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2014-2015 Plan Options - Tulare Joint Union High School District

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Tulare Joint Union High School District Certificated Management Plan Options 2014-2015
Plan Option #1
SISC Classic 90% plan
PBC 90-E $20
PLANS
Provider Network(s):
Hospital
Professional
Calendar Year Deductible(s)
Maximum Co-Insurance (Out-of-Pocket Max)
Co-insurance is the member's responsibility to pay when the plan is paying less
than 100% ( i.e. plan pays 80%, member
pays the other 20%)
Services
Office Visits
Inpatient Hospital
Room, Board & Support Services
(prior authorization required)
Ambulatory Surgery Center
Emergency Room (non-emergency)
Facility Expenses:
Professional Expenses:
Accident Care (48 hrs)/Emergency Room*
Facility Expenses:
Professional Expenses:
Prudent Buyer
Prudent Buyer
$300 per individual up to $600 per family
$600 per individual up to $1,800 per family
Once the member's 10% co-insurance
totals $600, the plan will pay 100% of
the allowable amount for the remainder
of the calendar year.
Participating
Non-Participating
Providers
Providers
Subscriber and Dependent - Same Benefits
$20 co-pay
Non-Par Fee
deductible waived
90%
$600 per day
90%
$350 per day
$100 co-pay (waived if admitted)
90%
50% C&R
90%
Plan Option #3
SISC Classic 100% plan
PBC 100-C $20
Plan Option #2
SISC Classic 90% plan
PBC 90-A $20
Prudent Buyer
Prudent Buyer
$100 per individual up to $300 per family
$300 per individual up to $900 per family
Once the member's 10% co-insurance
totals $300, the plan will pay 100% of
the allowable amount for the remainder
of the calendar year.
Participating
Non-Participating
Providers
Providers
Subscriber and Dependent - Same Benefits
$20 co-pay
Non-Par Fee
deductible waived
90%
$600 per day
90%
$50 co-pay, 50% up to
$350 per day
$100 co-pay (waived if admitted)
90%
50% C&R
Non-Par Fee
90%
Non-Par Fee
$100 co-pay (waived if admitted)
90%
90% C&R
$100 co-pay (waived if admitted)
90%
90% C&R
Plan Option #4
SISC Classic 100% plan
PBC 100-C $20
Prudent Buyer
Prudent Buyer
$200 per individual up to $400 per family
$0 per individual up to $0 per family
Once the member's 0% co-insurance
totals $0, the plan will pay 100% of
the allowable amount for the remainder
of the calendar year.
Participating
Non-Participating
Providers
Providers
Subscriber and Dependent - Same Benefits
$20 co-pay
Non-Par Fee
deductible waived
100%
$600 per day
100%
$50 co-pay, 50% up to
$350 per day
Prudent Buyer
Prudent Buyer
$200 per individual up to $400 per family
$0 per individual up to $0 per family
Once the member's 0% co-insurance
totals $0, the plan will pay 100% of
the allowable amount for the remainder
of the calendar year.
Participating
Non-Participating
Providers
Providers
Subscriber and Dependent - Same Benefits
$20 co-pay
Non-Par Fee
deductible waived
100%
$600 per day
100%
$50 co-pay, 50% up to
$350 per day
$100 co-pay (waived if admitted)
100%
50% C&R
$100 co-pay (waived if admitted)
100%
50% C&R
100%
100%
Non-Par Fee
Non-Par Fee
$100 co-pay (waived if admitted)
100%
100% C&R
$100 co-pay (waived if admitted)
100%
100% C&R
90%
90% C&R
90%
90% C&R
100%
100% C&R
100%
100% C&R
Surgeon & Anesthetist
Well Baby/Child Preventative Care
Birth to age six
90%
Deductible Waived
100%
Non-Par Fee
Non-Par Fee
90%
Deductible Waived
100%
Non-Par Fee
Non-Par Fee
100%
Deductible Waived
100%
Non-Par Fee
Non-Par Fee
100%
Deductible Waived
100%
Non-Par Fee
Non-Par Fee
Routine Preventative Care
Members age 7 and older
Deductible Waived
100%
*medical emergencies as defined by the plan
Diagnostic X-Ray & Lab
MRI, CT, PET & nuclear cardiac scan (UR)
Other diagnostic x-ray & lab
Cancer Screenings
(Industry standard, routine screenings)
Physical Medicine (OT, PT, Chiro)
(some limits may apply)
Chiropractic
Speech Therapy
Acupuncture
12 visits per year
Durable Medical Equipment
Rental or Purchase of DME
Hearing Aid ($700 maximum every 24 months)
Hospice
Ambulance (Ground or Air)
Home Health Care
100 4-hour visits/yr (prior authorization req'd)
Home Infusion
Psychiatric & Substance Abuse
Inpatient
Outpatient
Outpatient Prescription Drugs
Deductible Waived
100%
Not Covered
90%
90%
Deductible Waived
100%
90%
Non Par Fee
Non Par Fee
Non Par Fee
Not Covered
90%
90%
Deductible Waived
100%
Non Par Fee
Non Par Fee
90%
Non-Par Fee
Non Par Fee
Deductible Waived
100%
Not Covered
100%
100%
Deductible Waived
100%
Non Par Fee
Non Par Fee
100%
Non-Par Fee
Non Par Fee
Deductible Waived
100%
Not Covered
100%
100%
Deductible Waived
100%
Non Par Fee
Non Par Fee
100%
Non-Par Fee
Non Par Fee
Non-Par Fee
90%
Non-Par Fee
90%
Non-Par Fee
100%
Non-Par Fee
100%
Non-Par Fee
90% up to
$50 per visit
Non-Par Fee up to
$25 per visit
90% up to
$50 per visit
Non-Par Fee up to
$25 per visit
100% up to
$50 per visit
Non-Par Fee up to
$25 per visit
100% up to
$50 per visit
Non-Par Fee up to
$25 per visit
90%
90%
90%
90%
90%
Non Par Fee
Non-Par Fee
90%
90%
Non-Par Fee
90%
90%
90%
90%
90%
Non-Par Fee
Non-Par Fee
90%
90%
Non-Par Fee
100%
100%
100%
100%
100%
Non-Par Fee
Non-Par Fee
100%
100%
Non-Par Fee
100%
100%
100%
100%
100%
Non-Par Fee
Non-Par Fee
100%
100%
Non-Par Fee
90%
100% up to $600/day
90%
100% up to $600/day
100%
100% up to $600/day
100%
100% up to $600/day
Same as other medical benefits
Same as other medical benefits
Same as other medical benefits
Same as other medical benefits
SISC Medco Rx Plan $200/$10-35
Retail
Mail
30 days
90 days
$200 per individual / $500 per family
$10
$25
$35
$90
SISC Medco Rx Plan $7-25
Retail
Mail
30 days
90 days
Not applicable
$7
$14
$25
$60
SISC Medco Rx Plan $9-35
Retail
Mail
30 days
90 days
Not applicable
$9
$35
SISC Medco Rx Plan $200/$15-50
Retail
Mail
30 days
90 days
$200 per individual / $500 per family
$15
$50
This is only a brief summary of benefits.
For details, limitations and exclusions, please refer to the Summary Plan Description.
PBC 90-E $20
SISC 200/10-35
DENTAL $1500 max
VISION
LIFE
TOTAL PER EMPLOYEE PER MONTH
TOTAL COST PER EMPLOYEE PER YEAR
EMPLOYEE PAYS (SEP-JUN)
PBC 90-A $20
SISC 5-20
DENTAL $1500 max
VISION
LIFE
$1,111.00
$108.00
$22.10
$9.50
$1,250.60
$15,007.20
$
86.40
PBC 100-C $20
SISC 9-35
DENTAL $1500 max
VISION
LIFE
$1,233.00
$108.00
$22.10
$9.50
$1,372.60
$16,471.20
$
232.80
PBC 100-C $20
SISC $200/15-50
DENTAL $1500 max
VISION
LIFE
$1,232.00
$108.00
$22.10
$9.50
$1,371.60
$16,459.20
$
231.60
$1,182.00
$108.00
$22.10
$9.50
$1,321.60
$15,859.20
$
171.60
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