Table of Contents
INTRODUCTION............................................................................................................................................................................ 1
Plan Identification ............................................................................................................................................................................ 1
Plan Funding ...................................................................................................................................................................................... 2
Health Claims Administrator ........................................................................................................................................................ 2
Benefit Management Program Administrator ......................................................................................................................... 2
Prescription Drug Claims Administrator .................................................................................................................................. 3
SECTION I - SUMMARY OF BENEFITS ............................................................................................................................... 4
Summary............................................................................................................................................................................................. 4
Schedule A Benefits .......................................................................................................................................................................... 4
Classification Covered Persons................................................................................................................................................ 4
PHO Network ............................................................................................................................................................................... 4
Other Provider Networks.......................................................................................................................................................... 5
Allowable Fees .............................................................................................................................................................................. 5
Out of Network Providers. .................................................................................................................................................. 5
Network Participating Providers....................................................................................................................................... 5
Free Choice of Providers ........................................................................................................................................................... 5
Maternity Care............................................................................................................................................................................. 5
Federal Newbor n/Maternity Provision/ERISA Notice ................................................................................................ 6
Federal Mastectomy Provision/ERISA Notice .................................................................................................................... 6
Benefit Schedule A ...................................................................................................................................................................... 6
Deductibles and Copayments.............................................................................................................................................. 6
Schedule A Preventive Care Expenses ............................................................................................................................. 8
Out-of-Network Providers................................................................................................................................................... 8
Schedule A Hospital Expense Benefits (HEB)............................................................................................................... 9
Schedule A Medical Expense Benefits (MEB)...........................................................................................................10
Schedule A Prescription Drug Expense Benefits........................................................................................................14
Schedule B Benefits ........................................................................................................................................................................14
SSMC Hospital Charges and Related Ambulance Only.................................................................................................14
Potential Causes for Benefit Reduction....................................................................................................................................15
SECTION II - ELIGIBILITY AND ENROLLMENT.........................................................................................................16
Eligibility for Plan Enrollment ...................................................................................................................................................16
Employment Classifications ...................................................................................................................................................16
Schedule A Benefits Minimum Requirements ..............................................................................................................16
Schedule B Benefits Minimum Requirements................................................................................................................17
Dependent Eligibility Schedule A Benefits only...............................................................................................................17
Legal Spouse..........................................................................................................................................................................17
Unmarried Children of Active Employees ....................................................................................................................17
Persons Not Considered Eligible Dependents for Plan Enrollment ............................................................................19
Qualified Medical Child Support Orders ...........................................................................................................................19
Leave of Absence .......................................................................................................................................................................20
Enrollment ........................................................................................................................................................................................20
Individual or Personal Coverage ..........................................................................................................................................20
Family Coverage - Schedule A Benefits Only....................................................................................................................20
Enrollment Changes .................................................................................................................................................................20
Effective Dates of Benefits ............................................................................................................................................................21
Eligible Employment ................................................................................................................................................................21
Employment Waiting Periods ................................................................................................................................................21
Employee Effective Date ..........................................................................................................................................................21
Dependent General Rules........................................................................................................................................................22
Adding New Dependents ....................................................................................................................................................22
Cancellation of Another Health Plan..............................................................................................................................22
Late Entrant Enrollment ...................................................................................................................................................22
Monthly Participation Payment .................................................................................................................................................23
