Page 9 - 2013-14 AAACU Benefits & Notices

Alpena Alcona Area CU 2013-14

Alpena Alcona Area CU HRA PPO 5000 Plan In Network Out-of-Network
Benefit Summary
Deductible and Coinsurance Maximums
Deductible $5,000 Single / $10,000 Family $10,000 Single / $20,000 Family
Coinsurance (Percentage copays) 50% on selected services 20% or 50% most services
Annual Coinsurance Out-of-Pocket Max none $5,000 Single / $10,000 Family
Total Annual Out-of-Pocket Maximum* $5,000 Single / $10,000 Family $15,000 Single / $30,000 Family
* Does not include fixed dollar copays or private duty nursing coinsurance
Prescription Drugs
Generic (Tier I) - $15 copay; Preferred Brand (Tier II) - $50 copay; Brand Non-
Pharmacy (30 day supply) Formulary (Tier III) – 50% co-pay (min $70 – max $100).
Out-of-Network Pharmacy is reimbursed 75% of the approved amount less copay.
Pharmacy/Mail Order (90-day supply) $30 Generic; $100 Preferred Brand; 50% Brand Non-Formulary (min $140 – max $200)
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 $250 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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