Page 9 - 2013-14 MFCU benefits & Notices

Members First CU 2013-14

Members First CU PPO HRA 1500 Plan In Network Out-of-Network
Benefit Summary (ACTIVE EMPLOYEES)
Deductible and Coinsurance Maximums
Deductible $1,500 Single / $3,000 Family $3,000 Single / $6,000 Family
Coinsurance (Percentage copays) 50% on selected services 20% most services
Annual Coinsurance Out-of-Pocket Max None $5,000 Single / $10,000 Family
Total Annual Out-of-Pocket Maximum* $1,500 Single / $3,000 Family $8,000 Single / $16,000 Family
* Does not include fixed dollar copays or private duty nursing coinsurance
Prescription Drugs
Generic (Tier I) - $15 copay; Preferred Brand (Tier II) - $30 copay; Brand Non-
Pharmacy (30 day supply) Formulary (Tier III) - $60 copay.
Out-of-Network Pharmacy is reimbursed 75% of the approved amount less copay.
Pharmacy or Mail Order (90 day supply) $30 Generic; $60 Preferred Brand; $120 Brand Non-Formulary
Preventive Services (one service per calendar year)
Health Maintenance Exam 100% (no deductible) Not Covered
Annual Gynecological Exam & PAP 100% (no deductible) Not Covered
Prostate Specific Antigen (PSA) Screening 100% (no deductible) Not Covered
Mammography Screening 100% (no deductible) Not Covered
Expanded Women’s Preventive Care 100% (no deductible) Not Covered
Well-Baby and Child Care 100% (no deductible) Not Covered
Immunizations – pediatric & adult 100% (no deductible) Not Covered
Colonoscopy – screening or diagnostic 100% (no deductible) Not Covered
Physician Office Visits
Office visits, including Specialist visits $30 copay 80% after deductible
Emergency Medical Care
Hospital Emergency Room $50 copay per visits (waived if admitted to hospital or for accidental injury)
Facility Based Urgent Care Center $30 copay 80% after deductible
Ambulance Services (air/ground) 100% after IN NETWORK deductible
Diagnostic Services
Diagnostic Tests, Lab & X-Ray 100% after IN NETWORK deductible 80% after deductible
Maternity Services
Pre and Post-natal Care 100% after IN NETWORK deductible 80% after deductible
Delivery & Nursery Care 100% after IN NETWORK deductible 80% after deductible
Hospital Care
Semi-Private Room, Inpatient physician 100% after IN NETWORK deductible 80% after deductible
care, Hospital services and supplies
Inpatient Medical Care & Chemotherapy 100% after IN NETWORK deductible 80% after deductible
Alternatives to Hospital Care
Skilled Nursing Care 100% after IN NETWORK deductible 80% after deductible
Hospice Care 100% (no deductible)
Surgical Services
Surgery – includes related surgical services and
medically necessary in or out-patient facility 100% after IN NETWORK deductible 80% after deductible
charges
Voluntary Sterilization 100% after IN NETWORK deductible 80% after deductible
Human Organ Transplants
Specified Organ Transplants 100% (no deductible) 80% after deductible
Bone Marrow & Other Transplants 100% after IN NETWORK deductible 80% 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 (24 visits / year) $30 copay 80% after deductible
Outpatient Diabetes MT, DME, P&O appliances 100% after IN NETWORK deductible 80% after deductible
O/P Occ/SP/Physical Therapy (60) 100% after IN NETWORK deductible 80% after deductible
Allergy Testing & Therapy 100% after IN NETWORK deductible 80% after deductible

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