Page 9 - 2013 Salus Group Benefits and Notices

Benefits Partner, LLC dba Salus Group 2013

Salus Group BCN HMO HRA 2500 Plan In Network Out-of-Network
Benefit Summary
Deductible and Coinsurance Maximums
Deductible $2,500 Single / $5,000 Family $5,000 Single / $10,000 Family
Coinsurance (Percentage copays) 80% most services 60% most services
Annual Coinsurance Out-of-Pocket Max $2,500 Single / $5,000 Family $5,000 Single / $10,000 Family
Total Annual Out-of-Pocket Maximum* $5,000 Single / $10,000 Family $10,000 Single / $20,000 Family
* Does not include fixed dollar copays or private duty nursing coinsurance
Prescription Drugs
Generic (Tier I) - $10 copay; Preferred Brand (Tier II) - $40 copay; Brand Non-
Pharmacy (30 day supply) Formulary (Tier III) - $80 copay.
Out-of-Network Pharmacy is reimbursed 75% of the approved amount less copay.
Pharmacy or Mail Order (90 day supply) $20 Generic; $80 Preferred Brand; $160 Brand Non-Formulary
Preventive Services
Health Maintenance Exam 100% (one per calendar year) Not Covered
Annual Gynecological Exam & PAP 100% (one per calendar year) Not Covered
Prostate Specific Antigen (PSA) Screening 100% (one per calendar year) Not Covered
Mammography Screening 100% (one per calendar year) Not Covered
Expanded Women’s Preventive Care 100% (one per calendar year) Not Covered
Well-Baby and Child Care 100% (one per calendar year) Not Covered
Immunizations – pediatric & adult 100% (one per calendar year) Not Covered
Colonoscopy – screening or diagnostic 100% (one per calendar year) Not Covered
Physician Office Visits
Office visits, including Specialist visits $30 copay 60% after deductible
Emergency Medical Care
Hospital Emergency Room $150 copay per visits (waived if admitted to hospital)
Facility Based Urgent Care Center $30 copay 60% after deductible
Ambulance Services (air/ground) 80% after deductible
Diagnostic Services
Diagnostic Tests, Lab & X-Ray 80% after deductible 60% after deductible
Maternity Services
Pre and Post-natal Care 80% after deductible 60% after deductible
Delivery & Nursery Care 80% after deductible 60% after deductible
Hospital Care
Semi-Private Room, Inpatient physician 80% after deductible 60% after deductible
care, Hospital services and supplies
Inpatient Medical Care & Chemotherapy 80% after deductible 60% after deductible
Alternatives to Hospital Care
Skilled Nursing Care 80% after deductible 60% after deductible
Hospice Care 100%
Surgical Services
Surgery – includes related surgical services and
medically necessary in or out-patient facility 80% after deductible 60% after deductible
charges
Voluntary Sterilization 80% after deductible 60% after deductible
Human Organ Transplants
Specified Organ Transplants 100% covered 60% after deductible
Bone Marrow & Other Transplants 80% after deductible 60% after deductible
Mental Health & Substance Abuse Treatment
In Patient Mental & Substance Abuse Treatment 50% after deductible 50% after deductible
Out Patient Mental & Substance Abuse Treatment 50% after deductible 50% after deductible
Other Services
Chiropractic Care (12 visits / year) $30 copay 60% after deductible
Outpatient Diabetes MT, DME, P&O appliances 80% after deductible 60% after deductible
O/P Occ/SP/Physical Therapy (30) 80% after deductible 60% after deductible
Allergy Testing & Therapy 80% after deductible 60% after deductible

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