APPENDIX  A MEDICAL BENEFITS SUMMARY

Central Falls School District

The primary health insurance shall include benefits comparable to those listed below. The primary health insurance plan shall provide coverage throughout the United States and shall include at least 4,000 hospitals and at least 500,000 providers nationwide. The term “within network” below refers to providers who participate in the plan. The term “outside network” refers to providers who do not participate in the plan.

 

 

Within Network you pay:

 

Outside Network you pay:

 

Notes

 

 

Deductible

 

 

$500 per individual

 

 

$1000 per individual

For family coverage: Up
to a maximum of two family members must meet the individual amount per calendar year. In-and-out of- network deductibles accumulate separately.

Coinsurance

$0

20%

 

 

 

 

 

Out-of-pocket maximum

 

 

 

 

 

$0 per individual

 

 

 

 

 

$4,000 per individual

For family coverage: Up
to a maximum of two family members must meet the individual amount per calendar year. Once you exceed this amount, we will pay up to our allowance for most covered services. Deductibles and
copayments do not apply to your out-of-pocket maximum. In-and-out
of-network out-of-pocket maximums accumulate separately.

Preventative Care

 

Adult preventative care

 

$0

 

$15 plus $20% after deductible

Includes one physical
exam and one gynecological exam per year.

 

Pediatric preventative care

 

$0

 

$15 plus $20% after deductible

Pediatric preventative
care is covered according to federal guidelines.

 

Immunizations

 

 

$15 plus $20% after deductible

Includes adult, pediatric,
and travel immunizations.

 

Lab services, machine tests, and X-rays

 

$0 (Deductible does not apply)

 

20% after deductible

Includes Pap smears, screening mammograms, and prostate-specific antigen (PSA) tests.

 

Office Visits

Personal care physicians (PCP)

 

$15

$15 plus $20% after
deductible

 

 

Specialist

 

$25

 

$25 plus $20% after deductible

Chiropractic visits are
limited to 12 per calendar year. Routine eye exams are limited to
1 per calendar year.

 

Outpatient Services

Outpatient medical services/surgical care (facility and doctor services)

 

0% after deductible

 

20% after deductible

Surgery performed in a
physician's office or urgent care center is not subject to the deductible.

Lab services, machine tests, and X-rays (diagnostic)

 

0% (Deductible does not apply)

 

20% after deductible

 

 

Inpatient Services

 

 

 

 

Inpatient hospital services
- acute care
- maternity

 

0% after deductible

 

20% after deductible

Unlimited days at a general or specialty hospital. Up to 45 days per calendar year for physical rehabilitation.

 

Mental Health and Chemical Dependency Treatment Services

 

Inpatient

 

0% after deductible

 

20% after deductible

 

 

Outpatient

 

$0

 

20% after deductible

 

 

Office Visits

 

$25

$25 plus 20% after
deductible

 

 

Urgent Care or Emergency Care

 

Urgent care center

 

$50

$25 plus 20% after deductible

 

 

 

Emergency room care

 

 

 

$100

 

 

 

$100

If emergency room visit results in hospital admission, $100 copayment is waived. You may be billed an additional specialist copayment if you are seen by a specialist in the emergency room.

 

 

Ambulance services

 

 

$50

 

 

$50

Coverage for medically necessary/emergency services. Air and water ambulances are limited
to a maximum of $3,000 per occurrence.

 

Additional Services

Physical/occupationa l therapy

 

20% after deductible

 

20% after deductible

 

 

Durable medical equipment (DME)

 

 

20% after deductible

 

 

20% after deductible

Must be purchased from
participating DME
vendor.
Pharmacies are NOT participating in the DME network.

 

Home and hospice care

 

0% after deductible

 

20% after deductible

Includes physician,
nurse, and home health aide visits.

 

Key Terms

 

Coinsurance: The percentage of our allowance that you must pay for a covered healthcare service. Copayment: A fixed dollar amount that you must pay for a covered healthcare service. Deductible: A fixed amount that you must pay for covered healthcare services each calendar year before we start to pay for those services.
Out-of-pocket maximum: Highest amount of coinsurance that you must pay each calendar year for certain covered health care services.
Personal care physician (PCP): Includes family practitioners, internists, and pediatricians. Specialist: Includes office visits to all other medical providers who specialize in a certain area of medicine, such as but limited to: oncology, cardiology, ophthalmology, dermatology, or allergy.

Prescription Drug Benefit

Description                                                  Copayment per               Copayment foe mail Order
30-day supply                 90-day supply

 

Tier 1   Low cost generic drugs                               $7                                       $17.50

 

Tier 2   High cost generic and                                 $25                                     $62.50
preferred brand name drugs

 

Tier 3   Non-preferred brand named drugs           $40                                     $100

 

Tier 4   Specialty drugs                                             $40                                     N/A

* Infertility drugs, including oral and injectable drugs, are covered with a 20% co- insurance

Notes

Prescribed over-the-counter aspirin, folic acid, iron supplements and smoking cessation medications purchased at a retail pharmacy are covered at 100% according to federal guidelines.


The prescription drug plan provider shall maintain a network of retail pharmacies, including an option for mail order.

Specialty drugs must be purchased at one of the participating specialty pharmacies to receive the maximum benefit.  Tier 4 specialty drugs purchased at a non-participating specialty pharmacy must be paid in full at the time of purchase.  A 50% reimbursement allowance is provided for most specialty drugs.  Specialty infertility drugs are reimbursed at 80% of the allowance.

There is no coverage for non-participating retail and mail order pharmacies for Tier 1,
Tier 2 and Tier 3 drugs.

This is a general summary of the medical benefits and prescription drug program.  For details of coverage, including any limitations or exclusions not noted, please refer to the subscriber agreement