UT-Battelle, LLC Employee Assistance Program - Benefits

UT-Battelle, LLC Employee Assistance Program Coverage Period: 01/01/2013-12/31/2013Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employees, former employees andtheir dependents|Plan Type: EAPThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document athttp://benefits.ornl.gov/spd or by calling 1-800-888-2273..Important Questions Answers Why this Matters:What is the overalldeductible?Are there otherdeductibles for specificservices?Is there an out–of–pocket limit on myexpenses?What is not included inthe out–of–pocketlimit?Is there an overallannual limit on whatthe plan pays?Does this plan use anetwork of providers?Do I need a referral tosee a specialist?Are there services thisplan doesn’t cover?$0NoNoThis plan has no out-ofpocketlimit.NoThe EAP is a preventive care program for which no deductible is applicable.The EAP is a preventive care program. You don’t have to meet any deductiblesfor EAP services.There are no charges for EAP services obtained from a network EAP provider.As a result, there is no need for a limit on your expenses for these services.Not applicable because there’s no out-of-pocket limit on your expenses.The chart on page 2 describes any limits on what the plan will pay for specificcovered services, such as office visits.Yes. For a list of EAP If you use a network EAP provider, this plan will pay all of the costs of coveredcounselors, see www. services. See the chart on page 2 for how this plan pays different kinds ofmagellanhealth.com/member providers.or call 1-800-888-2273.No.Yes.The EAP does not cover specialists. If the EAP provider determines that youneed treatment from a specialist, the EAP provider will refer you to your grouphealth plan or treatment resources in your community.See your plan document for information about excluded services.Questions: Call 1-800-888-2273 or visit us at www. magellanhealth.com/member.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 6at www.magellanhealth.com/member or call 1-800-888-2273 to request a copy.OMB Control Numbers 1545-2229,1210-0147, and 0938-1146

Coverage ExampleAbout these CoverageExamples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.This isnot a costestimator.Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.See the next page forimportant information aboutthese examples.Having a baby(normal delivery) Amount owed to providers: $7,540 Plan pays $0Patient pays This condition is not covered bythis plan, so the patient pays 100%.Sample care costs:Hospital charges (mother) $2,700Routine obstetric care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200Radiology $200Vaccines, other preventive $40Total $7,540Patient pays: This condition is not covered, sothe patient pays 100%.Deductibles $Copays $Coinsurance $Limits or exclusions $Total $Managing type 2 diabetes(routine maintenance of awell-controlled condition) Amount owed to providers: $5,400 Plan pays $0Patient pays This condition is not covered bythis plan, so the patient pays 100%.Sample care costs:Prescriptions $2,900Medical Equipment and Supplies $1,300Office Visits and Procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100Total $5,400Patient pays: This condition is not covered, sothe patient pays 100%.Deductibles $Copays $Coinsurance $Limits or exclusions $Total $Questions: Call 1-800-888-2273 or visit us at www. magellanhealth.com/member.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 5 of 6at www.magellanhealth.com/member or call 1-800-888-2273 to request a copy.OMB Control Numbers 1545-2229,1210-0147, and 0938-1146