SSMC Employee Health Benefit Plan
14
Schedule A Prescription Drug Expense Benefits
Retail Pharmacy supply limited to 34-days for each covered prescription. Mail Order Pharmacy supply limited to 90 days
for each covered prescription.
Out-of-Network Allowable Fees: Plan limits to the Usual, Customary and Reasonable Charges (UCR) Participant must
pay charges that are more than the UCR allowance, plus applicable Copayment.
Schedule A Prescription
Drug Expense Benefits
EHS Network Pharmacy
Out-of-Network Pharmacy
(Claim Form Required)
Copayments (Retail or Mail
Order)
Brand Name with generic equivalent: $7.00 per prescription or refill. Plan pays
balance of Network Allowance or Out-of-Network Allowable Fee.
Generic / Brand Name with no Generic equivalent: No Copayment. Plan pays
100% of Network Allowance or Out-of-Network Allowable Fee.
C. Schedule B Benefits
(SSMC Hospital Only Plan)
SSMC Hospital Charges and Related Ambulance Only
Schedule B
Part-time Employees working 18 hours but less than 22.50 hours per week. Covers eligible Employee only.
Dependents are not covered. To be eligible for benefits, expenses must be billed by SSMC for their services and
Supplies, except professional ambulance. If done elsewhere, benefits are not available. Covered Services and Plan
Benefits are limited to those shown below in this Schedule B. No other Services or Supplies are covered. Coverage does
not include separate charges for professional services.
Schedule B Covered Services
Benefit Limits
SSMC Inpatient Expenses
Room and Board and related
Hospital Miscellaneous
services.
Plan pays 100% of Allowable Fees for the first 21 days, then Plan pays 50% of
Allowable Fees for days 22-201 Per Confinement. Private room charges are limited to
Average Semi-private Room Rates.
SSMC Outpatient Expenses
Diagnostic x-ray and lab
Plan pays 100% of Allowable Fees.
Emergency Room or
Outpatient Room.
Plan pays 100% of Allowable Fees. Coverage limited to initial emergency care
rendered within 24 hours of first symptoms for sudden and serious Illness or rendered
for Accidental Injury within 72 hours of an accident.
Pre-admission Testing
Plan pays 100% of Allowable Fees. Coverage limited to pre-admission testing
rendered within seven days before scheduled admission to SSMC.
Mammography Screening.
Plan pays 100% of Allowable Fees. Frequency based on Covered Person's age and
medical history.
Professional Ambulance
Plan pays 100% to and from SSMC when ambulance transportation found Medically
Necessary.
