Benefits Chart. See Benefits Chart on the following page. Wastren-EnergX Mission Support, LLC PORTS USW Benefit Plans Date: January 18, 2011 MEDICAL PLAN 100/90% PPO Plan Deductible In Network: Individual $0 Family $0 Out of network: Individual $100 Family $200 Out-of-Pocket Max In Network: Individual $0 Family $0 Out of network: Individual $600 Family $1200 Lifetime Max $1,000,000 Includes $10,000 yearly restoration. Office Visit Co-pay None MEDICAL PLAN (CONT’D.) 100/90% PPO Plan Benefits Doctor Visit In: 100% - No deductible Out: 90% - After deductible Second Surgical Opinion 100% However, Aetna recommends any SSO be covered at the same benefit levels as the physician charges. Hearing Aids 1 aid per ear per member covered at 100%. Not subject to deductible $500 max every 3 years. Physical Therapy 60 day visit limit per condition X-Ray and Lab. In: 100% - No deductible Out: 90% - After deductible Inpatient Hospital / Surgery In: 100% - No deductible Out: 90% - After deductible Outpatient Surgery In: 100% - No deductible Out: 90% - After deductible Pre-Admission & Post- Confinement Testing In: 100% - No deductible Out: 90% - After deductible (Aetna follows hospital guidelines to determine time frames for testing.) MEDICAL PLAN (CONT’D.) 100/90% PPO Plan Preventative Care Immunization In: 100% - No deductible Out: 90% - After deductible Flu shots are covered. Must be medically necessary. Well-Child In: 100% - No deductible Out: 90% - After deductible 6 visits year 1. 2 visits ages 1-2. Ages 2-6 = 1 per 12 mo. Ages 7-64 = 1 per 24 mo. Well-Woman In: 100% - No deductible Out: 90% - After deductible Limit 1 per cal year Routine Physical Exam In: 100% - No deductible Out: 90% - After deductible Limit to 1 visit each 24 months for ages 7-64 Routine Mammogram In: 100% - No deductible Out: 90% - After deductible For age 40+. Limit 1 per cal year Plan pays up to $85 Emergency Care Doctor Office In: 100% - No deductible Out: 90% - After deductible Emergency Room 100% - No deductible Emergency Conditions For treatment of sudden/serious onset of illness or injury Ambulance 90% - After deductible (must be medically necessary) 100/90% PPO Plan
Benefits Chart a list of the covered services you get as a member of the GHC MA Plan What are covered services? This section describes the medical benefits and coverage you get as a member of the GHC MA Plan. “Covered services,” means the medical care, services, supplies, and equipment that are covered by the GHC MA Plan. This section has a Benefits Chart that gives a list of your covered services and tells what you must pay for each covered service. The section that follows (Section 5) tells about services that are not covered (these are called “exclusions.”) There are some conditions that apply in order to get covered services Some general requirements apply to all covered services The covered services listed in the Benefits Chart in this section are covered only when all requirements listed below are met: • Services must be provided according to the Medicare coverage guidelines established by the Medicare program and GHC guidelines. • The medical care, services, supplies, and equipment that are listed as “covered services” must be medically necessary. Certain preventive care and screening tests are also covered. (See Section 13 for a definition of “medically necessary.”) • With few exceptions, covered services must either be provided by plan providers, be approved in advance by plan providers, or be authorized by GHC. The exceptions are care for a medical emergency, urgently needed care, and renal (kidney) dialysis you get when you are outside the plan’s service area. In addition, some covered services require “prior authorization” in order to be covered Some of the covered services listed in the Benefits Chart in this section are covered only if your doctor or other plan provider gets “prior authorization” (approval in advance) from GHC. Covered services that need prior authorization are marked by italics text in the Benefits Chart.
