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1993 Traditional Plan

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-291-1425 or go to s6xz.achador.net.  For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary.  You can view the Glossary at http://www.healthcare.gov/sbc-glossary   or call 1-800-291-1425 to request a copy.

           

Important Questions
What is the overall deductible?
See the Common Medical Events chart below for your costs for services this plan covers.
Are there services covered before you meet your deductible?
Are there other

deductibles for specific services?

What is the out-of-pocket limit for this plan?
What is not included in

the out-of-pocket limit?

Will you pay less if you use a participating  provider?
Do you need a referral to see a specialist?
Answers Why This Matters:
$ 0
See the Common Medical Events chart below for your costs for services this plan covers.
Yes This Plan does not have a deductible. But a copayment may apply.
No You don’t have to meet deductibles for specific services.
$ 400 / family for PPL* physician visits

$ 600 / family for PPL prescription drugs

$400 / family for non-PPL physician visits

$600 / family for non-PPL drugs

$600 / family for non-PPL hospital

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met.

 

* PPL means Participating Provider List.

 

The extra cost of using brand name or non-preferred drugs,

balance-billing charges, and health care this plan doesn’t cover.

(This plan has no premiums.)

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Yes. See s6xz.achador.net

or call 1-800-291-1425 for a list of participating providers.

This plan uses a Participating Provider List (PPL) network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
No You can see the specialist you choose without a referral.

 

 

 

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

 

Common Medical Event
Participating Provider

(You will pay the least)

If you visit a health care provider’s office or clinic
Specialist visit
Preventive care/screening/

immunization

If you have a test
Imaging (CT/PET scans, MRIs)
If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at s6xz.achador.net.

 

 

Brand drugs where generic is available

Non-Preferred brand drugs

 

Preferred Specialty drugs

 

 

Non-Preferred Specialty drugs

 

 

 

 

 

Specialty drugs not on the Specialty Drug List

If you have outpatient surgery
Physician/surgeon fees
If you need immediate medical attention
Emergency medical transportation
Urgent care
If you have a hospital stay
Physician/surgeon fees
If you need mental health, behavioral health, or substance abuse services
Inpatient services
If you are pregnant
Childbirth/delivery professional services
Childbirth/delivery facility services
If you need help recovering or have other special health needs
Rehabilitation services
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice services
If you need dental or eye care
Glasses
Dental check-up
Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information
Non-Participating Provider

(You will pay the most)

Primary care visit to treat an injury or illness $20 copay / visit $30 copay / visit None
$20 copay / visit $30 copay / visit None
$20 copay / visit $30 copay / visit Routine physical exams are covered for ages under 6 and over 54; annually or semi-annually by a gynecologist; or by a specialist as part of the specialist’s care of a medical condition.

Copayments apply.

Diagnostic test (x-ray, blood work) No charge No charge None
No charge No charge None
Generic drugs or

Preferred brand drugs

$15 copay per 30-day supply

$5 copay per 90-day supply for mail order

$30 copay per 30-day supply

 

Maximum supply for non-mail order is 90 days.

 

 

$15 copay per 30-day supply.*

$5 copay per 90-day supply for mail order.*

*Plus the difference in cost between the generic and brand product.

$30 copay per 30-day supply,

plus the difference in cost between the brand and generic product.

 

If the prescribing physician obtains a medical necessity authorization there will be no additional payment for the use of the brand drug.
$15 copay per 30-day supply.*

$5 copay per 90-day supply for mail order.*

*Plus the differential payment that is approximately equal to the difference in cost between the Preferred and Non-Preferred product.

$30 copay per 30-day supply,

plus the differential payment that is approximately equal to the difference in cost between the Preferred and Non-Preferred product.

If the prescribing physician obtains a medical necessity authorization there will be no additional payment for the use of the Non-Preferred drug.
$5 per 30-day supply at CVS Specialty Pharmacy

 

$5 per 30-day supply at CVS Specialty Pharmacy

 

 

 

 

$5 per 30-day supply at CVS Specialty Pharmacy

$15 per 30-day supply at any other Specialty pharmacy

If Specialty drugs are obtained at a non-network Specialty pharmacy, a $30 per 30-day supply copay applies.

 

 

 

Pre-authorization is required for all Specialty drugs.

 

All drugs on the Specialty Drug List must be obtained from a CVS Specialty Pharmacy.

 

If a Non-Preferred Specialty drug within the classes on the Specialty Drug List is selected, the prescriber will be asked to consider a Preferred drug to be used before the Non-Preferred drug will be covered.

Facility fee (e.g., ambulatory surgery center) No charge No charge None
No charge No charge None
Emergency room care $20 copay per visit $30 copay per visit Copay only applies to physician’s charge for the emergency room visit.
No charge No charge None
$20 copay per visit $30 copay per visit Copay only applies to physician’s charge for the visit.
Facility fee (e.g., hospital room) No charge The plan pays 90% of Participating Provider rate.  The Beneficiary is responsible for the remaining balance of charges up to the $600 annual out-of-pocket maximum.  Hold Harmless provisions may not apply. Private rooms are not covered unless patient’s condition requires isolation or no semi-private room is available.
$20 copay per visit $30 copay per visit Copay only applies to physician’s charge for hospital visits.
Outpatient services $20 copay per visit

 

$30 copay per visit

 

Alcoholism and drug rehabilitation programs must be provided by an accredited facility.
No charge The plan pays 90% of Participating Provider rate.  The Beneficiary is responsible for the remaining balance of charges up to the $600 annual out-of-pocket maximum.  Hold Harmless provisions may not apply. Inpatient services must be provided by an accredited facility.

Plan payment for non-PPL hospital and related benefits is limited to 90% of the amount that would have been paid to a PPL hospital.

 

Office visits

 

 

$20 copay per visit

 

 

 

$30 copay per visit

 

 

Depending on the type of services, a copayment may apply.

Copayment does not apply when childbirth/delivery is billed as a bundled service.

Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

No charge No charge Copayment does not apply when childbirth/delivery is billed as a bundled service.

 

No charge The plan pays 90% of Participating Provider rate.  The Beneficiary is responsible for the remaining balance of charges up to the $600 annual out-of-pocket maximum.  Hold Harmless provisions may not apply.

 

Plan payment for non-PPL hospital and related benefits is limited to 90% of the amount that would have been paid to a PPL hospital.
Home health care No charge No charge Must be medically justified with skilled care.
No charge No charge Must be medically justified with skilled care.
No charge No charge Must be medically justified with skilled care.
No charge No charge Must be medically justified with skilled care.
No charge Not covered Most equipment must be purchased through a DME network provider.  Some equipment must be prior approved.
Not covered Not covered None
Eye exam  

$46.77

 

 

Not Applicable

 

Covered once every 24 months.
$23.39 per lens single vision

$35.09 per lens bifocal

$46.77 per lens trifocal

$58.47 per lens lenticular

$35.09 per contact lens

$33.13 frames

Not Applicable Covered once every 24 months.

Lenses will not be covered unless the new prescription differs from the most recent one by an axis change of 20 degrees or .50 diopter sphere or cylinder change and the lens must improve visual acuity by at least one line on the standard chart.

Not covered Not covered None

 

Excluded Services & Other Covered Services:

 

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
·         Acupuncture

·         Chiropractic care

·         Cosmetic surgery

 

·         Dental care

·         Long-term care

·         Private-duty nursing unless necessary to preserve life and ICU is unavailable

 

·         Routine foot care

·         Weight loss programs

 

 

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
·         Bariatric surgery

·         Hearing aids

 

 

·         Infertility treatment (artificial insemination only)

·         Non-emergency care when traveling outside the U.S.

 

·         Routine eye care

 

 

 

 

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

 

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: The UMWA Funds at 1-800-291-1425 or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

 

Does this plan provide Minimum Essential Coverage?  Yes

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

 

Does this plan meet the Minimum Value Standards?  Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

 

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al  1-800-291-1425 (TTY: 711)

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa  1-800-291-1425 (TTY: 711)

Chinese (中文): 如果需要中文的帮助,请拨打这个号码  1-800-291-1425 (TTY: 711)

Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’  1-800-291-1425 (TTY: 711)

––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––

 

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