schedule of benefits -open access - ecasd documents... · schedule of benefits -open access...

Schedule of Benefits - OPEN ACCESSGroup 502281 - EAU CLAIRE AREA SCHOOL DISTRICTBenefit Year: July 1st Through June 30thEffective Date: 07/01/2016

Security Health Plan certifies that you and any covered dependents have coverage as described in your Certificate and Schedule of Benefits. The effective date isshown on the letter you received with your identification cards. Coverage is subject to the terms, conditions, exclusions, limitations and all other provisions of thegroup policy.

This Schedule shows how much you pay for certain types of services. It shows additional benefits, limitations or exclusions not shown in your Certificate. It alsoprovides a very general summary of your benefits for certain types of services. You will need to read it along with your Certificate for details about yourcoverage. Benefits are based on the benefit year shown above.

Reimbursement is limited for out-of-network benefits to the reasonable and customary charges for cost-effective services. It is also subject to applicabledeductible, coinsurance and copayment amounts. If a charge exceeds our reasonable and customary fee limit, we may reimburse less than the billed charge. Inthis case, the member is responsible for any amount charged in excess of such fees. The member is also responsible for applicable deductible, coinsurance andcopayment amounts.

Network Tier 1 ~ Security Health Plan primary networkNetwork Tier 2 ~ All other licensed providers in Wisconsin counties of Barron, Chippewa, Dunn, Eau Claire and TrempealeauNetwork Tier 3 ~ All other out-of-area and out-of-network licensed providersClairemont Center ~No deductible, co-pay or co-insurance for services rendered at the Clairemont Center.

Your Responsibilities Tier 1 - In-Network Tier 2 - Out-of-Network Tier 3 - Out-of-NetworkDeductible $3,000 per individual

$6,000 per family$3,000 per individual$6,000 per family

$6,000 per individual$12,000 per family

Coinsurance Covered services paid at 100%after deductible.

Covered services paid at 100%after deductible.

20% of the next$5,000 per individual$10,000 per family

Office visit copayment $25 copayment per office visit

(Copayment does not apply topreventive exams)

$25 copayment per office visit


Subject to deductible andcoinsurance

Emergency room facility copayment(Waived if admitted to the hospital as an inpatient)

$100 copayment per visit $100 copayment per visit $100 copayment per visit

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Your Responsibilities Tier 1 - In-Network Tier 2 - Out-of-Network Tier 3 - Out-of-NetworkAnnual out of pocket(Deductible, coinsurance & copayments)

In-network amounts accumulate to the out-of-network,out-of-pocket maximum. Out-of-network amountsaccumulate to the in-network, out-of-pocket maximum.




Dependent coverage out of areaIn addition to the benefits described in the Follow-upCare section of the Certificate, dependents livingoutside of the service area are provided benefits forcovered services from non-affiliated providers.

Such coverage shall be providedat the in network level of benefits.



Your Benefits Tier 1 - In-Network Tier 2 - Out-of-Network Tier 3 - Out-of-NetworkAmbulance services Subject to deductible Subject to deductible Subject to deductible and

coinsurance

Anesthesia services Subject to deductible Subject to deductible Subject to deductible andcoinsurance

Chiropractic services $25 copayment per office visit

(Applies for both chiropracticoffice visits and manipulationservices received)


(Applies for both chiropracticoffice visits and manipulationservices received)


Durable medical equipment and medical supplies(Including insulin pump and supplies)

Subject to deductible Subject to deductible Subject to deductible andcoinsurance

Hearing examinations Subject to deductible Subject to deductible Subject to deductible andcoinsurance

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Your Benefits Tier 1 - In-Network Tier 2 - Out-of-Network Tier 3 - Out-of-NetworkHome health care Subject to deductible

(Limited to 40 visits per individualper calendar year)

Subject to deductible




Hospice care Subject to deductible Subject to deductible Subject to deductible andcoinsurance

Hospital emergency room services

• Emergency room facility(Copayment waived if admitted to hospital asinpatient)

$100 copayment per visit $100 copayment per visit $100 copayment per visit

• Other emergency room services Subject to deductible Subject to deductible Subject to deductible andcoinsurance

Hospital inpatient services(Including semi-private or special care room, operatingroom, ancillary services and supplies)


Hospital outpatient and surgical center services Subject to deductible Subject to deductible Subject to deductible andcoinsurance

Maternity services

• Hospital services Subject to deductible Subject to deductible Subject to deductible andcoinsurance

• Physician services Subject to deductible Subject to deductible Subject to deductible andcoinsurance

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Your Benefits Tier 1 - In-Network Tier 2 - Out-of-Network Tier 3 - Out-of-NetworkMental health services

• Inpatient care Subject to deductible Subject to deductible Subject to deductible andcoinsurance

• Outpatient care 6 days covered at 100% percalendar year then subject todeductible

6 days covered at 100% percalendar year then subject todeductible


• Transitional care 6 days covered at 100% percalendar year then subject todeductible



Office visits $25 copayment per office visit





Outpatient laboratory services Covered at 100% Covered at 100% Subject to deductible andcoinsurance

Outpatient radiology services

• CT scans, MRIs and PET scans Subject to deductible Subject to deductible Subject to deductible andcoinsurance

• Radiology services (except CT scans, MRIsand PET scans)

Covered at 100% Covered at 100% Subject to deductible andcoinsurance

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Your Benefits Tier 1 - In-Network Tier 2 - Out-of-Network Tier 3 - Out-of-NetworkOutpatient therapy services

• Occupational therapy $25 copayment per visit $25 copayment per visit Subject to deductible andcoinsurance

• Physical therapy $25 copayment per visit $25 copayment per visit Subject to deductible andcoinsurance

• Speech therapy $25 copayment per visit $25 copayment per visit Subject to deductible andcoinsurance

Physician services

• Hospital services Subject to deductible Subject to deductible Subject to deductible andcoinsurance

• Other services in an office Subject to deductible

(Preventive immunizationscovered at 100%)


(Preventive immunizationscovered at 100%)


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Your Benefits Tier 1 - In-Network Tier 2 - Out-of-Network Tier 3 - Out-of-NetworkPreventive benefitPlease refer to the Security Health Plan wellness guideat www.securityhealth.org/preventive forrecommendations on frequency of preventive services.

• Routine preventive examination• Gynecological examination for women (breast exam

and pelvic exam)• Digital prostate examination for men• Preventive hearing test• Preventive vision examination• Mammograms to screen for breast cancer• Pap Smears to screen for cervical cancer• Sigmoidoscopy, colonoscopy, and/or fecal occult

blood testing to screen for colon or colorectal cancer• Screening laboratory services, including, but are not

limited to: basic metabolic panel, comprehensivemetabolic panel, general health panel, lipoprotein,lipid panel, glucose (blood sugar), complete bloodcount (CBC), hemoglobin, thyroid stimulatinghormone (TSH), prostate specific antigen (PSA), andurinalysis

• Bone mineral density (dexa scan) for osteoporosisscreening in women

• Chlamydia screen for women• Ultrasound for screen of an abdominal aortic

aneurysm for men• Immunizations and vaccinations (including those

needed for travel)

Covered at 100% Covered at 100% Subject to deductible andcoinsurance

Skilled nursing facility Subject to deductible

(Limited to 30 days per individualper confinement)





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Your Benefits Tier 1 - In-Network Tier 2 - Out-of-Network Tier 3 - Out-of-NetworkSubstance abuse services

• Inpatient care Subject to deductible Subject to deductible Subject to deductible andcoinsurance

• Outpatient care 6 days covered at 100% percalendar year then subject todeductible



• Transitional care 15 days covered at 100% percalendar year then subject todeductible



Surgical services Subject to deductible Subject to deductible Subject to deductible andcoinsurance

Temporomandibular joint disorders or TMJ non-surgical treatment


Transplant services Subject to deductible Subject to deductible Not covered

Vision examinations Subject to deductible Subject to deductible Subject to deductible andcoinsurance

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Pharmacy• Up to 30 days worth of medication constitutes a 1-month supply. For most

maintenance medications you may receive up to a 90-day supply and ifapplicable, 3 copayments and/or coinsurance and/or deductible will beassessed.

• Pharmacy mail service may supply maintenance medications in a 90-daysupply and if applicable, 2 copayments and/or coinsurance and/or deductiblewill be assessed.

• Copayments and/or coinsurance and/or deductible will be assessed on oralanti-diabetic medications.

• 100% coverage for tier 1 and tier 2 insulin and diabetic testing supplies. (Notsubject to deductible, if applicable.)

• Insulin and diabetic testing supplies not listed on tier 1 or tier 2 of theFormulary Guide will require medical exception review from the SecurityHealth Plan Pharmacy Services Department. (This does not include insulinpumps and related supplies. Please refer to the durable medical equipmentsection of the Schedule of Benefits for coverage.)

• 100% coverage for smoking cessation products, limited to 180 days perbenefit year, as indicated in the Formulary Guide.

• Limited coverage for sexual dysfunction medications, as indicated in theFormulary Guide.

• Over-the-counter (OTC) medications are generally excluded; however,coverage may be provided for selected OTC medications with a prescriptionauthorization, as indicated in the Formulary Guide.

• The use of a specialty pharmacy may be required for select medications, asindicated in the Formulary Guide.

$0 copayment per tier 1 prescription or refill.



Deductible, copayments and coinsurance may apply to the max out of pocketamounts.

Benefit year - July 1st thru June 30th

If the participant requests the brand name product for a medication where ageneric is available, the participant must pay the applicablecopayment/coinsurance plus the ancillary charge. The ancillary charge is thecost difference between the brand name product and the generic product. Theancillary charge will not count towards the prescription out-of-pocket limit.

Dependent CoverageDependent children are covered from birth through the end of the month they attain the age of 26.

In addition, a child who meets the criteria above and is a full-time student as defined in the Certificate has an extension past age 26 IF the child was called tofederal active duty in the National Guard or in a reserve component of the U.S. armed forces while the child was under 27 years of age and attending, on a full-time basis, an institution of higher learning. Such extension ends on the date described in the full-time student definition in the Certificate.

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Additional Exclusions and LimitationsPre-certification

The following services require pre-certification beforecare is provided. As a Security Health Plan member,you are responsible for notifying us before receivingthese services. Please call us at 1-800-548-1224.

• Air ambulance transport• Clinical trials• Continuous Passive Motion

(CPM) machine• Cosmetic/reconstructive

surgery• Durable Medical Equipment

(except: CPAP, oral appliance,continuous glucose monitoring;these services require a priorauthorization form)

• Elective inpatient admissionincluding medical (acute andbehavioral health) and surgical

• Experimental or investigationalservices

• Hospice• Non-emergent ambulance

transport• Office procedure with site of

service request other than inoffice setting

• Outpatient procedure with siteof service request as inpatientsetting

• Second opinion• Swing bed admission• TENS• Transplants























Prior authorization

Have your health care provider contact Security HealthPlan to request a prior authorization for payment beforethe service is provided. Prior authorization is required

• 72-hour continuous glucosemonitoring

• Abdominoplasty


• Abdominoplasty


• Abdominoplasty

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Additional Exclusions and Limitationsfor the services listed. Security Health Plan continuallyassesses prior authorizations that may be required fornew prescriptions and newly approved medicalservices. Please check our website for a complete listof prior authorizations at www.securityhealth.org/authorization.

• Amino acid formula• Antibiotic - antiviral intravenous

infusion• Autologous cultured

chondrocytes• Bone growth stimulator• Breast reconstruction post

mastectomy• Carpal tunnel - median

neuropathy - specialty consults• Chronic hip pain - osteoarthritis

or meniscal degeneration -specialty consults

• Chronic knee pain -osteoarthritis or meniscaldegeneration - specialtyconsults

• Concurrent outpatient therapytreatment

• Continuous positive airwaypressure (CPAP) - adult

• Continuous positive airwaypressure (CPAP) - children

• Electrical stimulation andelectromagnetic therapy

• Enteral feeding• Fecal transplant• Hearing aids for members over

18• Home Health prior

authorization form: skillednursing, physical therapy,occupational therapy, speechtherapy

• Home infusion - chemotherapy• Infuse bone graft• Initial outpatient therapy































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Additional Exclusions and Limitationstreatment

• Insulin pumps• Intrastromal corneal ring

segments• Intravenous immunoglobulin -

subcutaneous immunoglobulininfusion

• IV Infusion therapyauthorization request: TPN andhydration

• Lipectomy• Low back pain - orthopedic or

neurosurgery consults• Low dose CT for lung cancer

screening• Lung volume reduction surgery• Nonaffiliated provider request• Oral appliance for obstructive

sleep apnea• Panniculectomy• Parenteral nutrition home

infusion• Port wine stain - abnormal

vascular lesion treatment• Radiation oncology• Reduction mammoplasty• Rhinoplasty• Septoplasty• Spinal cord stimulator• Surgical treatment for obesity• Synagis

treatment• Insulin pumps• Intrastromal corneal ring










treatment• Insulin pumps• Intrastromal corneal ring










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Additional Exclusions and LimitationsShared decision making

Shared decision making is a required step for someprior authorizations. After the prior authorization formhas been submitted, members will be required tocomplete shared decision making prior to receiving thelist of surgeries or specialty consults.

• Hysterectomy with fibroiddiagnosis surgery

• Carpal tunnel specialtyconsults

• Chronic hip pain specialtyconsults

• Chronic knee pain specialtyconsults

• Low back pain specialtyconsults











Skilled nursing facility services

For the skilled nursing facility services listed, you willneed to work with your provider to notify NaviHealth.

• Acute rehabilitation admission• LTAC Admission• Skilled nursing facilities

admission


admission


admission

High end imaging

For all high-end imaging services, you may need towork with your provider to receive authorization fromeviCore Healthcare, formerly MedSolutions.

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