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FOOTNOTES:
(a) Deductible
means a fixed dollar amount that you must incur each calendar year before
the health plan begins to pay for covered medical services. The calendar year deductible applies
to all Covered Services except for those that a Co-payment applies, unless
otherwise noted. In-network
deductibles do not apply to out-of-network deductibles and visa versa.
(b) Coinsurance
means a fixed percentage of charges you must pay toward the cost of
covered medical services. Coinsurance applies to all Covered Services except
those for which a Co-payment applies unless otherwise noted.
(c) Out of Pocket Maximum
is the maximum coinsurance you would pay in
any calendar year. Excludes
co-payments and deductibles.
(d) Co-Payment means a fixed dollar
amount that you must pay each time you receive a particular medical service. You pay a Co-payment
when you obtain health care directly from your Network Primary Care Physician or
an In-Network Specialist. Referrals
are NOT required for Network Specialists office visits. Certain services
rendered in the Network Primary Care Physician or Network Specialist’s office
are not subject to coinsurance and do not apply to the deductible or the
out-of-pocket maximum. Services rendered in the Network Primary Care Physician
or Network Specialist’s office that are
subject to deductible and coinsurance include advanced imaging such as MRI, CT
Scans, PET Scans and Nuclear Medicine (imaging studies using medical
radioisotopes) Only routine
screenings are considered preventive care.
Procedures and testing performed once a diagnosis is made or problem
detected then become diagnostic in nature, and deductible and coinsurance will
apply.
(e) When you
obtain health care through a Non-QualChoice Provider, your Benefit payments for
covered services will be based on the Maximum Allowable Payment for
out-of-network services, as determined by QualChoice. Charges in excess of the Maximum
Allowable Payments do not count toward meeting the deductible or meeting the
limitation on your Out of Pocket maximum.
Non-QualChoice Providers may bill the patient for amounts in excess of
the Maximum Allowable Payment.
(f) Well baby/child visits from an
In-Network provider are covered in full from birth until the day the child
attains age 19.
(g)
Inpatient and other services are subject to Co-payment and coinsurance.
It is your responsibility to notify the Benefits
Section of Human Resources within 31
days of the birth or adoption of your child in order to obtain coverage for your
newborn.
(h)
Maximum combined Inpatient Co-payment per calendar year
is $1,000 per person (no more than one co-payment per 30 calendar days).
(i)
The TMJ deductible is separate from the any other
In-Network or Out-of-Network deductibles. The TMJ deductible is in addition to
any In-Network or Out-of-Network deductible and
requires pre-authorization.
(j) You can see any network
Ophthalmologist or any state licensed Optometrist.
(k)
Under the Point of Service Plan and the Classic Plan, Co-payments at
non-participating pharmacies will be $12 for generic, $32 for preferred name
brand, and $52 for non-preferred name brand.
If a new enrollee has to get a prescription prior to receiving his/her
pharmacy card, he/she will have to pay for the prescription in full, apply for
reimbursement, and will be reimbursed less the $12, $32, or $52 Co-payments.
Alternatively, if the enrollment process has been completed and benefits are in
effect, a temporary prescription drug ID card can be printed by going to
www.pharmacare.com, registering and
clicking on ‘print temporary ID card’.
A complete summary of prescription drug benefits is also on the above
web-address.
(l)
Any colorectal cancer screening done outside of the American Cancer
Society’s guidelines will be covered but subject to deductible and coinsurance. See the health plan Summary
Plan Description for details on coverage.
The following procedures for both the Point of Service Plan and the Classic Plan
will require pre-authorization before the services are rendered:
1. Any
admission to Inpatient Facilities or Partial Hospitalization Units
2. Any
referral by your PCP to an Out-of-Network Provider
3.
Pre-Natal/Maternity Care.
Authorization includes physician care and one ultra sound. Additional ultrasounds require
pre-authorization.
4. Home
Health Care, Home Infusion Services, or Hospice (Inpatient or Outpatient)
5.
Transplant Services (including the evaluation to determine if you are a
candidate for transplant by a transplant
program)
6. PET
Scan
7.
CTA Scan of the Chest
8.
MRI of the Breast
9.
SPECT Scan
For a complete list of services that require pre-authorization go to
www.qcark.com and click on members.
Note: Certain other services require Pre-authorization: Surgical treatment of
Temporomandibular Joint Dysfunction (TMJ), Accidental Injury to Teeth.
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