Mercy Health Plans

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Mercy Health Plans

Mercy Medical PlanSummary of Benefits – Effective January 1, 2012(This Summary of Benefits provides a simplified overview of the plan. The plan is governed by the terms of the Description of CoveredMedical Benefits and Schedule of Benefits and the Plan Document. We have taken care to ensure that the following benefits are accurate.However, if there is a conflict between this Summary of Benefits and the Description of Covered Medical Benefits and Schedule ofBenefits and The Plan Document, the Description of Covered Medical Benefits and Schedule of Benefits and the Plan Document will befollowed.)Plan Maximums Mercy Advantage (Tier 1) Comprehensive (Tier 2) Out-of-Network (Tier 3)Medical Benefit Maximum No Maximum Policy Benefit No Maximum Policy Benefit No Maximum Policy BenefitCalendar Year Deductible- Co-worker- Co-worker + 1 Dependent- Co-worker + 2 or More DependentsCalendar Year Out-of-Pocket Maximums(includes Deductible & Coinsurance)- Co-worker- Co-worker + 1 Dependent- Co-worker + 2 or More Dependents$200$400$600$500$1,000$1,500$3,000$6,000$9,000$1,450$2,900$4,350$3,500$7,000$10,500UnlimitedUnlimitedUnlimitedWhen one person meets the individual Deductible and Out-of-Pocket Maximum, that person is considered to have met their Deductible and Out-of-PocketMaximum even if the rest of the family Deductible and Out-of-Pocket Maximum remains.Benefit RequirementsAll care must be rendered by aPrior Authorization may be required for Mercy Advantage (Tier 1) networkcertain procedures regardless of provider or physician or provider.level of benefit.All care must be rendered by aComprehensive (Tier 2) networkphysician or provider.Benefit subject to usualcustomary and reasonablelimits. Balance billing mayapply.Services Member Cost Share Member Cost Share Member Cost ShareMedical ServicesPrimary Care VisitSpecialist VisitWellness ServicesAnnual Exam (well-woman or physical)Mammograms(35+ Years old - 1 per Calendar Year)Prostate Screening(1 per Calendar Year)Colon Cancer Screening(50+ Years old – 1 per 10 Years)A1c Test(2 per Calendar Year)Cholesterol Screening(1 per Calendar Year)Immunizations (per ACIP guidelines)Well Child CareOsteoporosis/Bone Density ScreeningPreventive Health Screenings in accordance with theU.S. Preventive Health Task Force, Federal law, andadditional preventive benefits provided by the MercyMedical Plan.Tobacco CessationTobacco Cessation ProgramAuriculotherapyAllergy Services- Primary Care VisitSpecialist Visit- Injections/TreatmentIf additional services are provided or billed separately additional member cost share will apply$20 copayment$35 copayment50% after deductible$35 copayment$50 copayment50% after deductible$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 Copayment$0 Copayment$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 (covered in full)$0 Copayment$0 CopaymentIn-Network OnlyIn-Network OnlyIn-Network OnlyIn-Network OnlyIn-Network OnlyIn-Network OnlyIn-Network OnlyIn-Network OnlyIn-Network OnlyIn-Network OnlyIn-Network Only$20 copayment$35 copayment$0 (covered in full)$35 copayment$50 copayment$0 (covered in full)50% after deductible50% after deductible50% after deductibleLaboratory Services 15% coinsurance after deductible 30% coinsurance after deductible 50% after deductibleX-ray & Other Diagnostic Services(including Flat-Film, Ultrasound, EKG,EEG, Echocardiogram & Hearing Tests)MRI, CAT & PET Scans, NuclearMedicine and Radiation TherapyMaternity- Office Visits (includes 2ultrasounds; all other relatedcharges such as Inpatient HospitalServices, Laboratory & Radiologyservices subject to benefits listedabove)15% coinsurance after deductible 30% coinsurance after deductible 50% after deductible25% coinsurance after deductible 40% coinsurance after deductible 50% after deductibleOne time $100 copayment for alloffice visits associated with prenatalcare during a single pregnancy –maternity related services onlyOne time $200 copayment for alloffice visits associated withprenatal care during a singlepregnancy – maternity relatedservices only50% after deductible


Services Mercy Advantage (Tier 1) Comprehensive (Tier 2) Out-of-Network (Tier 3)Inpatient Hospital Services 15% coinsurance after deductible 30% coinsurance after deductible 50% after deductibleOutpatient ServicesUrgent Care Center Services $50 copayment per visit $50 copayment per visit $50 copayment per visitEmergency Room Services and Supplies(Copayment waived if inpatient admissionfor the same condition occurs within 24hours.)Outpatient Surgery & Other OutpatientProcedures (Cardiac Catheterization, StressTest, Angioplasty, etc.)Rehabilitation Services–Outpatient Services(Limit 20 visits each per service per Year –Physical Therapy, Occupational Therapy &Speech Therapy)Cardiac Rehabilitative Therapy(Limit 36 visits or 12 weeks per event.One copayment for entire rehab session)Mental Health/Alcoholism/ChemicalDependencyInpatient Services for Mental Health,Alcoholism & Chemical DependencyOutpatient Services for Mental Health,Alcoholism & Chemical DependencyResidential Services for Mental Illness &Chemical Dependency(Limit 120 Days per Calendar Year forcombined services)Autism /Applied Behavioral Analysis (ABA)/Pervasive Developmental Disorders (PDD)Miscellaneous Covered Services$125 copayment per visit if TrueEmergency or if referred by Nurseon Call$250 copayment per visit if not aTrue Emergency$125 copayment per visit if TrueEmergency or if referred by Nurseon Call$250 copayment per visit if not aTrue Emergency$125 copayment per visit ifTrue Emergency or ifreferred by Nurse on Call$250 copayment per visit ifnot a True Emergency15% coinsurance after deductible 30% coinsurance after deductible 50% after deductible15% coinsurance after deductible 30% coinsurance after deductible 50% after deductibleOne time $35 Copayment One time $35 Copayment In-Network OnlyFor prior authorization of Inpatient and Outpatient services callMercy Managed Behavioral Health at 314-729-4600 or 1-800-413-800815% coinsurance after Mercy Advantage Network deductible 50% after DeductibleOutpatient (OP) Visit: $20 Copayment per Session50% after DeductibleIntensive Outpatient (IOP): 15% coinsurance after Mercy AdvantageNetwork deductible15% coinsurance after Mercy Advantage Network deductible 50% after Deductible$20 Copayment per Visit$20 Copayment per SessionAmbulance Services (Air and Ground)15% Coinsurance after Mercy Advantage Network deductibleChiropractic Care $25 co-pay per visit then covered 100% up to $500 annual max In-Network OnlyDialysis $0 (covered in full) 30% coinsurance after deductible In-Network OnlyDental Services – Accident Only $0 (covered in full) 30% coinsurance after deductible In-Network OnlyDurable Medical Equipment 15% coinsurance after deductible 30% coinsurance after deductible 50% after DeductibleHome Health Care(Limit 20 visits each per service per Year –Physical Therapy, Occupational Therapy,Speech Therapy & Skilled Nursing combined– Must be home bound)15% coinsurance after deductible 30% coinsurance after deductible 50% after DeductibleHospice Services $0 (covered in full) 30% coinsurance after deductible 50% after deductibleInpatient Rehabilitation Facility Services 15% coinsurance after deductible 30% coinsurance after deductible 50% after Deductible(Limit 120 days per Year)Long Term Acute Care15% coinsurance after deductible 30% coinsurance after deductible 50% after Deductible(Limit 120 days per Year)Medications Administered by a HealthcareProfessional(Received in a physician’s office, infusioncenter, outpatient hospital, or through homehealth)$55 Copayment for medicationsCopayment applies to the Mercy Advantage Out-of-Pocket MaximumIf additional services are provided or billed separately additional membercost share will applyIn-Network OnlyNutritional/ Dietary Counseling$35 copayment per visit $50 copayment per visit In-Network Only(Limit 3 visits per Year)Orthotics ($5000 Annual Maximum) 15% coinsurance after deductible 30% coinsurance after deductible 50% after DeductibleProsthetic Devices 15% coinsurance after deductible 30% coinsurance after deductible 50% after DeductibleSkilled Nursing Facility Services15% coinsurance after deductible 30% coinsurance after deductible 50% after Deductible(Limit 120 days per Year)Surgical Implants 15% coinsurance after deductible 30% coinsurance after deductible 50% after DeductibleTransplant Services15% Coinsurance after Mercy Advantage Network deductibleat a Mercy-Approved Transplant Center including the Coventry Transplant Network Facilities Only


Outpatient Prescription Drugs First Fill (30-Day Supply) All Refills (30-Day Supply)If you or your physician requests a brandname drug when a generic is available,you may be required to pay the genericcopayment plus the difference in costbetween the brand name and generic.Any Network PharmacyTier 1 - $ 4 copaymentTier 2 - $35 copaymentTier 3 - $55 copaymentPreferred PharmacyMercy Pharmacy*Tier 1 - $ 4 copaymentTier 2 - $35 copaymentTier 3 - $55 copaymentOther Network PharmaciesTier 1 - $20 copaymentTier 2 - $50 copaymentTier 3 - $75 copaymentSmoking Cessation Drugs covered at theappropriate Tier copayment listed.Walmart Pharmacy**Tier 1 - $ 4 copaymentTier 2 - $35 copaymentTier 3 - $55 copaymentGenerally, Tier 1 drugs are generic; Tier 2 drugs are preferred brand name; Tier 3 drugs are non-preferred brand name drugs.*If you are employed by one of the following facilities, your preferred pharmacy is Mercy:Kansas: Ft. Scott and IndependenceMissouri: Aurora, Cassville, Lebanon, Springfield, Mountain View, Ministry Office, St. Louis and Washington** If you are a retiree or you are employed by one of the following facilities Mercy or Wal-Mart will be your preferred pharmacies:Arkansas: Fort Smith, Hot Springs, NW Arkansas, Arkansas (Springfield-based), and BerryvilleKansas: Maude Norton (Columbus)Oklahoma: Ardmore and OklahomaMissouri: Joplin and Out of area Mercy90-Day Supply – You will pay two and half times (2.5 X) the applicable co-payment for up to a 90-day supply of medication if purchasedthrough your local Mercy pharmacy (if available) or LDI local pickup or mail order.Specialty Drugs - Select list of high-cost drugs used to treat certain serious illnesses. Mercy maintains a list of the specialty drugs included. Allspecialty drugs have a quantity limit and are limited to no more than a 30-day supply per fill.Utilization Management – Some drugs are subject to utilization management programs such as quantity limits, prior authorization and steptherapy.

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