2013 Employee Benefits Guidebook - Administration Home

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Includes: Routine office visits, routine physical examination, mammogram, gynecological exam, Pap smear, PSA eight additional services that will be covered without cost-sharing requirements, please refer to SPD for full deta routine lab and x-rays, routine colonoscopy, flexible sigmoidoscopy, and immunizations. *Note: Due to the Affordable Care Act, Women’s preventive health care services has been expanded to include Ambulance Service 75% after deductible Note: Pre-authorization with the Claims Administrator will be required for non-emergent transport. Advanced Radiological Imaging (i.e., MRIs, MRAs, CAT Scans, PET Scans and Nuclear Medicine) 75% No deductible or copayment will apply Not Covered Note: A pre-authorization is required prior to services being rendered. Please see the Covered Charges section fo Diagnostic X-ray & Lab Testing 100% Not Covered No deductible applies Durable Medical Equipment 100% Not Covered No deductible or copayment will apply Home Health Care 75% after deductible Not Covered Home Infusion Therapy 75% after deductible Not Covered Hospice Care 75% after deductible Not Covered Mental Disorders and Substance Abuse Treatment Inpatient Services Payable as any other Illness Not Covered Outpatient Visits 100% after $10 copayment Not Covered No deductible applies Morbid Obesity Benefit Payable as any other Illness Not Covered more information regarding this benefit. Nutritional Evaluation Payable as any other Illness 3 visits per Calendar Year maximum Not Covered Outpatient Short-Term Rehabilitation Therapy and Chiropractic Services 100% after $20 copay per visit No deductible applies Not Covered Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab, Cogniti Therapy and Chiropractic services. Multiple services provided on the same day constitute one visit, but a separate copayment will apply to the servic provided by each Physician. Orthotics 75% after deductible Not Covered Note: See Covered Charges section for details. Prosthetics 100% No deductible or copayment will apply Not Covered 2013 Employee Benefit Guidebook Updated August 2013
Pregnancy * Initial visit (to confirm Pregnancy) 100% after $75 Specialist office visit copayment Not Covered All subsequent prenatal visits, postnatal visits, and Physician’s delivery charges (i.e., global maternity fee) Physician’s office visits in addition to the global maternity fee (when performed by an OB/GYN or specialist) 75% after deductible 100% after $75 office visit copayment No deductible applies Not Covered Not Covered Delivery – Facility charges (Inpatient Hospital, Birthing Center) Payable per Inpatient Hospitalization benefit Not Covered * Note: If a Clinic referral is received either to confirm a Pregnancy or after the initial diagnosis has been made and the Covered Person also enrolls in the CareLink Priority Maternity Care program during the first trimester of the Pregnancy, the Covered Person will not be subject to the inpatient hospital copay, inpatient hospital deductible or inpatient Physician deductible for the delivery charges or other pregnancy related treatment (billed with a primary diagnosis of “Pregnancy”). ER copay will also be waived if the vi is Pregnancy related (billed with a primary diagnosis of “Pregnancy”) Organ Transplants Payable as any other Illness Not Covered Transportation Benefit Maximum (Available only when using a COE facility) $10,000 Lifetime Maximum Note: See the Covered Charges section for more information regarding this benefit. Wigs 75% after deductible $1,000 Lifetime Maximum Note: Limited to the initial purchase of a wig when deemed Medically Necesssary due to temporary or permanen hair loss. See the Covered Charges section for more information regarding this benefit. All Other Eligible Charges 75% after deductible Not Covered This Guidebook is only a summary of benefits and is not a binding contract. Summary Plan Documents, Certificates of Coverage, and the El Paso County Policies and Procedures Manual describes benefits in great detail and are available through ESS or by contacting the Employee Benefits office. Should there be differences between this summary and the plan documents, contracts or policies, the plan documents, contract, and/or policies will govern. 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 and 12: Questions regarding which protectio
Page 13 and 14: (including ER Physician services) M
Page 15 and 16: All subsequent prenatal visits, pos
Page 17: Note: The copayment will apply as l
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
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2013 Employee Benefits Guidebook - Administration Home

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