month life expectancy 		After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Occupational Therapy After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Rehabilitation Facility

 

 After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Physical Therapy

 

 After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Speech Therapy After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible,  60% of Usual and Customary paid by Plan.
Spinal Manipulation/ Chiropractic Services

$1,000 Annual Maximum

 After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
TMJ/Jaw Joint

$3,000 Annual Maximum

$10,000 Lifetime Maximum

 After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
MENTAL HEALTH AND SUBSTANCE ABUSE

Enhanced Plan In-Network PPO Benefits

Enhanced Plan Out-of-Network PPO Benefits

Standard Plan In-Network PPO Benefits

Standard Plan Out-of-Network PPO Benefits
Mental Health Inpatient

30-day Calendar Year Maximum

After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan. After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Mental Health Outpatient

Combined with:
Intensive Outpatient Program, Partial Hospitalization, & Psychiatric Day Tx.

60-visits Calendar Year Maximum

 After Deductible, 90% paid by Plan After Deductible, 70% paid by Plan of Usual and Customary paid by Plan. After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
Substance Abuse Inpatient

30-day Calendar Year Maximum

After Deductible, 90% paid by Plan After Deductible, 70% of Usual and Customary paid by Plan After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan
Substance Abuse Outpatient

Combined with:
Non-Residential Program and Intensive Outpatient Program.

60 visit Calendar Year Maximum

After Deductible, 90% paid by Plan After Deductible, 70% paid by Plan of Usual and Customary paid by Plan. After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
OTHER
  

Enhanced Plan In-Network PPO Benefits

Enhanced Plan Out-of-Network PPO Benefits

Standard Plan In-Network PPO Benefits

Standard Plan Out-of-Network PPO Benefits
Medical Supplies

(Medically
Necessary)		 After Deductible, 90% paid by Plan After Deductible, 70% paid by Plan of Usual and Customary paid by Plan. After Deductible, 80% paid by Plan After Deductible, 60% of Usual and Customary paid by Plan.
LabOne Diagnostic Service Benefit

When LabOne is not utilized, normal plan benefits apply.

No Deductible, 100%

 
PRESCRIPTION DRUGS
Prescription Drugs Calendar Year Out-of-Pocket

$1,000 Per Covered Person
$2,000 Per Family Unit
Prescription Drugs

34-day supply 

Generic Copayment -  the greater of $5.00 or 20% of the drug cost

Brand (with no generic available) Copayment- the greater of $10.00 or
             20% of the medication's cost

Brand (with generic available) Copayment - the greater of $15.00 or
             20% of the medication's cost
Prescription Drugs Mail Order Service

90-day supply

Generic Copayment -  the greater of $10.00 or 15% of the drug cost

Brand (with no generic available) Copayment- the greater of $20.00 or
             15% of the drug cost

Brand (with generic available) Copayment - the greater of $30.00 or
             15% of the drug cost
Non-Network Pharmacies Contact your Claims Account Manager for information regarding submitting your drug receipt to Express Scripts for reimbursement.
Dental Benefits
Class A Services
(no waiting period)		 Routine Oral Exams - 2 / 12 mo. period
Dental prophylaxis and scaling of teach - 2 /.12 mo. period
Bitewing X-ray series - 1 / 12 mo. period
Full mouth or Panorex X-ray - 1 / 24 mo. period
Fluoride treatment - 1 / 12 mo. period (up to age 19)
Emergency palliative treatment for pain

No deductible - 100% up to annual maximum of $1,500
Class B Services
Basic Dental Procedures
(no waiting period)		 Dental x-rays not included in Class A
Simple extractions
Simple restorative services (fillings other than gold)
Molar sealants (up to age 19)
General anesthetics
Consultations other than routine exams
Antibiotic drugs
Oral surgery - for tooth replacement or impactions
Re-cementing bridges, crowns or inlays
Space Maintainers
Endodontics (root canals)
Periodontics (gum treatment)

$25 deductible - 80% after deductible up to annual maximum of $1,500
Class C Services
Major Dental Procedures
(12 mo. waiting period)		 Gold restorations - includes inlays, onlays and foil fillings
Installations and replacement of prosthodontics - dentures
    crowns, inlays, onlays
Prosthetics - bridges, dentures, dental implants (consult
     Medical Plan for details/requirements.)
Dental Implants - does not include teeth lost prior to
     covered person's effective date under this plan.

$25 deductible - 50% after deductible upt o annual maximum of $1,500
Class D Services
Orthodontia
(24 mo. waiting period)		 Treatment to move teeth by means of appliances to correct a handicapping malocclusion of the mouth.  Includes preliminary study, including x-rays, diagnostic casts, and treatment plan; surgical therapy, appliance therapy, and functional/myofunctional therapy (when provided by a Dentists in conjunction with appliance therapy, and retention appliances for covered persons under nineteen (19) years of age.  See Medical Plan for further information.

No deductible - 50% up to annual limit of $300 and lifetime limit of $1,200.
Note: This benefit and information grid is a summary of the plan benefits.  For detailed information consult the Medical Plan Document
 
©1999 Westfield Classroom Teachers Association
Please send comments and suggestions to   shipew@wws.k12.in.us
Last Update: January 09, 2008