2014/2015 Plan Year - Lucia Mar Unified School District

Lucia Mar Unified School District - SISC Anthem Blue Cross PPO Plans
2014/2015 Plan Year (Benefits Effective October 1, 2014)
NEW
MANAGEMENT
Plan M1
40308B
Plan M2
40308F
Plan M3
40308C
Plan M4
40726B
Plan M5
40726F
( PBC 90-A $20 )
( PBC 90-E $20 )
( PBC 80-G $20 )
( PBC 80-J $30 )
( PBC 80-M $40 )
Group Number
SISC Plan Name
Provider Network(s):
Hospital
Professional
Deductibles-CALENDAR YEAR (Jan-Dec)
Prudent Buyer
Prudent Buyer
Prudent Buyer
Prudent Buyer
Prudent Buyer
Prudent Buyer
Prudent Buyer
Prudent Buyer
Prudent Buyer
Prudent Buyer
$200 per Individual / max $500 per Family
$300 per Individual / max $600 per Family
$500 per Individual / max $1,000 per Family
$750 per Individual / max $1,500 per Family
$3,500 per Individual / max $7,000 per Family
Maxiumum Out-Of-Pocket- Calendar Year
$500 per Individual / max $1,500 per family
$1,000 per Individual / max $3,000 per family
$2,000 per Individual / max $4,000 per family
$3,000 per Individual / max $6,000 per family
$6,000 per Individual / max $12,000 per family
e.g. Once the $500 deductible is met, the
plan pays 90%, member pays 10%. When
the Maximum out of pocket amount is met,
$1500, the plan will pay 100% of the
allowable amount for the remainder of the
calendar year.
No Limit
e.g. Once the $600 deductible is met, the
plan pays 90%, member pays 10%. When
the Maximum out of pocket amount is
met, $1800, the plan will pay 100% of the
allowable amount for the remainder of the
calendar year.
No Limit
Maxiumum Out-of-Pocket is the amount the
member pays after the deductible is met and
before the plan will begin covering at 100%. Copays made for office visits will now count toward
your Maximum out-of-pocket amount.
NO Lifetime Maximum
Services
Office Visits (Regardless of Deductible/Co-Ins)
Participating
Providers
Deductible Waived
$20 co-pay
Non-Participating
Providers
Non-Par Fee
Participating
Providers
Deductible Waived
$20 co-pay
Non-Par Fee
Participating
Providers
Deductible Waived
$20 co-pay
Non-Par Fee
No Limit
Participating
Providers
Deductible Waived
$30 co-pay
Non-Par Fee
Participating
Providers
Deductible Waived
$40 co-pay
Non-Par Fee
Well Baby / Child Preventative Care
Deductible Waived
100%
Non-Par Fee
100%
Non-Par Fee
100%
Non-Par Fee
100%
Non-Par Fee
100%
Non-Par Fee
Deductible Waived
100%
Non-Par Fee
Deductible Waived
100%
Non-Par Fee
Deductible Waived
100%
Non-Par Fee
Deductible Waived
100%
Non-Par Fee
Deductible Waived
100%
Non-Par Fee
90%
Non-Par Fee
90%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
Subject to medical necessity review administered
by American Sepciality Health (ASH)
90%
Non-Par Fee
90%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
Pregnancy & Maternity Care
90%
Non-Par Fee
90%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
90% up to
$50 per visit
Non-Par Fee up to
$25 per visit
80% up to
$50 per visit
Non-Par Fee up to
$25 per visit
80% up to
$50 per visit
Non-Par Fee up to
$25 per visit
80% up to
$50 per visit
Non-Par Fee up to
$25 per visit
Review Ambulance
coverage
Review Ambulance
coverage
Review Ambulance
coverage
Review Ambulance
coverage
Review Ambulance
coverage
Review Ambulance
coverage
Review Ambulance
coverage
Review Ambulance
coverage
(Plan Summary Description)
(Plan Summary Description)
(Plan Summary Description)
(Plan Summary Description)
Diagnostic X-Ray & Lab:
Cancer Screenings
(Routine Breast, Pelvic, Prostate, etc.)
MRI, CT, PET & Nuclear Cardiac Scans *
Other Diagnostic X-Ray & Lab
Deductible Waived
Deductible Waived
Not Covered
Deductible Waived
Deductible Waived
100%
Non-Participating
Providers
Routine physical exams & Immunizations
(birth to age 6)
Not Covered
Deductible Waived
100%
Non-Participating
Providers
e.g. Once the $7,000 deductible is met, the
plan pays 80%, member pays 20%. When the
Maximum out of pocket amount is met,
$12,000, the plan will pay 100% of the
allowable amount for the remainder of the
calendar year.
No Limit
Deductible Waived
100%
Not Covered
Deductible Waived
100%
Non-Participating
Providers
e.g. Once the $1,500 deductible is met, the
plan pays 80%, member pays 20%. When the
Maximum out of pocket amount is met, $6,000,
the plan will pay 100% of the allowable amount
for the remainder of the calendar year.
Routine Preventative Care
(Age 7 and older)
Not Covered
Deductible Waived
100%
Non-Participating
Providers
e.g. Once the $1000 deductible is met, the
plan pays 80%, member pays 20%. When
the Maximum out of pocket amount is
met, $4000, the plan will pay 100% of the
allowable amount for the remainder of the
calendar year.
No Limit
Not Covered
Deductible Waived
Physical Medicine (OT *, PT *, Chiro.)
Physician office visits
Normal delivery, c-section, complications of
pregnancy & abortion
(Review Plan Summary for full coverge information)
Acupuncture
(12 visits per calender year)
90% up to
$50 per visit
Review Ambulance
coverage
Ambulance (Ground or Air)
(Plan Summary Description)
Non-Par Fee up to
$25 per visit
Review Ambulance
coverage
(Plan Summary
Description)
(Plan Summary Description) (Plan Summary Description) (Plan Summary Description) (Plan Summary Description)
Emergency Care
ER services & supplies
($100 co-pay waived if admitted)
90%
($100 co-pay)
Limited to $600/day
after 48 hours
(review Plan Summary for
90%
($100 co-pay)
detailed coverage )
Outpatient Hospital - ER (non-emergency)
Facility Expenses
Professional Expenses
Inpatient Hospital
Room, Board & Support Services
(prior authorization required)
Limited to $600/day
after 48 hours
(review Plan Summary for
80%
($100 co-pay)
detailed coverage )
Limited to $600/day
after 48 hours
(review Plan Summary for
80%
($100 co-pay)
detailed coverage )
Limited to $600/day
after 48 hours
(review Plan Summary for
80%
($100 co-pay)
detailed coverage )
Limited to $600/day
after 48 hours
(review Plan Summary for
detailed coverage )
**$100 co-pay
90%
90%
100% C&R
Non-Par Fee
**$100 co-pay
90%
90%
90% C&R
Non-Par Fee
**$100 co-pay
80%
80%
50% C&R
Non-Par Fee
**$100 co-pay
80%
80%
50% C&R
Non-Par Fee
**$100 co-pay
80%
80%
50% C&R
Non-Par Fee
90%
$540 - $580 per day
90%
$540 - $580 per day
80%
$540 - $580 per day
80%
$540 - $580 per day
80%
$540 - $580 per day
Lucia Mar Unified School District - SISC Anthem Blue Cross PPO Plans
2014/2015 Plan Year (Benefits Effective October 1, 2014)
NEW
MANAGEMENT
Plan M1
40308B
Plan M2
40308F
Plan M3
40308C
Plan M4
40726B
Plan M5
40726F
( PBC 90-A $20 )
( PBC 90-E $20 )
( PBC 80-G $20 )
( PBC 80-J $30 )
( PBC 80-M $40 )
Group Number
SISC Plan Name
Ambulatory Surgery Center
Outpatient surgery, services & supplies
90%
Prudent Buyer
$350 per day
90%
Prudent Buyer
$350 per day
80%
Surgeon & Anesthetist
90%
Non-Par Fee
90%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
90%
Non-Par Fee
90%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
90%
90%
80%
80%
80%
80%
80%
80%
90%
100%
90%
Non-Par Fee
90%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
80%
Non-Par Fee
90%
100% up to $600/day
90%
100% up to $600/day
80%
100% up to $600/day
80%
100% up to $600/day
80%
100% up to $600/day
Durable Medical Equipment
Rental / Purchase of DME
Hearing Aid ($700 maximum every 24 months)
Hospice
Inpatient or outpatient services
(review Plan Summary)
Home Health Care
(Review Plan Summary)
Home Infusion
(Review Plan Summary)
Mental or Nervous Disorders
& Substance Abuse
Review detailed Plan Summary for full
coverage information
Review detailed Plan Summary for full
coverage information
Prudent Buyer
$50 co-pay
50% up to $350/day
Review detailed Plan Summary for full
coverage information
Prudent Buyer
$50 co-pay
50% up to $350/day
80%
Review detailed Plan Summary for full
coverage information
Prudent Buyer
$50 co-pay
50% up to $350/day
80%
Review detailed Plan Summary for full
coverage information
Prescription Drug Plans (NAVITUS)
The calendar year brand deductible is per individual up to the family maximum. Similar to the medical PPO plans, RX plans with a deductible do have a last quarter carryover. Once the deductible has been satisfied, the member will be responsible for
the brand name co-pay. Get your generic medication with a $0 co-pay (excluding some narcotic paid medications and some cough medications) FREE at Costco.
Navitus Rx Plan
($10 - $200, $35)
Navitus Rx Plan
($10 - $200, $35)
Navitus Rx Plan
($10 - $200, $35)
Navitus Rx Plan
($10 - $200, $35)
Navitus Rx Plan
($10 - $200, $35)
Retail
30 days
Mail
90 days
Retail
30 days
Mail
90 days
Retail
30 days
Mail
90 days
Retail
30 days
Mail
90 days
Retail
30 days
Mail
90 days
Generic Co-Pay
$10
$25
$10
$25
$10
$25
$10
$25
$10
$25
Brand Name Co-Pay
$35
$90
$35
$90
$35
$90
$35
$90
$35
$90
Brand Name Deductible (Calendar Year) $200 per individual / max $500 per family
$200 per individual / max $500 per family
$200 per individual / max $500 per family
$200 per individual / max $500 per family
$200 per individual / max $500 per family
This is a brief summary of benefits.
Check out the detailed Plan Summaries available on the LMUSD website under Employee Benefits for FULL coverage info.
or contact Anthem BC directly @ (800) 564-7475
LUCIA MAR UNIFIED SCHOOL DISTRICT
DELTA DENTAL PLANS - MANAGEMENT
SERVICES
Basis of Payment
PPO
(DPO)
Group # 7074-8216
Group # 7074-8316
Delta Dentist
Non-Delta
Dentist
Delta Participating Fee
Allowance
Non-Delta
Customary &
Reasonable
NONE
NONE
NONE
$25 member
$75 family
$25 member
$75 family
$1,500 Delta Premier Dentist
$1,700 Delta PPO Dentist
$1,500
$1,500
$1,000
$1,000
70%
80%
90%
100%
100%
50%
50%
YES
YES
YES
YES
Calendar Year Deductible(s)
Calendar Year Maximum
PREMIER **
(Incentive)
Delta Premier
Dentist
Non-Delta
Dentist
Delta PPO
Delta Premier
Participating Participating Fee
Fee Allowance
Allowance
Non-Delta
Customary &
Reasonable
Diagnostic & Preventative
Exams, X-Rays, Cleanings &
Emergency Treatment
70%
80%
90%
100%
Third Cleaning
YES
Other Basic Services
Oral Surgery, Fillings,
Procedures, Periodontic
70%
80%
90%
100%
1st year used
2nd year used
3rd year used
4th year used &
beyond
70%
80%
90%
100%
100%
50%
50%
Crowns
Crowns, Jackets &
Cast Restorations
70%
80%
90%
100%
1st year used
2nd year used
3rd year used
4th year used &
beyond
70%
80%
90%
100%
100%
50%
50%
Prosthodontics
Dentures, Bridges & Implants
50%
50%
50%
50%
50%
NONE
NONE
NONE
NONE
NONE
Root Canals & Sealants
Orthodontics
1st year used
2nd year used
3rd year used
4th year used &
beyond
Delta PPO
Dentist
** If you are new to the Premier (Incentive) Plan or ever have a lapse in coverage on this Plan your benefits will start at
70% regardless of any previous coverage level.
This sheet is not all inclusive of coverage details. Please refer to Evidence of Coverage Booklet
posted on LMUSD Human Resources Website for further details.
Go to www.deltadentalins.com or call (866) 499-3001 for additional information
including eligibility, benefits & claim status (current year available).
NE
Vision Service Plan (VSP)
Exam every 12 mos @ authorized optometrist (VSP Provider NOT Retail Stores/Chains) $15 co-pay
Every 12 mos: Frames/Lenses (Glasses) $25 co-pay - OR - $105 Allowance toward Contact Lenses
LUCIA MAR UNIFIED SCHOOL DISTRICT
2014/2015 MANAGEMENT INSURANCE RATES
YOUR ANNUAL DISTRICT PAID BENEFIT (FULL-TIME EMPLOYEES): $8,671.90
MEDICAL PLAN M1
NE
(40308B)
w/ DELTA DENTAL
PREMIER
(7074-8216)
OR
w/ DELTA DENTAL
PPO
(7074-8316)
Daily Hours
District Pays
You Pay (10thly)
You Pay (10thly)
8 HOURS
$867.19
$671.45
$663.05
7 HOURS
$758.80
$780.62
$772.22
6 HOURS
$650.39
$889.78
$881.38
5 HOURS
$542.00
$998.95
$990.55
4 HOURS
$433.60
$1,108.11
$1,099.71
w/ DELTA DENTAL
PREMIER
(7074-8216)
w/ DELTA DENTAL
PPO
(7074-8316)
MEDICAL PLAN M2
(40308F)
OR
Daily Hours
District Pays
You Pay (10thly)
You Pay (10thly)
8 HOURS
$867.19
$601.85
$593.45
7 HOURS
$758.80
$711.02
$702.62
6 HOURS
$650.39
$820.18
$811.78
5 HOURS
$542.00
$929.35
$920.95
4 HOURS
$433.60
$1,038.51
$1,030.11
w/ DELTA DENTAL
PREMIER
(7074-8216)
w/ DELTA DENTAL
PPO
(7074-8316)
MEDICAL PLAN M3
(40308C)
OR
Daily Hours
District Pays
You Pay (10thly)
You Pay (10thly)
8 HOURS
$867.19
$489.05
$480.65
7 HOURS
$758.80
$598.22
$589.82
6 HOURS
$650.39
$707.38
$698.98
5 HOURS
$542.00
$816.55
$808.15
4 HOURS
$433.60
$925.71
$917.31
w/ DELTA DENTAL
PREMIER
(7074-8216)
w/ DELTA DENTAL
PPO
(7074-8316)
MEDICAL PLAN M4
(40726B)
OR
Daily Hours
District Pays
You Pay (10thly)
You Pay (10thly)
8 HOURS
$867.19
$438.65
$430.25
7 HOURS
$758.80
$547.82
$539.42
6 HOURS
$650.39
$656.98
$648.58
5 HOURS
$542.00
$766.15
$757.75
4 HOURS
$433.60
$875.31
$866.91
w/ DELTA DENTAL
PREMIER
(7074-8216)
w/ DELTA DENTAL
PPO
(7074-8316)
MEDICAL PLAN M5
(40726F)
OR
Daily Hours
District Pays
You Pay (10thly)
You Pay (10thly)
8 HOURS
$867.19
$232.25
$223.85
7 HOURS
6 HOURS
$758.80
$650.39
$341.42
$450.58
$333.02
$442.18
5 HOURS
$542.00
$559.75
$551.35
4 HOURS
$433.60
$668.91
$660.51
All packages include $50,000 Life Ins, Vision, Behavioral Health & Supplemental Cancer coverage
The Deadline to turn in benefit forms for Open Enrollment:
August 20, 2014

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