Overview of
Medical Benefits -
Medical Choice PlanMedical Choice PlanEffective 04/01/2015
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Medical Choice PlanMedical Choice Plan
Annual Deductible• $750.00 per person; maximum of $2,250.00 per family.
• After annual deductible has been met, the Plan pays the percentage of covered charges as shown. When the annual out-of-pocket amount for network providers has been met, the Plan will pay 100% of covered charges for that calendar year. There is no out-of-pocket maximum for non-network providers.
Monterey Bay Public Employees TrustOverview of Medical Benefits
Medical Choice PlanMedical Choice Plan
Annual Out-of-Pocket Limit• In-P.H.A.-network: $3,750.00 per individual, $11,250.00 per family. Note: The calendar year deductibles are included in the out-of-pocket limits
• Out-of-P.H.A.-network: None.
Note: The prescription drug program has a separate individual and family out-of-pocket limit of $1,950.00
Monterey Bay Public Employees TrustOverview of Medical Benefits
Medical Choice PlanMedical Choice Plan
Lifetime Maximum• Lifetime Maximum: No Lifetime maximum per
person.
Monterey Bay Public Employees TrustOverview of Medical Benefits
Medical Choice PlanMedical Choice Plan
Life Insurance• Life Insurance: $25,000.00 term life insurance for active participants only.
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Physician (Surgery, Home, Office, Hospital)
• In-P.H.A.-network: 70% of contracted rates for surgeon/anesthetist. 70% for hospital visits and home visits. $20.00 co-payment for office visits (deductible does not apply).
• Out-of-P.H.A.-network: 50% of U.C.R. charges.
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Access to Specialists• In-P.H.A.-network: 70% of contracted rates for specialists. (Direct access to specialists allowed.)
• Out-of-P.H.A.-network: 50% of U.C.R. charges. (Direct access to specialists allowed.)
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Anesthesia• In-P.H.A.-network: 70% of contracted rates.
• Out-of-P.H.A.-network: 50% of U.C.R. charges.
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Hospital Services (slide 1 of 4)
• M.B.P.E.T. Hospitals of Distinction:• 90% of contracted rates. (Natividad Medical Center, George L. Mee Memorial Hospital, Hazel Hawkins Memorial Hospital, Salinas Valley Memorial Hospital, Watsonville Community Hospital and Community Hospital of the Monterey Peninsula.
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Hospital Services (slide 2 of 4) •M.B.P.E.T. Centers of Excellence: 100% of contracted rates; $250.00 daily per diem for family expenses for each day of in-patient medically necessary care (must be pre-approved by Executive Director). (Stanford Medical Center and other pre-approved facilities for specialized procedures or treatments).
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Hospital Services (slide 3 of 4)
• Network Hospitals: 80% of contracted rates.
•Non-Network Hospitals- 60% of U.C.R. covered expenses.
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Hospital Services (slide 4 of 4)
• Non-Network Hospitals: 60% of U.C.R. charges
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Skilled Nursing Facility• In-P.H.A.-network: 70% of contracted rates for the first ten (10) days and 60% of contracted rates for the next ninety (90) days - annual maximum of one-hundred (100) days. Pre-certification required; otherwise, penalties applied.
• Out-of-P.H.A.-network: None.
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X-Ray and Laboratory Services• In-P.H.A.-network: 70% of contracted rates.
• Out-of-P.H.A.-network: 50% of U.C.R. charges.
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Maternity and Interrupted Pregnancy• In-P.H.A.-network: Covered as any other medical condition.
• Out-of-P.H.A.-network: Covered as any other medical condition.
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Vasectomy• In-P.H.A.-network: Covered as any other medical condition.
• Out-of-P.H.A.-network: Covered as any other medical condition.
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Emergency Room• In-P.H.A.-network: 70% of contracted rates after a $200.00 co-payment.
90% of contracted rates in Hospitals of Distinction after a $200.00 co-payment.
• Out-of-P.H.A.-network: 50% of U.C.R. charges after a $200.00 co-payment.
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Wellness / Well Baby• In-P.H.A.-network: 100% of contracted rates. Well Baby Care is listed under the Affordable Care Act. There is no deductible or coinsurance.
• Out-of-P.H.A.-network: No coverage.
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Immunizations• In-P.H.A.-network: 100% of contracted rates as listed by the Affordable Care Act. There is no deductible or coinsurance.
• Out-of-P.H.A.-network: No coverage.
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Physical Exams and Mammograms• In-P.H.A.-network: 100% of contracted rates for routine gynecological exams and routine health exams as listed under the Affordable Care Act. There is no deductible or coinsurance.
• Out-of-P.H.A.-network: No coverage.
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Allergy Testing / Administration of Serum
• In-P.H.A.-network: 70% of contracted rates for testing/treatment with allowance of up to $400.00 per year for allergy serum.
• Out-of-P.H.A.-network: 50% of U.C.R. charges for testing/ treatment with allowance of up to $400.00 per year for allergy serum.
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Home Health Care• In-P.H.A.-network: 70% of contracted rates up to $6,000.00 annual maximum. Pre-certification required for more than ten (10) visits.
• Out-of-P.H.A.-network: 50% of U.C.R. charges up to $6,000.00 annual maximum. Pre-certification required for more than ten (10) visits.
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Hospice Care• In-P.H.A.-network: 70% of contracted rates up to $7,500.00 lifetime maximum. Two (2) visits for bereavement counseling. Pre-certification required; otherwise, penalties apply.
• Out-of-P.H.A.-network: None.
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Durable Medical Equipment / Prosthetics
• In-P.H.A.-network: 70% of contracted rates.
• Out-of-P.H.A.-network: 50% of U.C.R. charges.
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Hearing Services / Hearing Aids In-P.H.A.-network: 80% of contracted rates. Hearing Aid benefit up to $1,000.00 annual maximum provided once every thirty-six (36) months.
• Out-of-P.H.A.-network: 60% of U.C.R. charges. Hearing Aid benefit up to $1,000.00 annual maximum provided once every thirty-six (36) months.
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Acupuncture• In-P.H.A.-network: 70% of contracted rates to a maximum allowance of $50.00 per visit for up to fifteen (15) visits per calendar year.
• Out-of-P.H.A.-network: 70% of U.C.R. charges to a maximum allowance of $50.00 per visit for up to fifteen (15) visits per calendar year.
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Chiropractic Care• In-C.H.P.C.-network: $10.00 co-payment per visit up to forty-five (45) annual visits per calendar year.
• Out-of-C.H.P.C.-network: None.
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Prescription Drugs – Retail Store (slide 1 of 3)
• Generic: $10.00 co-payment for up to a thirty (30) day supply;
• Formulary Brand: $30.00 co-payment for up to a thirty (30 day supply;
• Non-Formulary Brand: $50.00 co-payment for up to a thirty (30) day supply.
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Prescription Drugs – CVS Pharmacy Stores
(slide 2 of 3)
• Generic: $0.00 co-payment for up to a thirty (30) day supply;
• Formulary Brand: $30.00 co-payment for up to a thirty (30) day supply;
• Non-Formulary Brand: $50.00 co-payment for up to a thirty (30) day supply.
Note: Ninety (90) day supply solely at CVS Pharmacy Stores at same co-payments as the prescription mail
order program except there is a zero co-pay for generics.
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Prescription Drugs - Mail Order (slide 2 of 2)
• Generic: $20.00 co-payment for up to a ninety (90) day supply;
• Formulary Brand: $60.00 co-payment for up a to ninety (90) day supply;
• Non-Formulary Brand: $100.00 co-payment for up to a ninety (90) day supply.
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Rates for active employees (effective 4/01/2014)
• Single: $879.58 per month.
• Two-Party: $1,285.26 per month.
• Family: $1,837.91 per month.
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Rates for retirees under 65 (effective 4/01/2014)
• Single: $879.58 per month.
• Two-Party: $1,285.25 per month.
• Family: $1,837.91 per month.
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Rates for retirees 65 and older (effective 4/01/2014)
• Single: $456.86 per month.
• Two-Party: $693.31 per month.
• Family: $853.75 per month.
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Disclaimer• This presentation provides only a general overview of the Medical benefits for the Medical Choice Plan;• For complete information, consult your copy of the Summary Plan Description or call Health Services & Benefit Administrators (1-831-757-1711 or 1-888-742-3380).