Additional Plan Information Clause Samples

Additional Plan Information a. High Deductible Health Plan (HDHP) b. Health Maintenance Organization (HMO) c. Preferred Provider Organization (PPO-In Network) d. Preferred Provider Organization (PPO-Out-of-Network) e. Plan design co-pays in PPO and HMO are as follows: 2020-2021 2021-2022 2022-2023 (1) generic substitution with a “dispensed as written” (DAW) provider override for brand drugs, (2) mandatory specialty drugs dispensed through Accredo specialty pharmacy.

Additional Plan Information a. This Plan is the primary plan for dental procedures that are covered under the enrollee’s health plan. b. Orthodontic services are a Covered Services as shown in Section 1.6, subject to the following conditions: (1) the Employer maintained a group dental program which was in effect immediately preceding the Effective Date, and (2) such program provided substantially the same coverage for Orthodontic Services as this Plan provides. c. Temporomandibular Joint Dysfunction (TMJ) – coverage should be predetermined and is limited to: (1) Those intra-oral services which would normally be provided by a Dentist in the relief of oral symptoms associated with malfunctions of the TMJ, but shall not include those services which would normally be provided under medical care including, but not limited to, psychotherapy, special joint exams and x-rays, joint surgery and medications. (2) The following procedures which are specified as intra-oral: – Closed reduction of dislocation – Occlusal Orthotic Device – Occlusal adjustment (limited) – Occlusal adjustment (complete) The above services require prior authorization by DDKS. (3) Benefits for fixed appliances and restorations are excluded. Diagnostic procedures not otherwise benefitted under the Plan are excluded. (4) The repair and/or replacement of any appliances furnished in whole or in part under TMJ coverage is not covered under the Plan. (5) All services for TMJ will be limited to the maximum amount stated above. No further benefits will be provided until five (5) years have passed from the last service in the prior course of treatment. If benefits from the initial course of treatment were less than the amount stated above, the unused amount does not carry forward to a subsequent course of treatment.

Additional Plan Information. Details of all insurance plans are filed in the office of the Board of Education and may be examined there during regular office hours. Additional information can be found in the Human Resources Section of the District Website. There is no annual deductible cost to the individual, no family deductible, and no co-insurance costs for those expenses incurred within the Network of doctors and hospitals. This plan includes an unlimited lifetime maximum. The annual deductible for out-of-network is $500 individual / $1,000 individual plus one / $1,500 family, 80% / 20% co-insurance (Years 1-3) on a calendar year basis, after the insured has paid $1,500 individual / $3000 individual plus one / $4,500 family in benefit payments including deductible, covered expenses are paid 100%. This plan includes a $2,000,000 lifetime maximum. There is no annual deductible for the individual and their families as long as they stay in the HMO Network. This Plan has no lifetime maximum if services are provided in Network. Out of the HMO Network the individual has total responsibility for medical expenses, except in an emergency. • Prescription co-pays ($5/$30/$45) apply after the deductible is satisfied. • The deductibles shall be $2,000/$4,000, and employees will be enrolled in a Health Savings Account (HSA). • The Board’s contribution to the deductible shall be made 50% in the first pay date in July and 50% in the first pay date in January. • Board contribution to deductible is 50%. • The Maximium Out of Pocket (MOOP) In Network shall be $3,000/$6,000. MOOP Out of Network shall be $5,000/$10,000. a. Plan design changes in PPO and HMO as follows: 2020-21 2021-22 2022-23 2023-24 Office Visit $30 $30 $30 $30 Specialist Visit $40 $40 $40 $40 ER $125 $125 $125 $125 Urgent Care $75 $75 $75 $75 Inpatient $250 $250 $250 $250 Out-patient $250 $250 $250 $250 Imaging $75/$375 $75/$375 $75/$375 $75/$375 Prescription $10/$25/$40* $10/$25/$40* $10/$25/$40* $10/$25/$40* *Prescriptions: Essential Package (prior authorization, step therapy, and quantity limits), mandatory generics & exclusive specialty pharmacy Retired administrators will be given the option of selecting one of the health insurance alternatives available to active employees.

Additional Plan Information