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Schedule of Medical Benefits - ProvSelect HSAMEDICAL BENEFITS / LIMITATIONSPRIMARYPPODURABLE MEDICAL EQUIPMENT/PROSTHETIC APPLIANCESSECONDARYPPONON-PPODeductible Applies, Benefit Percentage --- 80% 50%ORTHOTICSDeductible Applies, Benefit PercentageMaximum Benefit per 24 months / $500--- 80% 50%DIABETIC CARE (Additional Preventive health care if diagnosed with diabetes.Primary PPO and Secondary PPODeductible Applies, Benefit Percentage 100%Non-PPODeductible Applies, Benefit Percentage --- --- 50%Covered services, subject to the following benefit limits:‚ Influenza vaccine;‚ Pneumococcal vaccine, once every 5 Benefit Periods;‚ Dilated retinal exams by a qualified participating eye care specialist;‚ Glycosylated hemoglobin (HbA1c) test;‚ Urine test to test kidney function;‚ Blood test for lipid levels as appropriate;‚ Visual exam of mouth and teeth by a Physician (dental visits not covered);‚ Foot inspection without shoes or socks.BARIATRIC SURGERY BENEFIT (Includes complications)Deductible Applies, Benefit PercentageLimited to one procedure per lifetime100% 80% 50%Services must be performed at St. Patrick Hospital and Health Sciences Center or in a Medicareapproved Bariatric Center of Excellence.Western Montana Providence Health & Services - SPD 10Group #2000204 - January 1, 2011
PHARMACY BENEFITPrescription drug charges are payable only through the Plan’s Pharmacy Benefit Management (PBM)program, which program is sponsored in conjunction with and is an integral part of this Plan. Except forHSA, Copayments do not serve to satisfy the Medical Benefits Annual Deductible or Out-of-PocketMaximum. The Pharmacy Benefit Manager (PBM) will provide separate information for detailsregarding Network pharmacies, Preferred Brand prescriptions and Specialty Drugs uponenrollment for coverage under this Plan.Generics preferred - Physician choice (DAW2) - If the Physician does not prescribe “Dispense asWritten”, and there is a generic alternative for the prescription drug, and the Covered Person chooses abrand name instead, the Covered Person must pay the difference in cost between the generic and brandname medication plus the applicable brand copayment amount.If the Physician prescribes a brand name drug and communicates on the prescription “Dispense asWritten” (DAW), the Covered Person will pay the brand name copayment only.COST SHARING PROVISIONS (ProvPreferred PPO)Deductible ....................................................................WaivedOut-of-Pocket MaximumPer Covered Person ....................................................... $1,000Per Family ............................................................... $2,000Copayment per Prescription - Prescription drugs purchased from in house Pharmacies(St. Patrick Hospital Broadway Pharmacy or St. Joseph Medical Center Pharmacy)Drug TypeRetail - In House34-day supplyMail Order90-day supplyGeneric $5 $15 $5Preferred Brand $15 $45 $15Non-Preferred Brand $30 $90 $30Specialty DrugCopayment per Prescription - All other PharmaciesDrug TypeRetail - PBMNetwork30-day supplyMemberSubmit*34-day supplyMail Order90-day supplySpecialty DrugGeneric $15 $15 $30 $15Preferred Brand $25 $25 $50 $25Non-Preferred Brand $40 $40 $80 $40*For Member Submit prescriptions, the PBM will reimburse the contract cost of the prescription drug,less the applicable Copayment per Prescription. Contract cost is the PBM’s discounted cost of theprescription drug. Reimbursement will not exceed what the PBM would have reimbursed for a NetworkPrescription.Western Montana Providence Health & Services - SPD 11Group #2000204 - January 1, 2011
Page 2: Western Montana Providence Health &
Page 9 and 10: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 11 and 12: Schedule of Medical Benefits - Prov
Page 13 and 14: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 18 and 19: Pharmacy BenefitWhen Primary Covera
Page 20 and 21: Pharmacy BenefitPRIMARY COVERAGE UN
Page 22 and 23: MEDICAL BENEFIT DETERMINATION REQUI
Page 24 and 25: Medical Benefit Determination Requi
Page 26 and 27: Medical Benefits5. Charges made by
Page 28 and 29: Medical Benefits15. Charges for dru
Page 30 and 31: Medical BenefitsGENETIC AND INFERTI
Page 32 and 33: Medical BenefitsPREVENTIVE CARE“P
Page 34 and 35: Medical Benefits3. Services provide
Page 36 and 37: Medical BenefitsBody Mass Index (BM
Page 38 and 39: Pre-Authorization6. A letter of med
Page 40 and 41: Hospital Admission CertificationCON
Page 42 and 43: Medical Benefit Exclusions10. Charg
Page 44 and 45: GENERAL PLAN EXCLUSIONS AND LIMITAT
Page 46 and 47: General Plan Exclusions and Limitat
Page 48 and 49: Coordination of Benefits“Plan”
Page 50 and 51: Coordination of Benefits3. For Cove
Page 52 and 53: Procedures for Claiming Benefits1.
Page 54 and 55: Procedures for Claiming Benefits2.
Page 56 and 57: Eligibility ProvisionsD. The ABR is
Page 58 and 59: EFFECTIVE DATE OF COVERAGEAll cover
Page 60 and 61: Effective Date of CoverageD. Placem
Page 62 and 63: QUALIFIED MEDICAL CHILD SUPPORT ORD
Page 64 and 65: FAMILY AND MEDICAL LEAVE ACT OF 199
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Family and Medical Leave ActENFORCE
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Termination of Coverage7. The date
Page 70 and 71:
CONTINUATION COVERAGE AFTER TERMINA
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Continued Coverage After Terminatio
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Continued Coverage After Terminatio
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COVERAGE FOR A MILITARY RESERVISTTo
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Recovery/Reimbursement/SubrogationT
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PLAN ADMINISTRATIONPURPOSEThe purpo
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CREDITABLE COVERAGE PROCEDURESCERTI
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General ProvisionsWORKERS' COMPENSA
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General DefinitionsBENEFIT PERCENTA
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General DefinitionsCUSTODIAL CARE
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General Definitions“Reliable Evid
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General DefinitionsLATE ENROLLMENT
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General Definitions9. Are approved
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General DefinitionsPREVENTIVE CARE
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General DefinitionsTOTAL DISABILITY
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ERISA Statement of RightsIf you hav
Page 104 and 105:
HIPAA Privacy and Security Standard
Page 106:
Plan Summary9. IDENTIFICATION NUMBE
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