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2017 Benefits Summary

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Medical Plan In Network Out of Network*
Annual Deductible
    • Individual
    • Family

In network and out of network are not combined; they do not cross apply.

    • $ 500
    • $ 1,500 ($ 500 per individual)
    • $ 1,500
    • $ 4,500 ($ 1,500 per individual)
Medical Out-of-Pocket Maximum
  • All Coverage Levels

In-network and out-of-network are not combined; they do not cross apply.

The annual deductible, prescription drug and preventive care expenses do not count toward the out-of-pocket maximum. In addition, amounts over Reasonable & Customary (R&C) and non-covered services do not accumulate to the out-of-pocket maximum.

  • $1,500 per person, up to a $3,000 maximum (no more than $1,500 per person).
  • $5,000 per person, up to a $10,000 maximum (no more than $5,000 per person).
Lifetime Maximum

Lifetime Maximum.

$5,000,000 lifetime maximum per covered member; in network and out of network combined

 
Physician Office Visits
    • Non-surgical, internists, general physician, family practitioner or pediatrician.
    • Walk-in Clinic
      Immunizations and routine consults performed by Nurse Practitioners outside of traditional office visit setting.
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    •  
      Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    •  
      Plan pays 65%, after deductible
      You pay 35%, after deductible
Aexcel®-Designated Providers

Specialty Care/Office Visits.

Plan pays 90%, after deductible
You pay 10%, after deductible

Not Applicable

Non-Aexcel®-Designated Providers

Specialty Care/Office Visits.

Plan pays 85%, after deductible
You pay 15%, after deductible

Plan pays 65%, after deductible
You pay 35%, after deductible

Prescription Drug Coverage
  • Retail (Up to a 30-day supply)
    First three purchases of any medication*
    • Generic

    • Brand Name
      • Preferred brand name.
        (listed on formulary)
      • Non-preferred brand name.
        (not listed on formulary)
  • Mail Order (Up to a 90-day supply)
    • Generic

    • Brand Name
      • Preferred brand name.
        (listed on formulary)
      • Non-preferred brand name.
        (not listed on formulary)

*After the third purchase of a long-term medication, you pay an additional co-payment of up to $25 per additional fill of that medication at retail. To avoid this additional cost, use the Express Scripts mail order pharmacy service. Please note: The additional co-payment does not apply for certain represented groups. Check your enrollment materials for details.



    • You pay 10%, up to $25 maximum, for each prescription or refill

      • You pay 30%, up to $75 maximum, for each prescription or refill
      • You pay 50%, up to $175 maximum, for each prescription or refill

    • You pay 10%, up to $50 maximum, for each prescription or refill

      • You pay 30%, up to $150 maximum, for each prescription or refill
      • You pay 50%, up to $350 maximum, for each prescription or refill


    • Plan pays 50%, no deductible
      You pay 50%, no deductible

      • Plan pays 50%, no deductible
        You pay 50%, no deductible
      • Plan pays 50%, no deductible
        You pay 50%, no deductible

    • No Coverage


      • No Coverage

      • No Coverage

Diagnostic X-ray and Lab
    • Performed as part of physician office visit and billed by physician, covered same as physician office visits.
    • Performed in outpatient hospital or other outpatient facility setting, including independent lab.
    • Plan pays 85%, after deductible
      You pay 15%, after deductible

    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible

    • Plan pays 65%, after deductible
      You pay 35%, after deductible
Emergency Medical Care
    • Emergency Room.

    • Non-emergency use of an
      Emergency Room.
    • Ambulance.

    • Urgent Care Facility.

    • Non-urgent use of an Urgent Care Facility.

    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 50%, after deductible
      You pay 50%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 50%, after deductible
      You pay 50%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
Complex Imaging Services

MRA/MRS, MRI, CT Scan, PET Scan.

Precertification required for outpatient services.

Plan pays 85%, after deductible
You pay 15%, after deductible

Plan pays 65%, after deductible
You pay 35%, after deductible

Preventive Care

Routine physicals, immunizations,
and related lab fees.

    • Adults, age 18 and older
      Routine physical exam, immunizations, flu shots
      Y physical exam per year.
    • Colorectal Screenings
      For all members age 50 and over: Fecal occult blood test every year, Sigmoidoscopy (1 every 5 years), double contrast barium enema (1 every 5 years), Colonoscopy (1 every 10 years).
    • Gynecological
      Y routine GYN exam per year with 1 pap smear and related lab fees.
    • Hearing Exams
      Covered only as part of routine physical exam.
    • Mammograms
      Routine mammogram.
      Y baseline age 35-40.
      1 annual mammogram age 40+.
    • Prostate Specific Antigen (PSA) Test and Digital Rectal Exam (DRE)
      1 annual (PSA and DRE) exam for males ages 40 to 75; not covered age 76 and over.
    • Vision Screenings
      Covered only as part of routine physical exam.
    • Well Child Care
      Routine immunizations, flu shots.
      Child to age 18:
      7 exams in the 1st 12 months of life.
      3 exams in the 13-24th months of life.
      3 exams in the 25-36th months of life.
      1 exam per 12 months thereafter.

Plan pays 100% up to R&C,
deductible waived

Plan pays 100% up to R&C,
deductible waived

Maternity
    • OB Visits
      Hospital/facility delivery charges are covered under Hospital Services.
    •  
      Plan pays 85%, after deductible
      You pay 15%, after deductible
    •  
      Plan pays 65%, after deductible
      You pay 35%, after deductible
Hospital Services
    • Inpatient
      Inpatient surgery expenses, room & board & misc. fees, physician expenses, routine nursery care, prescription drugs, and all inpatient care; Precertification required.
    • Bariatric Surgery
      Inpatient and outpatient.
      Precertification required.
       
       
       
       
    • Second Surgical Opinion
       
    • Outpatient Hospital Expenses
      Hospital and other facilities.
    • Outpatient Surgery Performed in Office Setting
    •  
      Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
    •  
      Plan pays 85%, after deductible
      You pay 15%, after deductible

      Plan pays 90%, after deductible
      You pay 10%, after deductible if services performed in Institute of Quality (IOQ) facility
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    •  
      Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
    •  
      Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
Mental Health
    • Inpatient services; no maximum inpatient days per year; Precertification required.
    • Outpatient services; no visit maximum for medically necessary care; Precertification required (generally not required for outpatient therapy visits).
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
Substance Abuse
    • Inpatient rehabilitation and detoxification in a hospital or treatment facility; no maximum inpatient days per year; Precertification required.
    • Outpatient services in an office or other outpatient setting; no visit maximum for medically necessary care; Precertification required (generally not required for outpatient therapy visits).
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
Other Services
    • Allergy Testing and Treatment
      Office Visit.
    • Allergy Injections
       
    • Autism/Pervasive Development Delays
      Covers diagnosis and outpatient short-term rehabilitation. Limited to 60 visits per year, combined for speech, physical and occupational therapies. Short-Term Rehabilitation at an outpatient hospital setting is included in the 60 visits maximum.
    • Chiropractic Care
      All visits/services at a chiropractor count toward 20 visit annual maximum.
    • Contraceptive Devices, Implants and Injections
      Plan covers associated office visit for injection of Depo-Provera and Lunell, Diaphragm fitting, and cervical cap and IUD devices.
    • Convalescent Facility/Skilled Nursing Facility
      Semi-private room rate. Prior hospital confinement not required. Precertification required; up to 120 days per calendar year (combined in-network and out-of-network limit).
    • Durable Medical Equipment
      Precertification required for amounts in excess of $5,000.
    • Hearing Aids
      Limited to $1,000 per ear every 3 years.
    • Home Health Care
      Prior hospital confinement not required. Each visit by a Home Health Aide of up to 4 hours equals 1 visit. Each visit by a Nurse or Therapist equals 1 visit. Limited to 120 visits per year (Home Health Care and Private Duty Nurse visits combined); Precertification required for some services.
    • Hospice Care:
    • Inpatient Hospice Care; Precertification required.
       
    • Inpatient Hospice Lifetime Maximum.
    • Outpatient Hospice Care.
       
    • Outpatient Hospice Lifetime Maximum.
       
    • Infertility
      Covers diagnosis and treatment of underlying cause only.
    • Mouth, Jaws, Teeth
      Oral surgery procedures; Precertification required. Covers accident related injury to teeth, and medical in nature oral and jaw surgery.
    • Organ and Tissue Transplants
      Requires preauthorization by National Medical Excellence.
       
       
       
    • Outpatient Short-Term Rehabilitation
      Limited to 60 visits per year, combined for speech, physical and occupational therapies. Short-Term Rehabilitation at an outpatient hospital setting is included in the 60 visits maximum. Includes coverage for Autism/Pervasive Development Delays.
    • Private Duty Nursing (PDN)
      Outpatient care provided by a Registered Nurse or LPN, if member’s condition requires skilled nursing care and visiting nursing care is not adequate; Precertification required. Limited to 120 visits per year (Home Health Care and Private Duty Nurse visits combined). PDN maximum: 1 shift equals up to 8 hours.
    • Prosthetic Devices
      (Artificial limbs, breast prosthesis)
      Precertification required for amounts in excess of $5,000.
    • Sexual Disorders
      Excludes treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling that do not have a physiological or organic basis.
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
       
       
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
       
       
       
       
    •  
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Unlimited
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
    • Unlimited
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible

      Plan pays 90%, after deductible
      You pay 10%, after deductible if services performed in Institute of Quality (IOQ) facility
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
       
       
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
       
       
       
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
    • Plan pays 85%, after deductible
      You pay 15%, after deductible
       
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
       
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
       
       
       
       
    •  
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    • Unlimited
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
    • Unlimited
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
       
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
       
       
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
    • Plan pays 65%, after deductible
      You pay 35%, after deductible
       
       
       
Precertification Penalty
    • Inpatient Hospital
      Precertification required for treatment facilities, skilled nursing facilities and inpatient mental health / substance abuse.
    • Outpatient Hospital
      Precertification required for home health care, private duty nursing and some other outpatient services; generally not required for outpatient therapy visits.
    • Precertification required;
      provider responsible - no penalty
       
       
    • Precertification required;
      provider responsible - no penalty
       
       
    • You are responsible for precertification;
      $500 penalty for failure to precertify
       
       
    • You are responsible for precertification;
      $300 penalty for failure to precertify
       
       
Pre-existing Conditions

Pre-existing Conditions.

No restrictions

No restrictions

Dependent Limiting Age

Plan covers eligible dependent children from birth to age 26.

 

 

Claims Administrator Information

Medical Administered by:

Aetna
P.O. Box 981106
El Paso, TX 79998-1106

Prescription Administered by:

Express Scripts, Inc.
P.O. Box 14711
Lexington, KY 40512-4230

 
Out-of-Area Plan Definition
Disclaimer:

The information provided in this “Benefits Summary” is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Consult the formal plan documents to determine governing plan provisions, including procedures, exclusions and limitations relating to the plan. While this information is believed to be accurate as of the plan effective date (January 1, 2017), it is subject to change.

* Benefits paid by the LM HealthWorks Plan for out-of-network and out-of-area care are based on Reasonable and Customary charges. Reasonable and Customary charges are those most often made for a given health care service or supply in a geographical area.

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