Page 10 - 2013 Allied Printing Benefit & Notices

Allied Printing Co., Inc. 2013

Allied Printing FB HSA 1250 Plan Benefit In Network Out-of-Network
Summary
Deductible and Coinsurance Maximums
Deductible $1,250 Single / $2,500 Family $2,500 Single / $5,000 Family
Coinsurance (Percentage copays) n/a 20% most services
Annual Coinsurance Out-of-Pocket Max n/a $1,000 Single / $2,000 Family
Total Annual Out-of-Pocket Maximum* $1,250 Single / $5,000 Family $3,500 Single / $7,000 Family
* Does not include fixed dollar copays or private duty nursing coinsurance
Prescription Drugs (paid AFTER Deductible is met)
Generic (Tier I) - $0 copay; Preferred Brand (Tier II) - $0 copay; Brand Non-
Formulary (Tier III) - $0 copay.
Pharmacy (30 day supply)
Out-of-Network Pharmacy is reimbursed 80% of the approved amount after FB
out-of-network deductible.
Pharmacy or Mail Order (90 day supply) $0 Generic; $0 Preferred Brand; $0 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 DRAFT
$150 copay per visits (waived if admitted to hospital)
Facility Based Urgent Care Center 100% after deductible 80% after deductible
Ambulance Services (air/ground) 100% after deductible
Diagnostic Services
Diagnostic Tests, Lab & X-Ray 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Maternity Services
Pre and Post-natal Care 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Delivery & Nursery Care 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Hospital Care
Semi-Private Room, Inpatient physician 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
care, Hospital services and supplies
Inpatient Medical Care & Chemotherapy 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Alternatives to Hospital Care
Skilled Nursing Care 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Hospice Care 100% after IN NETWORK deductible
Surgical Services
Surgery – includes related surgical services and
medically necessary in or out-patient facility 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
charges
Voluntary Sterilization 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Human Organ Transplants
Specified Organ Transplants 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Bone Marrow & Other Transplants 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Mental Health & Substance Abuse Treatment
In Patient Mental & Substance Abuse Treatment 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Out Patient Mental & Substance Abuse Treatment 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Other Services
Chiropractic Care (12 visits / year) 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Outpatient Diabetes MT, DME, P&O appliances 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
O/P Occ/SP/Physical Therapy (60) 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible
Allergy Testing & Therapy 100% after IN NETWORK deductible 80% after OUT OF NETWORK deductible

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