WEST SUBURBAN HEALTH GROUP IMPORTANT - PLEASE READ
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- Suzanna Mosley
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1 WEST SUBURBAN HEALTH GROUP IMPORTANT - PLEASE READ The attached benefit comparison chart is a high level overview of the plans offered by WSHG. The plan documents available to registered users on the carrier websites are the documents that describe full and complete plan details. The carrier documents are the only documents that coverage is based on. Should you have a question about specific coverage, you will need to contact the Member Service number on your ID card for detail or visit the carrier website.
2 WEST SUBURBAN HEALTH GROUP Effective HEALTH PLAN COMPARISON CHART July 1, 2014 red font indicates change or BLUE NE Lifetime Benefit Maximum None None None None None None None None None None None None Deductible - (Benchmark Plans only) applies to: In-patient Admission; Out-patient Surgery; ER, High Tech Imaging (MRI, CT, & PET) and Diagnostic Tests & Procedures. Does not apply to office visits or pharmacy. Per plan (July 1 to June 30) - See plan document for full details None IND $100 / FAM $200 per calendar None IND $250/ FAM $750 None IND $250/ FAM $750 None IND $100 / FAM $200 None IND $250/ FAM $750 None IND $250/ FAM $750 Out-of-Pocket (OOP) Maximum - Once your out-of-pocket expenses for applicable services reaches this amount, you pay $0 for remainder of plan. NOTE: Prescription co-pays do not count towards the OOP maximum. $2,000 per member $4,000 per family per calendar - see plan for details $1,600 per member $3,200 per family per calendar - see plan for details $4,000 Family plan plan $4,000 Family plan $1,500 per member per not to exceed $3,000 per family per plan plan plan $1,000 Individual $2,000 Family per plan plan 2
3 BLUE NE Family Covered and adult children until age 26 and adult children until age 26 and adult children until age 26 and adult children until age 26 Selection of Primary Care Physician (PCP) Any PCP in network No selection required Member must select Member must select Member must select Member must select Any PCP in network No requirement No selection required No selection required Member must select Member must select Specialist Referrals Any HPHC Specialist Any licensed specialist PCP must refer PCP must refer PCP must refer PCP must refer PCP refers within the plan Any licensed specialist No referral required No referral required PCP must refer PCP must refer Providers of Service HARVARD PILGRIM Any licensed HARVARD PILGRIM - Members provider; any hospital except in also have access to a wide range of through the Private Health Care Systems network while outside of MA, NH and ME HARVARD PILGRIM except in HMO BLUE in all 6 New England states except in Hospital Tiers: Tier 1: Enhanced Tier 2: Standard Tier 3: Basic HMO BLUE in all 6 New England states except in TUFTS HEALTH PLAN except in Any licensed TUFTS HEALTH provider; any hospital PLAN except in TUFTS HEALTH PLAN except in **SELECT CARE - **SELECT CARE - An expansive An expansive network that includes network that includes physician practices, physician practices, community-based community-based hospitals and hospitals and medical facilities medical facilities across the across the Commonwealth. The Commonwealth. The network network encompasses more encompasses more than 17,000 than 17,000 and 50 and 50 *DIRECTCARE - A tailored network custom-built around several of the Commonwealth's premier provider groups and community-based hospitals. *DIRECTCARE - A tailored network custom-built around several of the Commonwealth's premier provider groups and community-based hospitals. Pre-existing Conditions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions 3
4 BLUE NE INPATIENT General Hospital/Mental Hospital/Substance Abuse Facility (semiprivate room and board and ancillary services) $250 Deductible applies then: Tier 1 & Tier 2 :$300 per/admit Tier 3 : $700 per/admit NOTE- Mental Health/Substance Abuse $200 Enhanced: $250 Standard: $500 Basic: $500 Out-of-state : $250 NOTE-Mental Health/Substance Abuse $250 Deductible, then $300/$700 Semi-private room & board & ancillary services Tier 1: $150 Tier 2: $250 NOTE-Mental Health/Substance Abuse $150 Semi-private room & board & ancillary services Tier 1: $300, then deductible applies Tier 2: $700, then deductible applies NOTE- Mental Health/Substance Abuse $300 $250 per $300 per admission ($1,000 admission, then out-of-pocket deductible maximum) No co-pay No co-pay or or deductible for deductible for Mental Mental Hospital/Substance Hospital/Substance Abuse Facility Abuse Facility Physician Services (Hospital applies), after deductible Skilled Nursing Facility up to 100 days per calendar up to 100 days per calendar $250 ment for each admission, up to 100 days per Deductible applies, then 20% Coinsurance - Limited to 100 days per Plan Year up to 100 days per up to 100 days per calendar up to 100 days per plan Covered in full up to 100 days per plan Covered in Full after $250 ment for Deductible, up to 100 each admission, up days per plan to 100 days per $300 per admission, then deductible Max of 100 days per. Newborn Well Baby Care (Inpatient) OUTPATIENT Emergency Room Visits for Emergency or Accident Care $40, waived if admitted $40, waived if admitted $75 Deductible applies, $75 (Inpatient then $100 Copay per (Inpatient applies if admitted) in visit. Copay is waived applies if admitted) Service Area if admitted to the hospital directly from the emergency room, then Inpatient would apply Deductible applies, $25, waived if then $100 Copay per admitted visit. Copay is waived if admitted to the hospital directly from the emergency room, then Inpatient would apply $25, waived if admitted $75 (Inpatient applies if admitted) $100, then deductible applies (Inpatient applies if admitted) $75 (waived if admitted then Inpatient applies) $100, then deductible applies (waived if admitted, then Inpatient applies) Emergency Care in Doctor's Office n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 4
5 BLUE NE Outpatient Surgery in a Day Surgery facility or Hospital $125 per outpatient surgery Deductible applies, then $150 per visit Enhanced: $150 Standard: $250 Basic: $250 Out-of-State $150 $150 $125 per outpatient surgery $150 per outpatient surgery, then deductible $125 per outpatient surgery $150 per outpatient surgery, then deductible CT, MRI and Pet Scans Deductible applies, then $100 Copay per procedure General Hospitals: Enhanced: $75 Standard: $150 Basic: $150 Other Providers: $75 $100 (scheduled outpatient) $75 *Copay will not be charged when a member has a cancer diagnosis $100 $100, then deducutible Hemodialysis Non - hospital based - Deductible applies, then no charge Hospital based - See Inpatient Services Physical Therapy $5 per visit $20 (shortterm); up to 90 consecutive days per condition Copay: $20 per visit - Limited to 30 visits per PlanYear $45 ; up to 60 visits per calendar $20 ; up to 60 visits per calendar $5 office, 30 visits per Speech and shortterm PT/OT $20 per visit; 30 visits per plan Speech and shortterm PT/OT $20 per visit; 30 visits per plan $20. PT / OT Max limit up to 60 visits per calendar $20. PT / OT Max limit up to 60 visits per calendar Office Visits Primary Care Physician $5 per visit Not covered $20 per visit $20 per visit Enhanced: $15 Standard: $25 Basic $45 Out-of-state $20 $5 per visit $20 per visit $20 per visit $20 per visit $20 per visit Preventive OV - PCP Medical Care/Mental Health Care/Substance Abuse Care (Mental Health s excluded from OOP max) $5 per visit $20 per visit $5 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit Enhanced: $15 Standard: $25 Basic: $45 Out-of-state : $15 NOTE: Mental Health Care $15 5
6 BLUE NE Office Visits Specialist $5 per visit $35 per visit Tier 1 - $25 per visit Tier 2 - $35 per visit Tier 3 - $45 per visit $45 per visit $35 per visit $5 per visit $35 per visit $35 per visit $35 per visit $35 per visit OB/GYN $5 per visit GYN-Preventive Office visit Diagnostic X-ray and Lab $20 per visit $20 per visit $45 per visit $20 per visit $5 per visit $20 per visit $20 per visit $20 per visit $20 per visit Routine Vision Exam $5 per visit; one visit per calendar. $0 for children under 5 s of age $20 per visit; one visit per calendar. $0 for children under 5 s of age $20 per visit; one exam every 2 plan s $0 for children under 5 s of age $0 ; one visit every 24 months $0 ; one visit every 12 months $5, 1 visit per plan, 1 visit per plan $20 per visit; one visit per plan $20 per visit; one visit per plan $0 per visit; one visit every 12 months $0 per visit; one visit every 12 months EYEMed EYEMed Pre-Admission Testing - Maternity Care visits for prenatal and postnatal outpatient care for prenatal and postnatal outpatient care for prenatal and postnatal outpatient care Prenatal: $20 first visit only; Post natal: $20 per visit Prenatal: $20 first visit only; Post // $20 per visit 6
7 BLUE NE Dental Services 14 - Covered in full for preventative care. All members - $5 for extraction of impacted teeth and initial emergency treatment % coinsurance after deductible for preventative care. All members - for extraction of impacted teeth and initial emergency treatment Preventative dental when authorized by PCP; up to two exams per calendar, including cleaning, fluoride treatment and x-rays. Initial emergency treatment (within 72 hours of injury) necessary to repair oral injuries. Extraction of impacted teeth. Preventative dental No coverage for children up to age 13 - Tier 1 Copayment per visit up to two exams per calendar, including cleaning, fluoride treatment and x-rays. Initial emergency treatment (within 72 hours of injury) necessary to repair oral injuries. Extraction of impacted teeth. 12: Preventive dental up to two exams per cal. yr., incl. Cleaning, fluoride treatment and x-rays. All members: Extraction of impacted teeth imbedded in the bone. Facility charges ONLY when a serious medical condition that requires admittance to a network hospital as inpatient in order for dental care to be safely performed. Not covered. Exceptions: All members- Emergency Services - LIMITED TO X RAYS AND EMERGENCY ORAL SURGERY ER or OFFICE VISIT COPAY WILL APPLY Not covered. Exceptions: All members- Emergency Services - LIMITED TO X RAYS AND EMERGENCY ORAL SURGERY ER or OFFICE VISIT COPAY WILL APPLY 12; Preventative dental, periodic oral exam, cleaning, fluoride treatment once every six months. X-rays: Full mouth once every five s, bitewing x-rays once every six months, and periapicals as needed. MUST use dentist.emergency Services - LIMITED TO X RAYS AND EMERGENCY ORAL SURGERY ER or OFFICE VISIT COPAY WILL APPLY 12; Preventative dental, periodic oral exam, cleaning, fluoride treatment once every six months. X-rays: Full mouth once every five s, bitewing x- rays once every six months, and periapicals as needed. MUST use dentist. Emergency Services - LIMITED TO X RAYS AND EMERGENCY ORAL SURGERY ER or OFFICE VISIT COPAY WILL APPLY Family dental coverage: $10 for exam, cleaning, x-rays every 6 months. Variable s for minor restorative (fillings) % discount available for sealants, crowns and inlays, bridges, root canals, gingivectomies and dentures. Must use dentists. Family dental coverage: $10 for exam, cleaning, x-rays every 6 months. Variable s for minor restorative (fillings) % discount available for sealants, crowns and inlays, bridges, root canals, gingivectomies and dentures. Must use dentists. OTHER FEATURES Private Duty Nursing when (only when medically necessary) Home Health Care when when Member cost sharing depends on types of services provided and tier placement of provider rendering dervices, as listed in the Schedule of Benefits. For example, for services provided by a physician, see "physician and Other Professional Office Visits." For inpatient hospital care, see "Hospital - Inpatient Services." when when Not covered Not covered when when when when 7
8 BLUE NE Hospice Care Same as Home Health Care Durable Medical Equipment Ambulance 20% of equipment cost to HPHC not to exceed a member's expense of $1000,, when 20% of equipment cost to HPHC not to exceed a member's expense of $1000, when 20% of HPHC cost when when 20% coinsurance Prosthetics covered in full when 20% coinsurance Deductible then 80% Covered 80% Covered, after deductible, when when 80% Covered when Deductible then for prosthetic limbs which replace, in whole or in part, an arm or leg. when after the deductlbe for prosthetic limbs which replace, in whole or in part, an arm or leg. Deductible then Radiation Therapy Chemotherapy Chiropractor Visits $5 per visit, up to $500 per calendar $35 per visit. $20, 20 visits 12 visit maximum per per plan calendar $45 per visit. 12 visits maximum per calendar $20 per visit. 12 visits maximum per calendar $5 per visit, up to 12 visits per calendar, up to 12 visits per calendar $20 per visit; up to 12 visits per calendar $20 per visit; up to 12 visits per calendar $20 per visit; up to 12 visits per calendar. $20 per visit; up to 12 visits per calendar. Prescription Drugs Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: (Inpatient drugs paid in Tier 1: $5 Tier 1: $5 Tier 1: $10.00 Tier 1: $10.00 Tier 1: $15.00 Tier 1: $10.00 Tier 1: $5 No coverage Tier 1: $10.00 Tier 1: $15.00 Tier 1: $10.00 Tier 1: $10.00 Tier 2: $10 Tier 2: $10 Tier 2: $25.00 Tier 2: $25.00 Tier 2: $30.00 Tier 2: $25.00 Tier 2: $10 except at PCS Tier 2: $25.00 Tier 2: $25.00 Tier 2: $25.00 Tier 2: $25.00 Co-pays do not count Tier 3: $25 Tier 3: $25 Tier 3: $45.00 Tier 3: $50.00 Tier 3: $50.00 Tier 3: $50.00 Tier 3: $25 Tier 3: $45.00 Tier 3: $50.00 Tier 3: $45.00 Tier 3: $50.00 towards OOP Maximum up to a 30 day supply up to a 30 day supply (up to a 30-day supply (up to a 30-day supply (up to a 30-day supply (up to a 30-day supply up to a 30 day supply pharmacies (up to a 30-day supply (up to a 30-day supply (up to a 30-day supply(up to a 30-day 8
9 BLUE NE MedImpact Mail Order: Tier 1: $10 No mail order coverage except through MedImpact Mail Order Mail Order: No mail order coverage except through PCS Tier 1: $20.00 Tier 1: $20.00 Tier 1: $30.00 Tier 1: $20.00 Tier 1: $10 Tier 1: $20.00 Tier 1: $30.00 Tier 1: $20.00 Tier 1: $20.00 Tier 2: $20 Tier 2: $50.00 Tier 2: $50.00 Tier 2: $60.00 Tier 2: $50.00 Tier 2: $20 Tier 2: $50.00 Tier 2: $50.00 Tier 2: $50.00 Tier 2: $50.00 Tier 3: $75 Tier 3: $90.00 Tier 3: $ Tier 3: $ Tier 3: $ Tier 3: $50 Tier 3: $90.00 Tier 3: $ Tier 3: $90.00 Tier 3: $ up to a 90 day supply up to a 90 day supply Fitness Benefit Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Up to $300 reimbursement Up to $300 reimbursement Fitness reimbursement up to at a Health & Fitness at a Health & Fitness at a Health & Fitness at a Health & Fitness toward membership toward membership at a Health & Fitness at a Health & Fitness at a Health & Fitness club per calendar club per calendar club per calendar club per calendar or exercise classes or exercise classes club,including at a fitness facility club,including club,including. Must be an. Must be an. Must be an. Must be an at a health club. at a health club. exercise classes per per calendar. exercise classes per exercise classes per active member of HPHC for at least 4 active member of HPHC for at least 4 active member of HPHC for at least 4 active member of HPHC for at least 4 calendar. See plan materials for Must be an active member of the THP calendar. See plan materials for calendar. See plan materials for months and an active months and an active months and an active months and an active member of the health member of the health member of the health member of the health details. and fitness facility 4 months. details. facility for at least 4 months. facility for at least 4 months. facility for at least 4 months. facility for at least 4 months. It Fits! Program reimburses families on Select Care up to $400 per family contract ($200 for individual contracts)and Direct Care members up to $500 per family contract ($250 for individual contracts) to use toward health club memberships, Pilates, Yoga classes Weight Watchers programs, and local, school sports programs and now fitness related equipment. It Fits! Program reimburses families on Select Care up to $400 per family contract ($200 for individual contracts)and Direct Care members up to $500 per family contract ($250 for individual contracts) to use toward health club memberships, Pilates, Yoga classes Weight Watchers programs, and local, school sports programs and now fitness related equipment. 9
10 BLUE NE Discounts at IFCNaffiliated clubs. Discount at Weight Watchers Discounts at IFCNaffiliated clubs. Discount at Weight Watchers Discounts at IFCNaffiliated clubs. Discount at Weight Watchers Discounts at IFCNaffiliated clubs. Discount at Weight Watchers Enroll in a qualified Weight Watchers or hospital based weight loss program and receive up to $150 per calendar toward your program fees. Enroll in a qualified Weight Watchers or hospital based weight loss program and receive up to $150 per calendar toward your program fees. JENNY CRAIG DISCOUNTS: -FREE 30 DAY -25% OFF A PREMIUM/METABO LIC NUTRISYSTEM DISCOUNT: -12% DISCOUNT - OFF CURRENT PROMO -CORE OR SELECT JENNY CRAIG DISCOUNTS: -FREE 30 DAY -25% OFF A PREMIUM/METABO LIC NUTRISYSTEM DISCOUNT: -12% DISCOUNT - OFF CURRENT PROMO -CORE OR SELECT JENNY CRAIG DISCOUNTS: -FREE 30 DAY -25% OFF A PREMIUM/METABO LIC NUTRISYSTEM DISCOUNT: -12% DISCOUNT - OFF CURRENT PROMO -CORE OR SELECT JENNY CRAIG DISCOUNTS: -FREE 30 DAY -25% OFF A PREMIUM/METABO LIC NUTRISYSTEM DISCOUNT: -12% DISCOUNT - OFF CURRENT PROMO -CORE OR SELECT The equipment must be new, purchased from a retail store and not Craig's List or EBay. Other discounts also available. See plan materials The equipment must be new, purchased from a retail store and not Craig's List or EBay. Other discounts also available. See plan materials * Fallon DirectCare - Members now have access to Acton Medical Associates, Charles River Medical Associates and Southboro Medical Group, Fallon Clinic, Highland Healthcare Associates IPA, Lahey Clinic, Lawrence General IPA, Lowell General PHO, Mount Auburn Cambridge IPA, and Northeast PHO. **FCHP SelectCare - Members have access to FCHP Clinic, as well as hundreds of private practice physicians in Central, Northern, Eastern and Southeastern, Massachusetts. 10
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