Teacher's Contract and Salary Schedule 2011-2014

TRUMBULL PUBLIC SCHOOLS TEACHER HEALTH PLAN SUMMARYPREFERRED PROVIDER ORGANIZATION (PPO) PLANPrefen'ed provider organization (1'1'0) plan.In-NctworkCOST SHARE PROVISIONSMember pays:Office Visit (OV) Copayment$25 per visitHospital (BSP) Copayment$150 per admission* cjJixtive 711112$175 per admission* EjJective 711113$200 per admissionUrgent Care (lJ R) Copayment- processed as out of network ER $50Emergency Room (ER) Copayment - waived ifadmiued $75* Effective 711112$/00 capayEmergency Office Visit $25Outpatient Surgery (OS) Copayment $75* Effective 711//2$/00 copay* Elfective 7111/3$125 copayCalendar Year Deductible (individua/12-mel7lber fal7lilyl3+ memberfamily)Not ApplicableCoinsuranceCoinsurance Maximulll (individuaI12-l17emberfal17ilyI3+ memberfomily)Cost Share Maximum (individua/12-member familyl3+member family)Lifetime MaximumPREVENTIVE CAREWell child carePeriodic, routine health examinationsRoutine OB/GYN visitsMammographyHearing screeningRoutine Eye ExamMEDICAL CAREOffice visitsOutpatient mental health & substance abuse - prior authorization requiredOB/GYN careMaternity care - inilial visit subject to copaymenl. no charge thereafterDiagnostic lab and x-rayAcupuncture - with a licensed providerHigh-cost outpatient diagnostic - prior authorization requiredThe fiJ/iolVing are subject 10 copay: MR/, MRA, CA7: CTA, PE7: SPECTscansUnlimitedNo Co paymentNo CopaymentNo CopaymentNo Charge$25 Copayment$25 Copayment$25 Copavmenl$25 CopaYll1enl$25 Copayment$25 CopaymentNo Charge$25 CopaymentNo CopaYlllent perserviceOu t-of- N ctwo d,Member {Jays:Deductible & CoinsuranceDeductible & CoinsuranceNot covered$75Deductible & CoinsuranceDeductible & Coinsurance$500/$1000/$1000* LJfective 711//2$SOO/$/,OOOI$I,SOO20% after deductible up to$1,000/$2000/$2000* LJfeclive 711112$1,0001$2,0001$3,000$1,500/$3,000/$3,000* Effective 71/112$1,5001$3,(}OOI$4,SOO$1,000,000Deductible & CoinsuranceDeductible & CoinsuranceA lIergy servicesOffice visits/testingInjections-Unlimited$25 CopaymentNo Copayment