WellChoice Medical Schedule of Benefits (Effective July 01, 2016) AAMC Employees and Eligible Dependents

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Job Randolph Fisher
5 years ago
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1 Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Individual $0 Family $0 Individual $2000 Family $5000 Unlimited Acupuncture Allergy Tests & Procedures Medically necessary services for anesthesia, pain control, and therapeutic purposes Allergy tests Desensitization materials and serum $15 co-pay for office visit, then ($15 co-pay for office visit, then 80% at EHP provider) (20 visit annual maximum) 80% of allowed amount Ambulance Transportation Medically necessary transport 80% of allowed amount Biofeedback Biofeedback 80% of allowed amount (pre-authorization required) Chemo & Radiation Therapy Chiropractic Care Physician visit Materials and treatment Chiropractor restricted to initial exam, x-rays, and spinal manipulations Chiropractor with PT privileges (physical therapy services) $40 co-pay for office visit, then $15 co-pay for office visit, then ($15 co-pay for office visit, then 80% at EHP provider) (20 visit annual maximum) Refer to Therapy Section Dialysis Medically necessary services 80% of allowed amount (pre-authorization required) Durable Medical Equipment Breast pumps (standard) and related supplies Contraceptive devices Custom DME, including custom wheelchairs Custom-molded orthotics Insulin pumps, Continuous Glucose Monitor and related supplies Hearing aids Non-custom medical equipment and supplies Prosthetic devices (includes EHP network providers) (includes EHP network providers) 80% of allowed amount (includes EHP network providers) (80% at EHP provider); (for dependent children under age 26; pre-authorization required; replacement aids once every 36 months 80% of allowed amount (includes EHP network providers) A00003 Page 1 of 6

2 Emergency Services Home Health Services Emergency care (facility fees) Emergency care (professional fees) Medically necessary services Home infusion therapy $150 co-pay, then ; (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage $15 co-pay, then (80% at EHP network providers); (90 visits per year maximum; pre-authorization required) Hospice Care Inpatient and home hospice 80% of allowed amount (pre-authorization required) Hospital Care Inpatient care including newborn nursery care; NICU (facility fees) Inpatient care (professional fees) Skilled nursing/rehabilitation facility Short-term acute rehabilitation Observation care (facility fees) Observation care (professional fees) Outpatient surgery & ambulatory surgical center (facility fees) Outpatient surgery & ambulatory surgical center (professional fees) $500 co-pay per admission, then (pre-authorization required) ($1,000 co-pay per admission, then 80% of allowed amount at EHP provider if unavailable under AAMC provider) $15 co-pay per day, then 80% of allowed amount for the first 30 days, remaining days at 80% of allowed amount (120 days per year maximum, combined with short-term acute rehabilitation, for medically necessary services; preauthorization required) $15 co-pay per day, then 80% of allowed amount for the first 30 days, remaining days at 80% of allowed amount (120 days per year maximum, combined with skilled nursing/rehabilitation facility, for medically necessary services; pre-authorization required) $150 co-pay, then ; (if admitted, Observation co-pay waived); see Inpatient Facility Care for coverage $15 co-pay, then (includes freestanding surgical centers) $15 co-pay, then Hyperbaric Oxygen Therapy Medically necessary services (pre-authorization required) Immunizations Infusion Therapy Preventive immunizations for communicable diseases Travel immunizations Home infusion therapy Outpatient infusion therapy (includes EHP network primary care providers) Not covered 80% of allowed amount (pre-authorization required) A00003 Page 2 of 6

3 Injections Injections Materials and serum 80% of allowed amount 80% of allowed amount Laboratory Laboratory tests including pathology ; (80% of allowed amount at LabCorp and Quest) Mental Health & Substance Abuse Services Outpatient mental health care (facility fees) Outpatient mental health care (professional fees) Inpatient mental health care (facility fees) Inpatient mental health care (professional fees) Outpatient substance abuse care (facility fees) Outpatient substance abuse care (professional fees) Inpatient substance abuse care (facility fees) Inpatient substance abuse care (professional fees) Intensive outpatient program Partial hospital facility services Medication management Mental health testing and procedures $15 co-pay, then ($15 co-pay, then 80% of allowed amount at EHP network provider) $15 co-pay, then ($15 co-pay, then 80% of allowed amount at EHP network provider) $500 co-pay per admission, then (pre-authorization required) ($1,000 co-pay per admission, then 80% of allowed amount at EHP network provider) (80% of allowed amount at EHP network provider) $15 co-pay, then ($15 co-pay, then 80% of allowed amount at EHP network provider) $15 co-pay, then ($15 co-pay, then 80% of allowed amount at EHP network provider) $500 co-pay per admission, then ($1,000 co-pay per admission, then 80% of allowed amount at EHP provider (pre-authorization required) (80% of allowed amount at EHP network provider) $15 co-pay per day, then ($15 co-pay, then 80% of allowed amount at EHP network provider) (pre-authorization required) $15 co-pay per day, then ($15 co-pay, then 80% of allowed amount at EHP network provider) (pre-authorization required) $15 co-pay, then ($15 co-pay, then 80% of allowed amount at EHP network provider) $15 co-pay, then ($15 co-pay, then 80% of allowed amount at EHP network provider) (pre-authorization required) Methadone Treatment Medically necessary outpatient care $15 co-pay, then Nutritional Counseling Medically necessary services $40 co-pay for office visit, then (limited to 2 visits without pre-authorization per plan year; additional visits must be pre-authorized) A00003 Page 3 of 6

4 Office Visits for Treatment of Illness or Injury Preventive Services Primary care office visit only (Adult) Primary care office visit (Pediatric: age 19 and under) Primary care office visit only (GYN) Specialty care office visit only (Adult & Pediatric) Treatment and diagnostic services in the office Preventive exam (PCP, GYN and Well Child care) Diagnostic services for preventive exam Routine preventive screenings: mammogram, colonoscopy, PAP test, etc. Routine hearing exams $15 co-pay, then (includes EHP network primary care providers) $15 co-pay, then (includes EHP network primary care providers) $15 co-pay, then (includes EHP network primary care providers) $40 co-pay, then (includes EHP network primary care providers) (includes EHP network primary care providers) (includes EHP network primary care providers) Not Covered Private Duty Nursing Private Duty Nursing Not Covered Radiology Procedures Advance imaging including MRI, CT and PET scans All other imaging studies; including X-Ray and Ultrasound $150 co-pay, then A00003 Page 4 of 6

5 Reproductive Health Surgical Procedures Physician office visits (prenatal care only) Infertility treatment Birthing centers (facility fees) Birthing centers (professional fees) Inpatient maternity care and delivery; newborn nursery care; NICU (facility fees) Inpatient maternity care and delivery; newborn nursery care; NICU (professional fees) Interruption of pregnancy Female sterilization (professional services for surgery, anesthesia and related pathology) Male sterilization (professional services for surgery, anesthesia and related pathology) Surgical treatment for morbid obesity Primary care office surgical procedures Specialist care office surgical procedures Outpatient surgery (including freestanding surgical centers) (facility fees) Outpatient surgery (including freestanding surgical centers) (professional fees) Inpatient surgery (facility fees) Inpatient surgery (professional fees) Covered at AAMC Shady Grove office only 80% of allowed amount (pre-authorization required) ($10,000 lifetime maximum) $500 co-pay per admission, then (pre-authorization required) ($1,000 co-pay per admission, then 80% of allowed amount at EHP provider if unavailable under AAMC provider) (pre-authorization required) $15 co-pay, then $500 co-pay per admission, then (pre-authorization required) ($1,000 co-pay per admission, then 80% of allowed amount at EHP provider if unavailable under AAMC provider) A00003 Page 5 of 6

6 Therapy Urgent Care Center Habilitative services for children under the age of 19 Physical therapy/occupational therapy medically necessary services Speech therapy (non-developmental medically necessary services) Pulmonary rehabilitation Cardiac rehabilitation Vision therapy Physician visit Diagnostic services and treatment ; pre-authorization required (80% at EHP Provider if unavailable under AAMC provider) $40 co-pay, then ; (60 visits per year maximum; PT/OT pre-authorization required for visits 21-60) $40 co-pay, then ; (30 visits per year maximum; pre-authorization required) (pre-authorization required) (pre-authorization required) Not Covered $40 co-pay, then ($15 co-pay at AAMC FastCare, then ) A00003 Page 6 of 6

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