TRICARE Supplement - Northrop Grumman Corporation

Northrop Grumman Corporation
Retiree Medical Plan - Benefits Summary
Benefit Plan Year 1/1/15 - 12/31/15
Plan Facts
TRICARE Supplement Plan
Web site
www.asicorporation.com/NGC
Member services phone number
1-800-638-2610; option 1
Binding arbitration
No
Additional Comments
Please remember that this plan is only offered
to active or retired military employees
Cost
General Medical Expenses
Deductible: Individual/Family
$100 Individual; $200 Family; fiscal year plan
deductible; in and out of network combined; all
services subject to plan deductible
Primary doctor office visit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
After TRICARE Catastrophic Cap is met the
Supplement plan continues to reimburse
applicable excess charges
Specialist office visit
Out-of-pocket maximum
Lifetime coverage limit
Limit does not apply
Inpatient Hospital Care
Hospital copay
20% TRICARE Extra cost share reimbursed;
25% TRICARE Standard cost share reimbursed
Hospital semi-private room
20% TRICARE Extra cost share reimbursed;
25% TRICARE Standard cost share reimbursed
Inpatient lab and X-ray
20% TRICARE Extra cost share reimbursed;
25% TRICARE Standard cost share reimbursed
Inpatient lab and X-ray
20% TRICARE Extra cost share reimbursed;
25% TRICARE Standard cost share reimbursed
Inpatient physician and surgeon services
20% TRICARE Extra cost share reimbursed;
25% TRICARE Standard cost share reimbursed
Inpatient surgery
20% TRICARE Extra cost share reimbursed;
25% TRICARE Standard cost share reimbursed
Outpatient Care
Outpatient surgery
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Outpatient laboratory services
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Outpatient X-ray
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Emergency room (not followed by admission)
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Urgent care clinic visit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Prescription Drug Expenses
Prescription drug vendor
Same as medical plan
Prescription drug Web site
Same as medical plan
Prescription drug member services phone
number
Annual prescription deductible
Same as medical plan
Annual prescription out-of-pocket maximum
Not applicable
Included with medical deductible
Annual prescription out-of-pocket maximum
Not applicable
Retail generic
$5 copay under Standard/Extra; 30 day supply
in-network; $17 copay or 20% cost share
whichever is greater under Standard/Extra; 30
day supply out-of-network
Retail formulary brand
$17 copay under Standard/Extra; 30 day supply
in-network; $17 copay or 20% cost share
whichever is greater under Standard/Extra; 30
day supply out-of-network
Retail nonformulary brand
$44 copay under Standard/Extra; 30 day supply
in-network; $44 copay or 20% cost share
whichever is greater under Standard/Extra; 30
day supply out-of-network
Mail order generic
No copay required
Mail order formulary brand
$13 copay reimbursed for Standard/Extra; 90
day supply
$43 copay reimbursed for Standard/Extra; 90
day supply
Retail and mail order available; applicable
prescription drug reimbursement applies innetwork; not covered out-of-network
Mail order nonformulary brand
Oral contraceptives
Retail injectable drugs
Applicable medical or prescription drug
reimbursement applies in-network; not covered
out-of-network
Coverage
Adult Preventive Care
Physical exam
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Well-woman exam (includes pap)
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Mammogram
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Cancer screenings
Cardiovascular screenings
Colorectal screening
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Family Planning
Fertility drugs
Covered; check with Plan for details in-network;
not covered out-of-network
Fertility services
Covered; check with Plan for
details/authorization
Artificial insemination
Not covered
In vitro fertilization
Not covered
Male vasectomy
Covered; check with Plan for
details/authorization
Female tubal ligation
Covered; check with Plan for
details/authorization
Maternity Care
Office visit: Pre/postnatal
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
In-hospital delivery services
20% TRICARE Extra cost share reimbursed;
25% TRICARE Standard cost share reimbursed
In-hospital delivery services
20% TRICARE Extra cost share reimbursed;
25% TRICARE Standard cost share reimbursed
Newborn nursery services
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed
Prenatal care management
Yes; offered through TRICARE
Well-Baby/ Well-Child Preventive Care
Well-child exams
Immunizations (child)
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Mental Health Care
Mental Health/Substance Abuse vendor
Check with Plan
Mental Health/Substance Abuse Web site
Check with Plan
Mental Health/Substance Abuse member
services phone number
Mental Health: Combined with substance abuse
Check with Plan
Mental Health: Outpatient coverage
Limited to $500 per person per benefit year
after TRICARE pays
Mental Health: Inpatient coverage
Limited to 30 days per benefit year for adults;
limited to 45 days per benefit year for children
to age 19; check with Plan for details
Yes
Substance Abuse Care
Detox: Outpatient coverage
Included with outpatient mental health benefits
Detox: Inpatient coverage
Included with inpatient mental health benefits
Rehab: Outpatient coverage
Included with outpatient mental health benefits
Rehab: Outpatient coverage
Included with outpatient mental health benefits
Rehab: Inpatient coverage
Included with inpatient mental health benefits
Dental Care
Implants
Not covered
Accidental injury to teeth
Covered; preauthorization required; check with
Plan for details/authorization
Surgical removal of tumors, cysts, and impacted Covered; limitations apply; check with Plan for
teeth
details/authorization
Vision Care
Routine vision exams
Covered under well-baby visit; check with Plan
for details/authorization
Regular lenses and frames
Not covered; check with Plan for exceptions
Contact lenses
Not covered
Other Services
Ambulance services
Allergy tests and treatments
Durable medical equipment
Prosthetic devices
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Prosthetic devices
Hearing Care
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Hearing evaluations
Covered in connection with surgery or some
medical problems; also covered under well-baby
visit; check with Plan for details
Hearing aids
Not covered
Medical Therapy
Acupuncture
Not covered
Chiropractic
Not covered
Outpatient physical therapy
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Outpatient speech therapy
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Outpatient occupational therapy
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
20% TRICARE Extra cost share reimbursed;
25% Standard cost shares reimbursed; 50% of
Standard ded; 100% applicable excess charges
reimbursed for non-par/non network providers
not to exceed Legal Limit
Outpatient cardiac rehabilitation
Care at Alternate Sites
Noncustodial home health care
Covered; check with Plan for
details/authorization
Prescribed care in noncustodial skilled nursing
facility
Covered; check with Plan for
details/authorization
Prescribed care in noncustodial skilled nursing
facility
Covered; check with Plan for
details/authorization
Hospice care
25% cost share reimbursed for Standard
Access
Out-of-area dependent coverage
Yes
Out-of-area participant coverage
Yes
Ease of Use
Need to file claims
Yes; exceptions apply; check with your provider
Ability to self-refer to OB/GYN
Yes; if TRICARE Standard member
Ability to self-refer to specialists
Yes; if TRICARE Standard member
Domestic partner benefits
No
Care Management: Education and Assistance
Asthma care management
Yes; offered through TRICARE
Cancer care management
Yes; offered through TRICARE
Diabetes care management
Yes; offered through TRICARE
Heart disease care management
Yes; offered through TRICARE
Hypertension care management
Yes; offered through TRICARE
Smoking cessation program
Yes; offered through TRICARE
Weight control program
Yes; offered through TRICARE
The comparison charts are compiled using information that applies to a large number of health plan users and
is commonly reported by the health plans. Depending on the chart type, such as charts for dental and vision
plans, certain information and/or sections won't appear because the necessary data isn't available. If you
have questions about a topic that isn't covered in the charts, refer to the plan's SPD or contact the health
provider's member services department for additional information. Also, keep in mind that the information on
access and quality of care is provided by the health plans. Neither Northrop Grumman nor Aon Hewitt
Associates is responsible for the accuracy of this information. If there is a discrepancy between the
information displayed on these charts and the official plan documents, the official plan documents will control.
Northrop Grumman reserves the right to amend, suspend, or terminate the plan(s) or program(s) at any
time.

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