2013 Employee Benefits Guidebook - Administration Home

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STANDARD MEDICAL EPO BENEFITS SUMMARY PARTICIPATING PROVIDERS CALENDAR YEAR ANNUAL LIMIT $2,000 ,000 NON-PARTICIPATING PROVIDERS DEDUCTIBLE, PER CALENDAR YEAR Per Covered Person $2,000 Not Covered Per Family Unit $6,000 Not Covered MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR Per Covered Person $8,000 Not Covered Per Family Unit $16,000 Not Covered The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%. Copayments COVERED CHARGES Hospital Services Inpatient Room and Board 75% after deductible and $500 copayment per admission semiprivate room rate Intensive Care Unit 75% after deductible and $500 copayment per admission Not Covered Not Covered Outpatient Facility Services Hospital's ICU Charge 75% after $250 copayment per visit No deductible applies Not Covered Outpatient Physician services 75%, no deductible or copayment applies Note: The copayment will apply as long as services billed include one or more of the facility room charges: Operating room, recovery room, procedures room, treatment room, and observation room. Skilled Nursing Facility, Rehabilitation 75% after deductible the Not Covered Hospital and Sub-Acute Facilities facility's semiprivate room rate Emergency Room Services 100% after $200 copayment per visit; 2013 Employee Benefit Guidebook Updated August 2013
(including ER Physician services) Medical Non-Emergency Care Note: The ER copayment will be waived if admitted to the Hospital directly from the ER. Urgent Care Services 100% after $100 copayment per visit; No deductible applies No deductible applies Not Covered Not Covered Note: The Urgent Care copayment will be waived if admitted to the Hospital directly from Urgent Care. Physician Services Inpatient Services 75% after deductible Not Covered El Paso County Employee Health Center (“Clinic”) Office Visit Primary Care Physician (PCP) Office Visit 100% after $10 copayment per visit No deductible applies 100% after $50 copayment per visit Not Covered Not Covered No deductible applies Note: A Primary Care Physician (PCP) is defined as a general practitioner, family practitioner, general internist (internist whose practice is 70% general medicine), Nurse Practitioner, Physician’s Assistant, or pediatrician. An OB/GYN will be considered a specialist. Specialist office visits Surgery performed in the office (including any medical supplies and injections rendered during the surgery) 100% after $75 copayment per visit No deductible applies 100% after $10 Clinic, $50 PCP or $75 Specialist copayment per visit Not Covered Not Covered No deductible applies Injections (other than allergy or 100% chemotherapy) No deductible or copayment will apply Allergy serum and injections 100% No deductible or copayment will apply Preventive Care Routine Well Care (ages birth through adult) 100% after $10 Clinic copay or $40 copayment for all other providers No deductible applies Not Covered Not Covered Not Covered Includes: Routine office visits, routine physical examination, mammogram, gynecological exam, Pap smear, PSA, routine lab and x-rays, routine colonoscopy, flexible sigmoidoscopy, and immunizations. 2013 Employee Benefit Guidebook Updated August 2013
Page 1 and 2: EMPLOYEE BENEFITS Open Enrollment G
Page 3 and 4: PHONE DIRECTORY Employment, Benefit
Page 5 and 6: IMPORTANT INFORMATION SUMMARY OF BE
Page 7 and 8: EMPLOYEE CONTRIBUTIONS AND POP: The
Page 9 and 10: MEDICAL, VISION AND DENTAL PLAN PRE
Page 11: Questions regarding which protectio
Page 15 and 16: All subsequent prenatal visits, pos
Page 17 and 18: Note: The copayment will apply as l
Page 19 and 20: Pregnancy * Initial visit (to confi
Page 21 and 22: Wellness Exams The County Employee
Page 23 and 24: Walgreens Health Initiatives now Ca
Page 25 and 26: Medication List (PML)/formulary is
Page 27 and 28: 2013 Employee Benefit Guidebook Upd
Page 29 and 30: Guardian DENTAL PLANS El Paso Count
Page 31 and 32: What is an FSA? FLEXIBLE SPENDING A
Page 33 and 34: You can only be reimbursed up to th
Page 35 and 36: VOLUNTARY TERM LIFE INSURANCE Volun
Page 37 and 38: DISABILITY BENEFITS SHORT TERM DISA
Page 49: 2013 Employee Benefit Guidebook Upd

2013 Employee Benefits Guidebook - Administration Home

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