Post on 22-Aug-2020
401k Retirement SavingsThis benefit is a retirement savings plan employees can contribute to via payroll
deductions. To be eligible for this benefit, employees need to have worked for
Jacobson on assignment for one year and 1000 hours. Email
benefits@jacobsononline.com with any questions.
2019 Temporary Employee Benefits Package
Medical Insurance Options
• Talltree Administrators – Third Party Administrator www.talltreehealth.com (877) 453-4201• Optum RX – Pharmacy Benefit Manager (PBM) | www.optumrx.com• Sherppa – Telemedicine | www.sherpaa.com• Focus Health Solutions – Insurance Carrier• Multiplan’s PHCS Network – Provider, Hospital and Facility Network www.multiplan.com
Other Benefit Options
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) All MEC and MEC Plus Services $7,150 (individual) deductible Emergency Room and Inpatient Hospital Services (no day cap) Primary Care and Specialist visits Imaging, Laboratory Services, X-Rays and Diagnostic Imaging Certain Generic and Preferred Brand drugs TeleMed
Basic Preventativeand Wellness,Primary Care andSpecialist OfficeVisits (10 EachPer Year) Urgent Care
(3 Per Year) Basic Diagnostic
Services Inpatient Services
with Annual DayCap (NoDeductable) Outpatient Services
with Annual VisitCap (NoDeductable) Allergy Services and Home Health Care Perscriptions and TeleMed
All MEC PlusServices WithNo Office Visitor Urgent CareLimit Specialist
Office Visits(Exam orConsultation) Basic and Major
DiagnosticServices Emergency Room
(2 Per Year) Perscriptions and
TeleMed
Basic Preventativeand Wellness Primary Care
Office Visits (3 Per Year) Discount on
Specialist OfficeVisits, DiagnosticServices, andEmergency Room Urgent Care
(1 Per Year) Prescription
Drug Benefit TeleMed
Jacobson Benefit Timeline
2019 Benefit Deduction Schedule Deductions are taken once a month as follows:
Helpful Hints • You will need to provide the birthday(s) and social security number(s)
for your spouse/dependents at the time of enrollment.• If you end an assignment with Jacobson and begin a new assignment
within 13 weeks, you will be automatically enrolled in your previousbenefit selections.
• If you have any questions, please email benefits@jacobsononline.comor call (800) 466-1578 and ask for HR.
• You will recieve a link from Employee Navigator with instructions on how to register
Your first week on assignment
• You must accept, upgrade, or waive benefits
Within 30 days of your hire date
• Benefits are prepaid monthly. Deductions begin on the last paycheck before your benefiteffective date
Last week of the month before your effective date
• This is your benefit effective date. You will recieve benefit enrollment materials in the mailto the address provided to Jacobson.
First of the month following sixty days of employment
• This is the last day your benefits will be in effect.
The last day of the month of termination/assignment completion
Paycheck Date Pays For Benefits In December 27, 2018 January
January 31, 2019 February February 27, 2019 March March 28, 2019 April April 25, 2019 May May 30, 2019 June June 27, 2019 July July 25, 2019 August
August 29, 2019 September September 26, 2019 October October 31, 2019 November
November 28, 2019 December
2019 Benefit Costs All listed rates are monthly. Deductions are made on the last paycheck of the month to
prepay for the following month’s coverage.
MEC Plus Employee Only $106.00 per month
Employee + Spouse $161.00 per month Employee + Children $172.00 per month
Family $249.00 per month
MEC Enhanced Employee Only $184.00 per month
Employee + Spouse $376.00 per month Employee + Children $387.00 per month
Family $523.00 per month
Limited Day Medical Employee Only $298.00 per month
Employee + Spouse $656.00 per month Employee + Children $537.00 per month
Family $895.00 per month
MVP * Employee Only $398.00 per month
Employee + Spouse $718.00 per month Employee + Children $725.00 per month
Family $1,115.00 per month *Full time employees making less than $31.00 per hour may qualify for an employer subsidy for the MVP plan.
Applicable to employees making less than $31.00 per hour. Employees making more the $31.00 per hour will be responsible for the full cost of the plan.*
We hope you find our online enrollment tool simple and easy to use. We’ve broken the process down into five basic steps:
1. Receive your registration link2. Register3. Learn about your benefits and review your required tasks4. Enter personal information, select your enrollees and select your benefits5. Confirm your coverage and logout
Step 1: Receive your registration link
Within a week after your hire date you will receive a welcome email from noreply@employeenavigator.com with a registration link and instructions.
Step 2: Register
You will need to create a username, password and confirm the last 4 of your Social Security Number. Use your personal email address as your username. The Company Identifier is “jacobson”.
Benefit Enrollment Instructions via EmployeeNavigator.com
Tasks
Benefit Information
Step 3: Learn about your benefits and review your required tasks
• Learn About Your Benefits:o Under the “Compliance Documents” header you will see a link that directs you to a
summary of each benefit.
• Review Your Required Taskso Click the “go” button next to review the company’s Minimum Essential Coverage
Policy
Step 4: Enter personal information, select enrollees and select benefits
You must have your spouse/dependents’ social security number(s) and birthday(s) to enroll.
1) Click Start Benefits link to begin2) Add dependents3) Select enrollees4) Choose benefit5) When enrolling spouse/dependents, be sure the circle next to their names are checked.6) Click “save and continue” or “don’t want this benefit” to decline.
Questions? Email benefits@jacobsononline.com or call 800-466-1578 and ask for Human Resources.
Step 5: Confirm your coverage
Once you have gone through the benefit election process, a confirmation screen will appear showing you the benefits you elected and the cost that will be deducted from your paycheck each month (not a weekly deduction). Click “Agree” to confirm and finish.
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$28.07
2019Benefit Enrollment Guide
ENROLLMENT
You can enroll during your employer’s open enrollment period, during your new hire window or during a qualifying event.
If you are a new hire YOU MUST complete the enrollment process within 30 days from your hire date.
You can only make changes to your enrollment if you experience a qualifying event. A qualifying event is defined as a change in your status due to one of the following: marriage, divorce, birth or adoption, termination, loss of dependent and loss of prior coverage.
1)
2)
3)
IT IS OUR COMPANY POLICY THAT ALL EMPLOYEES COMPLETE THE ENROLLMENT PROCESS.
TO ENROLL?
Our 2019 health insurance offering aims at providing multiple benefit options for you and your family. Each plan delivers different levels of benefits designed to give you various coverage options corresponding to the respective premium.
All preventative mandated services
Primary Care office visits
Urgent Care
Telemedicine
Same as MEC Plus
Diagnostic Services(Basic and Major)
Emergency Room Benefit
Primary Care & Specialists
Inpatient and OutpatientHospital Benefit
Maternity Benefit
And More!
To remain compliant under the Healthcare Reform Employer Mandate, we offer twoMinimum Essential Coverage Plans (MEC’s) and a Limited Day Medical Plan. OurLimited Day Medical Plan is designed to give you the best possible benefits for thepremium. Additionally, a high dollar deductible Minimum Value Plan is beingoffered to further comply with the Affordable Care Act.
You may enroll during open enrollment, your new hire window or upon a qualifying event.
Understanding Your 2019 Health Insurance Options
BENEFIT
Please refer to the schedule of benefits on the next page.
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
MonthlyPremium
MEC Plus
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
MEC Enhanced
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Limited Day MedicalHEALTH INSURANCE OPTIONS
$106$161$172$249
MonthlyPremium
$184$376$387$523
MonthlyPremium
$298$656$537$895
PLAN FEATURES
CoveredServices MECPlus MECEnhanced LimitedDayMedical
ACAMandatedPreventiveandWellness
Coveredat100% Coveredat100% Coveredat100%
AnnualDeductible None None None
AnnualCo-pay/Co-insuranceandOutofPocketMaximums
Individual:$4,000Family:$7,500
Individual:$4,000Family:$7,500
Individual:$5,000Family:$10,000
OfficeVisitsandUrgentCare
OfficeVisits-PrimaryCare $20Co-Pay,Limitedto3VisitsAnnually
$20Co-Pay,NoLimit $15Co-Pay,Limitedto10VisitsAnnually
OfficeVisits-Specialist(ExamorConsultation)
ValuePointNetworkDiscount
$40Co-Pay,NoLimit $25Co-pay,Limitedto10VisitsAnnually
UrgentCare $50Co-Pay,Limitedto1VisitAnnually
$50Co-Pay,NoLimit $35Co-payLimitedto3VisitsAnnually
DiagnosticServices
DiagnosticServicesBasic-Labsandx-rays
ValuePointNetworkDiscount(asrelatedtoPrimaryCareVisit)
$50Co-Pay $50Co-Pay-Limitedto3VisitsAnnually
DiagnosticServicesMajor-MRI,CT,PET
ValuePointNetworkDiscount
$400Co-Pay Seebelowunder"OutpatientServices"
InpatientServices $350Co-PayPerDayPerInpatientStayforallCoveredServices
DailyIn-Hospital NoBenefit NoBenefit SubjecttoCo-Pay-Limitedto6DaysAnnually
InpatientPhysicianVisits NoBenefit NoBenefit SubjecttoCo-Pay-Limitedto6DaysAnnually
InpatientSurgery NoBenefit NoBenefit SubjecttoCo-Pay-Limitedto3DaysAnnually
Anesthesia NoBenefit NoBenefit SubjecttoCo-Pay-Limitedto3DaysAnnually
InpatientDiagnosticTesting-All NoBenefit NoBenefit IncludedasInpatientHospitalStayInpatientMentalHealth/SubstanceAbuse/ChemicalDependency
NoBenefit NoBenefit $100Co-Pay-Limitedto6DaysAnnually
Maternity NoBenefit NoBenefit IncludedasInpatientHospitalStay-Limitedto6daysAnnually
OutpatientServicesOutpatientHospitalServices NoBenefit NoBenefit $350Co-Pay-Limitedto2VisitsAnnuallyOutpatientSurgery NoBenefit NoBenefit $350Co-Pay-Limitedto2VisitsAnnuallyOutpatientAnesthesia NoBenefit NoBenefit $350Co-Pay-Limitedto2VisitsAnnuallyOutpatientDiagnosticServicesMajor-MRI,CT,PET
NoBenefit Seeaboveunder"DiagnosticServices"
$350Co-Pay-Limitedto2VisitsAnnually
OutpatientMentalHealth/SubstanceAbuse/ChemicalDependency
NoBenefit NoBenefit $25Co-pay-Limitedto10VisitsAnnually
EmergencyRoom/Services
EmergencyRoomValuePointNetworkDiscount
$400Co-Pay,Limitedto2VisitsAnnually.Maximum$1,000AnnualBenefit
$350Co-Pay,Limitedto1VisitAnnually
OtherServices
AllergyServices NoBenefit NoBenefit$25Co-Pay,IncludedinSpecialistOfficeVisit
HomeHealthCare NoBenefit NoBenefit $25Co-Pay,Limitedto30VisitsAnnuallyTelemedicine(www.Sherpaa.com) PlanPays100% PlanPays100% PlanPays100%
**Thisgridisdesignedtogiveyouahighlevelsidebysidecomparisonofyour3corehealthplans.ALLSERVICESBELOWARESHOWNASIN-NETWORKBENEFITS.ForadetailedlistingofeachplanpleaserefertoTheScheduleofBenefitsinthisenrollmentguide.TheLimitedDayBenefitPlanPaysat150%ofMedicare.
Group ID:FHINS
P.O. Box 1807Draper, Utah 84020Emdeon Payor ID: 88067Customer Service: 877-453-4201
Lifetime Max: None Network Providers Non-Network Providers Benefit Limits Per Calendar Year
Annual Deductibles
Does not include Co-pays.
In-network and Out-of-network are separate
accumulations and do not cross apply
Individual: NoneFamily: None
Individual: NoneFamily: None
Annual Co-pay and Co-Insurance
Out of Pocket Maximums
(Medical and Rx Co-pays apply to the annual out
of pocket maximums)
Individual $4,000Family $7,500
Individual: UnlimitedFamily: Unlimited
Office Visits - Primary Care(exam or consultation) $20 Co-pay, Plan pays 100% No Benefit Limited to 3 visits annually.
Office Visits - Specialist(exam or consultation) Network Discount Card applies No Benefit
Diagnostic Services - Basic labs/x-rays(related to office visit, LabCorp, etc.) Network Discount Card applies No Benefit Included on 3 visits annually.
Diagnostic Services - Major (Facility Charges)(MRI, CT, PET, Nuclear Medicine,etc.) Network Discount Card applies No Benefit
Diagnostic Services - Major (Physician Charges)(MRI, CT, PET, Nuclear Medicine,etc.) Network Discount Card applies No Benefit
Diagnostic Services - Minor(ultrasounds, bone density, ecography,etc) Network Discount Card applies No Benefit
Emergency Room Facilities Network Discount Card applies No Benefit
Emergency Room - All covered services other thanfacility charges Network Discount Card applies No Benefit
Urgent Care Center & 24 Hour Clinic $50 Co-pay, Plan pays 100% No Benefit Limited to 1 visit annually.
Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits
Office Visit Exam & Includes Services For: Plan pays 100% No Benefit Limited to preventive diagnosis only.
Abdominal Aortic Aneurysm Plan pays 100% No Benefit One time screening for males of ages65 to 75 who have ever smoked
Alcohol Misuse Screening and Counseling Plan pays 100% No Benefit
Aspirin use for Men and Women Plan pays 100% No BenefitA low-dose aspirin for prevention of cardiovascular
disease and colorectal cancer in adults aged 50-59 years(see plan document for further criteria)
Blood Pressure Screening Plan pays 100% No BenefitOne screening every two years for ages 18 to 39
One Screening per calendar year for ages 40 and over
Cholesterol Screening Plan pays 100% No Benefit
One screening per calendar year for men 35 and older.Men under 35 who have heart disease or risk factors
for heart disease or women who have heart disease orrisk factors for heart disease
Colorectal Cancer Screening Plan pays 100% No Benefit Screening for adults over age 50
Schedule of Medical Benefits
PHCS Specific Services Network
Insurance Staffers
Enhanced Minimum Essential Coverage (MEC Plus) Plan
PPO Provider Network:
Minimum weekly hours for full time: 30 hours/130 per month
Covered Preventive Services for Adults as defined by CMS Preventive Services
Option ID: INS9I
Limits are per person per calendar year
Beginning on January 1 and ending on December 31
This Plan provides Minimal Essential Coverage for Medical Care.
If the service is not listed on this Schedule of Benefits it is not covered. Claims Address
Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination.
Depression Screening Plan pays 100% No Benefit Screening for depression in the general adult population,including pregnant and postpartum women.
Type 2 Diabetes Screening Plan pays 100% No Benefit Screening for adults with high blood pressure only
Diet Counseling Plan pays 100% No Benefit Screening for adults at higher risk of chronic disease
Hepatitis B Screening Plan pays 100% No Benefit
For members at high risk, including members in countries with 2% or more Hepatitis B prevalence, andU.S. Born people not vaccinated as infants and with at
least on parent born in a region with 8% or moreHepatitis B prevalence
Hepatitis C Screening Plan pays 100% No Benefit For adults at increased risk, and one time for everyoneborn between 1945 - 1965
HIV Screening Plan pays 100% No Benefit Screening for adults at higher risk
Immunizations* Hepatitis A* Hepatitis B* Herpes Zoster* Human Papillomavirus* Influenza (Flu Shot)* Measles, Mumps, Rubella* Meningococcal* Pneumococcal* Tetanus, Diphtheria, Pertussis* Varicella
Plan pays 100% No BenefitListed immunizations are once per calendar year.
Human Papillomavirus shots up to age 26.Pneumococcal shots for adults 65 and older
Latent Tuberculosis Infection Plan pays 100% No Benefit Screening for latent tuberculosis infection (LTBI) inpopulations at increased risk
Lung Cancer Screening Plan pays 100% No Benefit For adults 55 - 80 at high risk for lung cancer becausethey're heavy smokers or have quit in the past 15 years
Obesity Screening and Counseling Plan pays 100% No Benefit
Sexually Transmitted Infection (STI)Screening and Counseling Plan pays 100% No Benefit Prevention counseling for adults at higher risk
Statin Plan pays 100% No Benefit
Adults aged 40-75 years with no history ofcardiovascular disease (CVD) use a low-to moderate-
dose statin for the prevention of CVD events andmortality when they have one or more cardiovascular
disease risk factors, and a calculated 10-year CVD eventrisk of 10% or greater; screening for cardiac risk may
include assessment of blood pressure smoking status,screening for lipid disorders and use of ACC/AHA CVD
to estimate 10-year risk
Syphilis Screening Plan pays 100% No Benefit For all adults at higher risk
Tobacco Use Screening Plan pays 100% No Benefit Screenings for adults and cessationinterventions for tobacco users
Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits
Well-Women Visits Plan pays 100% No Benefit
Anemia Screening Plan pays 100% No Benefit For pregnant women
BRCA Counseling Plan pays 100% No Benefit Includes genetic test for women at high risk
Breast Cancer Mammography Screening Plan pays 100% No BenefitScreenings every 1 to 2 years for
women over 40 through age 74. (see plan document forfurther criteria)
Breast Cancer Chemoprevention Counseling Plan pays 100% No Benefit Counseling for women at high risk
Breastfeeding Consultations Plan pays 100% No Benefit
Providing interventions during pregnancy and after birthto support breastfeeding. Comprehensive support andcounseling from trained providers, as well as access to
breastfeeding supplies, for pregnant and nursing women.
Covered Preventive Services for Women - Including Pregnant Women
Cervical Cancer Screening Plan pays 100% No Benefit
For ages 21-29, PAP smear every 3 years
For ages 30-65, with cytology and human papillomavirustesting (HPV) with Pap smear every 5 years or a regular
cytology alone (without HPV testing) every 3 years
Women with an average risk shouldn’t be screened more than once every 3 years
Chlamydia Infection Screening Plan pays 100% No Benefit For younger women and women at high risk
Contraception Plan pays 100% No Benefit
Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education
and counseling, not including abortifacient drugs.Counseling and follow-up care are included with this
benefit. Birth control pills will be covered under your Rxbenefits.
Depression Screening Plan pays 100% No Benefit Screening for depression in the general adult population,including pregnant and postpartum women
Domestic and Interpersonal Violence Screening Plan pays 100% No Benefit
Annual screening for women to obtain a referral to initial intervention services, which include counseling,
education, harm reduction strategies and referral toappropriate support services.
Folic Acid Supplements Plan pays 100% No Benefit All women who are planning or capable of pregnancytake a daily supplement containing 0.4-0.8mg
Gestational Diabetes Screening Plan pays 100% No BenefitFor women 24 to 28 weeks pregnant and / or at
high risk of developing gestational diabetes should bescreened prior to 24 weeks of gestation
Gonorrhea Screening Plan pays 100% No Benefit For all women at higher risk
Hepatitis B Screening Plan pays 100% No Benefit For pregnant women at their first prenatal visit
Human Immunodeficiency Virus (HIV)Screening and counseling Plan pays 100% No Benefit For women sexually active
Human Paillomavirus (HPV) DNA Test Plan pays 100% No Benefit One test every 3 years for woment withnormal cytology results who are 30 or older
Osteoporosis Screening Plan pays 100% No Benefit For women over age 60 or at high risk
Preeclampsia Plan pays 100% No Benefit Screening for preeclampsia in pregnant women withblood pressure measurements throughout pregnancy
Rh Incompatibility Screening Plan pays 100% No Benefit For pregnant women and follow-up testingfor women at higher risk
Tobacco Use Screening and interventions Plan pays 100% No Benefit
Syphilis Screening Plan pays 100% No Benefit For all pregant woment or other women at increase risk
Sexually Transmitted Infection (STI) and Sexually transmitted Diseases (STD) Screening andcounseling, includes Gonorrhea & Syphilis Screening
Plan pays 100% No Benefit For sexually active women
Urinary Tract or Other Infection Screening forPregnant Women Plan pays 100% No Benefit
Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits
Alcohol and Drug Use Assessments Plan pays 100% No Benefit
Autism Screening Plan pays 100% No Benefit For children at 18 months to 24 months
Behavioral Assessments Plan pays 100% No Benefit For children to age 18
Blood Pressure Screening Plan pays 100% No Benefit For children to age 18
Cervical Dysplasia Screening Plan pays 100% No Benefit For sexually active females
Congenital Hypothyroidism Screening Plan pays 100% No Benefit For newborns
Contraception Plan pays 100% No Benefit
Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education
and counseling, not including abortifacient drugs.Counseling and follow-up care are included with this
benefit. Birth control pills will be covered under your Rxbenefits.
Covered Preventive Services for Children
Depression Screening Plan pays 100% No Benefit Screening for major depressive disorder (MDD) inadolescents aged 12 to 18 years
Developmental Screening Plan pays 100% No Benefit For children under age 3 andsurveillance throughout childhood
Dyslipidemia Screening Plan pays 100% No Benefit For children at high risk of lipid disorders
Fluoride Chemoprevention Supplements Plan pays 100% No Benefit For children without fluoride in their water sources
Gonorrhea Preventive Medicaiton for the Eyes of AllNewborns Plan pays 100% No Benefit
Hearing Screenings Plan pays 100% No Benefit For all newborns
Height, Weight and Body Mass Index Measurements Plan pays 100% No Benefit For children to age 18
Hematocrit or Hemoglobin Screening Plan pays 100% No Benefit For children to age 18
Hemoglobinopathies of Sickle Cell Screening Plan pays 100% No Benefit For all newborns
HIV Screening Plan pays 100% No Benefit For sexually active children
Hypothyroidism Screening for Newborns Plan pays 100% No Benefit
Immunizations:* Acellular Pertussis* Diphtheria, Tetanus, Pertussis* Haemophilus influenza type B* Hemophilia* Hepatitis A* Hepatitis B* Human Papillomavirus* Inactivated Poliovirus* Influenza (Flu Shot)* Measles, Mumps, Rubella* Meningococcal* Meningococcal B Vaccine* Pneumococcal* Rotavirus* Varicella
Plan pays 100% No Benefit For children to age 18
Interpersonal and Domestic Violence Screening Plan pays 100% No Benefit
Annual screening for women to obtain a referral to initial intervention services, which include counseling,
education, harm reduction strategies and referral toappropriate supportive services.
Iron Supplements Plan pays 100% No Benefit For children ages 6 to 12 months at risk of anemia
Lead Screening Plan pays 100% No Benefit For children at risk of exposure
Medical History Plan pays 100% No Benefit For all children throughout development
Obesity Plan pays 100% No Benefit
Screening for obesity in children and adolescents sixyears and older and offer to refer them to
comprehensive, intensive behavioral interventions topromote improvements in weight status
Oral Health Plan pays 100% No Benefit At risk assessment for your childrenages newborn to age 10
Phenylketonuria (PKU) Screening Plan pays 100% No Benefit For genetic disorders in newborns
Sexually Transmitted Infection (STI) and Sexually Transmitted Diseases (STD)Screening and Counseling
Plan pays 100% No Benefit For children at higher risk, includes gonorrhea preventivemedication for newborn eyes
Syphilis Screening Plan pays 100% No Benefit For all adolescents at higher risk
Tuberculin Testing Plan pays 100% No Benefit For children at higher risk of tuberculosis to age 18
Vision Screening Plan pays 100% No Benefit screening at least once in all children ages three to fiveyears to detect amblyopia or its risk factors
Prescription Benefits
Covered Prescription Drugs - OptumRx
Customer Service: 1-844-265-1719
Pre-Auth Line: 1-844-265-1719
Rx Bin:610011
Rx PCN: IRX
Rx GROUP: FH2FHTT
Generic Prescriptions <$9.99 = 100% coinsurance
Generic Prescriptions >$10 = 45% coinsurance
Brand Name Prescriptions = No Benefit
No Benefit
Specialty Medications: No Benefit
All prescriptions are limited to 31 day supply
Insulin and Rescue inhalers are covered.
$600 benefit maximum per family per year.
Telemedicine
Sherpaa Go to www.sherpaa.com for more information.
Effective: 1/1/2019
No Pre-existing for employees or dependents.
Dependents are covered to age 26 regardless of student or marital status.Timely Filing: Claims must be filed within 6 months from the date the service incurred. Life Threatening services incurred at an out of network provider will be paid in network. Pre-existing is not applicable for any member of the Plan.Coordination of benefits - Non duplicating meaning this Plan will not pay in excess of the normal plan benefit in absence of other insurance.
We believe this coverage is a non grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA)
Visit www.talltreehealth.com to view the Plan Document, Schedule of Benefits, enrollment information, your claims history, link to the PPO network and more.All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a guarantee of payment.
Rural Area is defined as 30 miles. If preventive services are not available within 30 miles of your residence the provider will be paid in network.
Note: Any non-allowed or not covered amounts or services are the responsibility of the patient and are not included in the Out-of-Pocket Maximum.
Plan pays 100%
Out of Country services will be paid as a in-network for covered medical emergencies only, to a maximum of $15,000 of billed charges.
Group ID: FHINS
Claims Address
P.O. Box 1807 PPO Provider Network:Draper, Utah 84020 PHCS Specific Services NetworkEmdeon Payor ID: 88067Customer Service: 877-453-4201
Lifetime Max: None Network Providers Benefit Limits Per Calendar Year
Annual Deductibles
Does not include Co-pays.
In-network and Out-of-network are separate accumulations
and do not cross apply
Individual: None Family: None
Annual Co-pay and Co-Insurance Out of Pocket Maximums
(Medical and Rx Co-pays apply to the annual out of pocket
maximums)Individual $7,150 Family $14,300
Office Visits - Primary Care (exam or consultation)$20 Co-pay, Plan pays 100%
Office Visits - Specialist (exam or consultation)$40 Co-pay, Plan pays 100%
Diagnostic Services - Basic labs/x-rays (related to office visit, LabCorp, etc.) $50 Co-pay, Plan pays 100%
Diagnostic Services - Major (Facility Charges) (MRI, CT, PET, Nuclear Medicine,etc.)
$400 Co-pay, Plan pays 100% of allowed amount
Diagnostic Services - Major (Physician Charges) (MRI, CT, PET, Nuclear Medicine,etc.) Plan pays 100% of allowed amount
Diagnostic Services - Minor(ultrasounds, bone density, ecography,etc) $50 Co-pay, Plan pays 100%
Emergency Room Facilities$400 Co-pay, Plan pays 100%
Emergency Room - All covered services other than facility charges $400 Co-pay, Plan pays 100%
Urgent Care Center & 24 Hour Clinic$50 Co-pay, Plan pays 100%
Wellness Office Visits and Lab Services Network Providers Benefit Limits
Office Visit Exam & Includes Services For:Plan pays 100% Limited to preventive diagnosis only.
Abdominal Aortic AneurysmPlan pays 100% One time screening for males of ages 65 to 75 who have ever
smoked
Alcohol Misuse Screening and CounselingPlan pays 100%
Aspirin use for Men and WomenPlan pays 100%
A low-dose aspirin for prevention of cardiovascular disease and colorectal cancer in adults aged 50-59 years (see plan document for
further criteria)Blood Pressure Screening
Plan pays 100% One screening every two years for ages 18 to 39One Screening per calendar year for ages 40 and over
Cholesterol Screening Plan pays 100%One screening per calendar year for men 35 and older. Men under 35
who have heart disease or risk factors for heart disease or women who have heart disease or risk factors for heart disease
Colorectal Cancer ScreeningPlan pays 100% Screening for adults over age 50
Depression ScreeningPlan pays 100% Screening for depression in the general adult population, including
pregnant and postpartum women.
Type 2 Diabetes ScreeningPlan pays 100% Screening for adults with high blood pressure only
This Plan provides Minimal Essential Coverage for Medical Care.
If the service is not listed on this Schedule of Benefits it is not covered.
Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination.Minimum weekly hours for full time: 30 hours/130 per month
Non-Network Providers
Individual $500Family $1,000
All benefits and accumulations are on a Calendar Year.
Individual: Unlimited Family: Unlimited
Deductible, Plan pays 60% of allowed amount
Deductible, Plan pays 60% of allowed amount
Deductible, Plan pays 60% of allowed amount
$400 Co-pay, Plan pays 60% of allowed amount
Deductible, Plan pays 60% of allowed amount
Deductible, Plan pays 60% of allowed amount
$400 Co-pay, Plan pays 100% of allowed amount Limited to 2 visits per year.
Maximum: $1,000No Benefit
Deductible, Plan pays 60% of allowed amount
Covered Preventive Services for Adults as defined by CMS Preventive ServicesNon-Network Providers
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Insurance Staffers
Minimum Essential Coverage (Enhanced MEC) PlanSchedule of Medical Benefits
Option ID: INS9C
Diet CounselingPlan pays 100% Screening for adults at higher risk of chronic disease
Hepatitis B Screening
Plan pays 100%
For members at high risk, including members in countries with 2% or more Hepatitis B prevalence, and
U.S. Born people not vaccinated as infants and with at least on parent born in a region with 8% or more
Hepatitis B prevalence
Hepatitis C ScreeningPlan pays 100% For adults at increased risk, and one time for everyone born between
1945 - 1965
HIV ScreeningPlan pays 100% Screening for adults at higher risk
Immunizations* Hepatitis A* Hepatitis B* Herpes Zoster* Human Papillomavirus* Influenza (Flu Shot)* Measles, Mumps, Rubella* Meningococcal* Pneumococcal* Tetanus, Diphtheria, Pertussis* Varicella
Plan pays 100% Listed immunizations are once per plan year. Human Papillomavirus shots up to age 26. Pneumococcal shots for adults 65 and older
Latent Tuberculosis Infection Plan pays 100% Screening for latent tuberculosis infection (LTBI) in populations at increased risk
Lung Cancer ScreeningPlan pays 100% For adults 55 - 80 at high risk for lung cancer because they're heavy
smokers or have quit in the past 15 years
Obesity Screening and CounselingPlan pays 100%
Sexually Transmitted Infection (STI) Screening and CounselingPlan pays 100% Prevention counseling for adults at higher risk
Statin Plan pays 100%
Adults aged 40-75 years with no history of cardiovascular disease (CVD) use a low-to moderate-dose statin for the prevention of CVD events and mortality when they have one or more cardiovascular
disease risk factors, and a calculated 10-year CVD event risk of 10% or greater; screening for cardiac risk may include assessment of
blood pressure smoking status, screening for lipid disorders and use of ACC/AHA CVD to estimate 10-year risk
Syphilis Screening Plan pays 100% For all adults at higher risk
Tobacco Use Screening Plan pays 100% Screenings for adults and cessation interventions for tobacco users
Wellness Office Visits and Lab Services Network Providers Benefit Limits
Well-Women Visits Plan pays 100%
Anemia Screening Plan pays 100% For pregnant women
BRCA Counseling Plan pays 100% Includes genetic test for women at high risk
Breast Cancer Mammography Screening Plan pays 100%Screenings every 1 to 2 years for
women over 40 through age 74. (see plan document for further criteria)
Breast Cancer Chemoprevention Counseling Plan pays 100% Counseling for women at high risk
Breast Pumps Plan pays 100% One per delivery. Purchase Breast Pump at a local retail store and submit the receipt for reimbursement
Breastfeeding Consultations Plan pays 100%
Providing interventions during pregnancy and after birth to support breastfeeding. Comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant
and nursing women.
Cervical Cancer Screening Plan pays 100%
For ages 21-29, PAP smear every 3 years
For ages 30-65, with cytology and human papillomavirus testing (HPV) with Pap smear every 5 years or a regular cytology alone
(without HPV testing) every 3 years
Women with an average risk shouldn’t be screened more than once every 3 years
Chlamydia Infection Screening Plan pays 100% For younger women and women at high risk
Contraception Plan pays 100%
Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs. Counseling and follow-up care are included with this benefit. Birth control pills will be covered under
your Rx benefits.
Depression Screening Plan pays 100% Screening for depression in the general adult population, including pregnant and postpartum women
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Covered Preventive Services for Women - Including Pregnant WomenNon-Network Providers
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Domestic and Interpersonal Violence Screening Plan pays 100%Annual screening for women to obtain a referral to initial intervention
services, which include counseling, education, harm reduction strategies and referral to appropriate support services.
Folic Acid Supplements Plan pays 100% All women who are planning or capable of pregnancy take a daily supplement containing 0.4-0.8mg
Gestational Diabetes Screening Plan pays 100%For women 24 to 28 weeks pregnant and / or at
high risk of developing gestational diabetes should be screened prior to 24 weeks of gestation
Gonorrhea Screening Plan pays 100% For all women at higher risk
Hepatitis B Screening Plan pays 100% For pregnant women at their first prenatal visit
Human Immunodeficiency Virus (HIV) Screening and counseling Plan pays 100% For women sexually active
Human Paillomavirus (HPV) DNA Test Plan pays 100% One test every 3 years for woment with normal cytology results who are 30 or older
Osteoporosis Screening Plan pays 100% For women over age 60 or at high risk
Preeclampsia Plan pays 100% Screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy
Rh Incompatibility Screening Plan pays 100% For pregnant women and follow-up testing for women at higher risk
Tobacco Use Screening and interventions Plan pays 100%
Syphilis Screening Plan pays 100% For all pregant woment or other women at increase risk
Sexually Transmitted Infection (STI) and Sexually transmitted Diseases (STD) Screening and counseling, includes Gonorrhea & Syphilis Screening
Plan pays 100% For sexually active women
Urinary Tract or Other Infection Screening for Pregnant Women Plan pays 100%
Wellness Office Visits and Lab Services Network Providers Benefit LimitsAlcohol and Drug Use Assessments
Plan pays 100%
Autism ScreeningPlan pays 100%
For children at 18 months to 24 months
Behavioral AssessmentsPlan pays 100%
For children to age 18
Blood Pressure ScreeningPlan pays 100%
For children to age 18
Cervical Dysplasia ScreeningPlan pays 100%
For sexually active females
Congenital Hypothyroidism ScreeningPlan pays 100%
For newborns
Contraception Plan pays 100%
Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs. Counseling and follow-up care are included with this benefit. Birth control pills will be covered under
your Rx benefits.
Depression Screening Plan pays 100% Screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years
Developmental Screening Plan pays 100% For children under age 3 and surveillance throughout childhood
Dyslipidemia Screening Plan pays 100% For children at high risk of lipid disorders
Fluoride Chemoprevention Supplements Plan pays 100% For children without fluoride in their water sources
Gonorrhea Preventive Medicaiton for the Eyes of All Newborns Plan pays 100%
Hearing Screenings Plan pays 100% For all newborns
Height, Weight and Body Mass Index Measurements Plan pays 100% For children to age 18
Hematocrit or Hemoglobin Screening Plan pays 100% For children to age 18
Hemoglobinopathies of Sickle Cell Screening Plan pays 100% For all newborns
HIV Screening Plan pays 100% For sexually active children
Hypothyroidism Screening for Newborns Plan pays 100%
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Covered Preventive Services for ChildrenNon-Network Providers
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Immunizations: * Acellular Pertussis * Diphtheria, Tetanus, Pertussis * Haemophilus influenza type B * Hemophilia * Hepatitis A * Hepatitis B * Human Papillomavirus * Inactivated Poliovirus * Influenza (Flu Shot) * Measles, Mumps, Rubella * Meningococcal * Meningococcal B Vaccine * Pneumococcal * Rotavirus * Varicella
Plan pays 100% For children to age 18
Interpersonal and Domestic Violence Screening Plan pays 100%Annual screening for women to obtain a referral to initial intervention
services, which include counseling, education, harm reduction strategies and referral to appropriate supportive services.
Iron Supplements Plan pays 100% For children ages 6 to 12 months at risk of anemia
Lead Screening Plan pays 100% For children at risk of exposure
Medical History Plan pays 100% For all children throughout development
Obesity Plan pays 100%Screening for obesity in children and adolescents six years and older
and offer to refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status
Oral Health Plan pays 100% At risk assessment for your children ages newborn to age 10
Phenylketonuria (PKU) Screening Plan pays 100% For genetic disorders in newborns
Sexually Transmitted Infection (STI) Screening and Counseling Plan pays 100% For children at higher risk, includes gonorrhea preventive medication for newborn eyes
Syphilis Screening Plan pays 100% For all adolescents at higher risk
Tuberculin Testing Plan pays 100% For children at higher risk of tuberculosis to age 18
Vision Screening Plan pays 100% screening at least once in all children ages three to five years to detect amblyopia or its risk factors
Covered Prescription Drugs - OptumRx
Customer Service: 1-844-265-1719
Pre-Auth Line: 1-844-265-1719
Rx Bin: 610011
Rx PCN: IRX
Rx GROUP: FH2FHTT
Generic Prescriptions <$9.99 = 100% coinsurance
Generic Prescriptions >$10 = 45% coinsurance
Brand Name Prescriptions = No Benefit
Specialty Medications: No Benefit
All prescriptions are limited to 31 day supply
Insulin and Rescue inhalers are covered.
$600 benefit maximum per family per year.
Sherpaa Go to www.sherpaa.com for more information.
Effective: 01/01/2019
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
Plan pays 100%
Prescription Benefits
No Benefit
Telemedicine
Deductible, Plan pays 40% of allowed amount
Deductible, Plan pays 40% of allowed amount
All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a
guarantee of payment.
Claims are determined upon receipt of the claim and any additional information required to make a benefit determination.
Note: Any non-allowed or not covered amounts or services are the responsibility of the patient and are not included in the Out-of-PocketMaximum.Dependents are covered to age 26 regardless of student or marital status.
Timely Filing: Claims must be filed within 6 months from the date the service incurred. Life Threatening services incurred at an out ofnetwork provider will be paid in network. Pre-existing is not applicable for any member of the Plan.
Coordination of benefits - Non duplicating meaning this Plan will not pay in excess of the normal plan benefit in absence of other insurance. Rural Area is defined as 30 miles. If preventive services are not available within 30 miles of your residence the provider will be paid in network.No Pre-existing for employees or dependents. Out of Country services will be paid as a in-network for covered medical emergencies only, to a maximum of $15,000 of billed charges.We believe this coverage is a non grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA)
Visit www.talltreehealth.com to view the Plan Document, Schedule of Benefits, enrollment information, your claims history, link to the PPO network and more.
Group ID: FHINS
* Pre-Certification: Arizona Foundation - FoundationUM (AZF) 833-291-2519
Claims Address:P.O. Box 1807 PPO Provider Network:Draper, Utah 84020 Physicians: PHCS- Specific Services NetworkEmdeon Payor ID: 88067 Facilities: 150% of MedicareCustomer Service: 877-453-4201
Minimum hours for full time: 130 per month/30 per weekLifetime Max: None Network Providers Non-Network Providers Benefit Limits Per Calendar Year
Annual Deductibles
Does not include Co-pays.
In-network and Out-of-network are separate
accumulations and do not cross apply
Individual: NoneFamily: None No Benefit
Annual Co-pay and Co-Insurance
Out of Pocket Maximums
(Medical and Rx co-pays apply to the annual out
of pocket maximums)
Individual: $5,000Family: $10,000 No Benefit
Office Visits - Primary Care(exam or consultation) $15 Co-pay, Plan pays 100% No Benefit Limited to 10 visits per calendar year
Office Visits - Specialist(exam or consultation) $25 Co-pay, Plan pays 100% No Benefit Limited to 10 visits per calendar year
Office Services - basic services with exam(does not include pain management, chemo, surgical services)
Plan pays 100% No Benefit
Telemedicine through Sherpaa Go to www.sherpaa.com for more information.
Wellness Care - Adult Plan pays 100% No Benefit
Wellness Care - Children Plan pays 100% No Benefit
Allergy Services Covered 100% after Specialist Office Visit Co-pay No Benefit
Ambulance(Ground Services Only) $250 copay, Plan pays 100% No Benefit Limited to 1 visit per calendar year
Birth Control / IUD No Benefit No Benefit
Breast Pumps One per delivery. Purchase Breast Pump at a local retail store and submit the receipt for reimbursement
Chemical Dependency - Inpatient
Limited to 6 days per calendar year
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
Chemical Dependency - Outpatient $25 copay, Plan pays 100% No Benefit Limited to 6 visits per calendar year
Chemotherapy / Radiation Therapy No Benefit No Benefit
Chiropractic Services No Benefit No Benefit
Colonoscopy (For Medical Reasons) No Benefit No Benefit
Diagnostic Services - Basic labs/x-rays(related to office visit, LabCorp, etc.) $50 Co-pay, Plan pays 100% No Benefit Limited to 3 visits per calendar year
Diagnostic Services - Major(MRI, CT, PET, Nuclear Medicine,etc.)
Covered 100% after Outpatient Services Co-pay No Benefit Limited to 2 visits per calendar year
Diagnostic Services - Minor (ultrasounds, bone density, echography, etc) $350 copay, Plan pays 100% No Benefit Limited to 2 visits per calendar year
Diabetic Education No Benefit No Benefit
Dialysis No Benefit No Benefit
Durable Medical Equipment(includes orthotics & prosthetics) No Benefit No Benefit
Emergency Room Facilities
Limited to 1 visit per calendar year
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
Emergency Room - All covered services other than facility charges
Plan pays 100% after $350 Co-pay No Benefit Limited to 1 visit per calendar year
Gastric Bypass Surgery / Lap Banding No Benefit No Benefit
Home Health Care $25 copay, Plan pays 100% No Benefit Limited to 30 visits per calendar year
Hospice Care No Benefit No Benefit
Insurance Staffers
Plan pays 100%
$350 copay, Plan pays 100% (Plan payment based on 150% of Medicare Allowable Payment)
Limited Day Medical Plan 7 Schedule of Medical Benefits
Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination.
Plan pays 100%
$100 copay, Plan pays 100%, (Plan payment based on 150% of Medicare Allowable Payment)
This Plan provides Minimal Value Coverage for Medical Care.
If the service is not listed on this Schedule of Benefits it is not covered.
Limits are per person per calendar year.
Beginning January 1 and ending December 31.
Wellness Care includes, but not limited to: pap smear, mammogram, prostate screening, gynecological exam, routine physical exam, routine vision exam for children, routine hearing exam for children, immunizations and related laboratory blood tests, colonoscopies. Other preventive services as identified by the Patient Protection and Affordable Care Act (PPACA) will be covered.
AZF * Hospital Facility - Inpatient Services
Limited to 6 days per calendar year
* Pre Certification Required. Failure to obtain Pre Certification may result in a reduction of $250 or denial of benefits.
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
Hospital - Inpatient Surgery Covered 100% after Inpatient Services Co-pay No Benefit
Limited to 3 days per calendar year
* Pre Certification Required for inpatient services Attending Physician and Surgeon charges during an inpatient hospital confinement
Covered 100% after Inpatient Services Co-pay No Benefit Limited to 6 days per calendar year
Anesthesiologist charges during an inpatient hospital confinement
Covered 100% after Inpatient Services Co-pay No Benefit Limited to 3 days per calendar year
Hospital - Outpatient Services(any charge billed from a hospital)
Limited to 2 visits per calendar year
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
Hospital - Outpatient Surgery Covered 100% after Outpatient Services Co-pay No Benefit Limited to 3 days per calendar year
Attending Physician, Surgeon and Anesthesiologist charges during an outpatient hospital confinement
Covered 100% after Outpatient Services Co-pay No Benefit Limited to 3 days per calendar year
Infertility Services No Benefit No Benefit
Maternity - Prenatal Office Visits Only (billed separately from total delivery) Plan pays 100% No Benefit
Maternity - (Labs, x-rays, ultrasounds and related covered services) No Benefit No Benefit
* Maternity - Facility Covered 100% after Inpatient Services Co-pay No Benefit
Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement
Covered 100% after Inpatient Services Co-pay No Benefit
Medical Supplies (Including but not limited to: Insulin, Diabetic test strips, Insulin pumps, etc.) These supplies may also be covered under Prescription Benefit.
No Benefit No Benefit
AZF * Mental Health - Inpatient
Limited to 10 days per calendar year
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
Mental Health - Outpatient $25 copay, Plan pays 100% No Benefit Limited to 6 visits per calendar year
Outpatient TherapyPhysical, Speech and Occupational No Benefit No Benefit
Outpatient Surgery performed in an office or urgent care facility No Benefit No Benefit
Skilled Nursing No Benefit No Benefit
Sleep Studies No Benefit No Benefit
Sterilization for Women Plan pays 100% No Benefit
Sterilization for Men No Benefit No Benefit
TMJ and Orthognathic No Benefit No Benefit
Transplant Facility No Benefit No Benefit
Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement No Benefit No Benefit
Urgent Care Center & 24 Hours $35 Co-pay, Plan pays 100% No Benefit Limited to 3 visits per calendar year
Covered Prescription Drugs - OptumRx
Customer Service: 1-844-265-1719
Pre-Auth Line: 1-844-265-1719
Rx Bin: 610011
Rx PCN: IRX
Rx GROUP: FH2FHTT
Generic Prescriptions: 20% Coinsurance per drug
Brand Prescriptions: No Benefit
No Benefit
Specialty Medications: No Benefit
All prescriptions are limited to 31 day supply
Plan maximum is $100 per drug and covers retail only
Effective: 1/1/2019
** Payment will be capped at 150% of the Medicare Allowable Payment. If provider does not accept the Medicare Allowable Amount, patient may be
balance billed.
$350 Co-pay, Plan pays 100% (Plan payment based on 150% of Medicare Allowable Payment)
$350 copay, Plan pays 100% (Plan payment based on 150% of Medicare Allowable Payment)
Coordination of benefits - Non duplicating meaning this Plan will not pay in excess of the normal plan benefit in absence of other insurance.
$100 copay, Plan pays 100%, (Plan payment based on 150% of Medicare Allowable Payment)
No Pre-existing for employees or dependents.
Note: Any non-allowed or not covered amounts or services are the responsibility of the patient and are not included in the Out-of-Pocket Maximum.
Timely Filing - Claims must be filed within 12 months from the date of service.
Visit www.talltreehealth.com to view the Plan Document, Schedule of Benefits, enrollment information, your claims history, link to the PPO network and more.
Out of Country services will be paid as a in-network for covered medical emergencies only, to a maximum of $15,000 of billed charges.
Rural Area is defined as 30 miles. If covered services are not available in the network within 30 miles the provider will be paid in network.
Dependents are covered to age 26 regardless of student or marital status.
* Pre Certification Required. Failure to obtain Pre Certification may result in a reduction of $250 or denial of benefits.
All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a guarantee of payment.
Claims are determined upon receipt of the claim and any additional information required to make a benefit determination.
Prescription Benefits
We believe this coverage is a non grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA)
ABOUT MY BENEFITS
Q1. What does the “Network Discount Card Applies” mean in the MEC Plus?
The MEC Plus does not cover services that state “Network Discount Card Applies". The Value Point program allows you to access the Multiplan Network (same network in your MEC Plus) for the “discounted provider” rate. You get to pay the discounted provider rate – i.e. the contractual rate your provider (Doctor) has with the network (Multiplan) - https://www.multiplan.com/providers/valuepoint_faq.cfmKeep in mind; You will receive a separate Value Point Card.
Q2. What is Minimum Essential Coverage and why are there 2 options?
Minimum Essential Coverage is a required mandatory offering under the Affordable Care Act’s Employer Mandate provision. We offer a MEC Plus and MEC Enhanced in order to increase the level of benefits and give you more options.
Q3. How does my prescription drug coverage work?
All health plans use Optum RX as the prescription vendor or PBM (Pharmacy Benefit Manager). Each plan has different levels of restrictions based on the plan’s premium. Please refer to the RX documents in this enrollment guide for more information.
Q4. What is the Limited Day Medical Benefit (LDM)?
The LDM is designed to give you the best possible benefit for the lowest premium. Along with the lowest premium come certain benefits and certain limitations. The LDM offers “first dollar coverage” – meaning you don’t have to meet a deductible for you to receive benefits under the plan. The plancovers hospital inpatient, outpatient, surgery, maternity benefits and more. However, the plan limitsthe days and/or visits for each benefit. Please refer to the schedule of benefits to understand thelimits.
AMERICAN MEDICAL PLAN
PROVIDER NETWORKS &CONTACT INFORMATION
Understanding Your Provider Networks and Who to Contact
Medical Network - https://www.multiplan.com/webcenter/portal/ProviderSearchAll our medical plans use the PHCS Network through Multiplan. This is considered your in-network benefit for physician and facility (I.E. Doctors and Hospitals). The link below will help you find an in-network provider.
Pharmacy – RX Coverage - www.OptumRx.comOptum RX manages the Pharmacy Benefit Management (PBM) component of your health plan. Please refer to the Optum handouts in this guide to better manage your
Telemedicine - https://www.sherpaa.comAll medical plans come with a telemedicine service that allows you to communicate with a Doctor.
Talltree Administrators - http://www.talltreehealth.comTalltree provides the function of day to day support. Talltree can help with missing ID cards, change of address and other customer service functions.877.453.4201
AMERICAN MEDICAL PLAN
More and more employers are adopting consumer-driven healthcare programs to replace or complement their
traditional insurance benefit plans. aluePoint by MultiPlan® is a medical access card program designed to help you reach
this growing population of consumers. Participating providers have specifically agreed to extend their MultiPlan Networ contracted discounts to your eligible members in exchange for payment in full by the member at the point of service.
ValuePoint by MultiPlan
®
Imagine more…
Imagine the best of an insurance-based PPO network tailored for non-insurance programs.
What It Offers Who Should Use It How It Works
• Provider Choice
o 1,300 hospitals
o 60,000 ancillary facilities
o 450,000 practitioner locations
• Savings
o National average savings of 39%for practitioner claims
o National average savings of 28%for ancillary facilities
o National average hospital savingsof 22% for inpatient claims, 21% for outpatient claims
• Programs like shopping clubs thatmay want to partially subsidize fees
• Employers who want a fully orpartially funded alternative totraditional plans
• Employers who want to complementa limited benefit pla
• Employers who want to complementa consumer-directed health plan witha fund or account like an FSA, HRA or HSA
• Member chooses a provider fromonline or telephone directory
• You confirm member eligibility witID card, letter or phone call
• Member presents his/her memberID card featuring the ValuePoint logoat appointment
• If needed, provider calls thenumber on the ID card to obtain thecontractual reimbursement amountfor the service
• The provider collects the discountedamount in full from the member orestablishes payment schedule
Applicable Markets
multiplan.com
MultiPlan, Inc. 115 Fifth Avenue, New York, NY 10003 • multiplan.com
© 2016 MultiPlan, Inc. All rights reserved. MKT5096 10/2016
ValuePoint by MultiPlan® Participating Providers
The table below represents the number of locations by provider type and state as of October 2016. Note that there may be
overlap in the location counts for primary care physicians (PCPs) and specialists.
State Facilities Practitioners
Hospital Ancillary Primary Specialist
Alabama 44 970 2,440 6,620
Alaska 12 163 201 848
Arizona 67 2,287 1,386 4,835
Arkansas 38 576 634 2,719
California 162 5,408 8,115 27,579
Colorado 23 1,195 1,189 5,256
Connecticut 5 694 1,484 5,854
Delaware 2 187 182 864
Dist. of Columbia 2 71 270 693
Florida 34 5,032 7,314 23,203
Georgia 32 2,186 2,298 10,705
Hawaii 4 77 177 1,044
Idaho 14 230 329 1,726
Illinois 24 2,640 1,600 8,172
Indiana 34 1,427 1,458 6,933
Iowa 15 724 618 2,878
Kansas 16 722 869 3,491
Kentucky 9 891 1,255 5,646
Louisiana 46 1,399 1,902 6,684
Maine 10 188 708 1,952
Maryland 18 1,239 2,544 8,002
Massachusetts 8 1,002 1,535 10,603
Michigan 30 1,701 2,182 7,377
Minnesota 27 839 671 2,514
Mississippi 28 617 658 2,444
Missouri 26 1,581 2,138 6,778
StateFacilities Practitioners
Hospital Ancillary Primary Specialist
Montana 3 128 105 488
Nebraska 12 428 251 1,178
Nevada 9 758 1,324 5,183
New Hampshire 8 181 345 1,678
New Jersey 11 1,834 6,610 15,052
New Mexico 15 458 501 2,715
New York 71 3,596 13,884 49,093
North Carolina 15 1,491 1,722 12,097
North Dakota 4 77 112 399
Ohio 39 2,904 2,695 10,371
Oklahoma 31 846 756 3,249
Oregon 17 628 891 6,402
Pennsylvania 46 3,107 5,608 18,285
Rhode Island 7 188 701 1,643
South Carolina 10 870 1,929 6,673
South Dakota 10 109 265 1,183
Tennessee 31 1,827 1,745 8,856
Texas 146 6,106 8,314 29,619
Utah 15 406 2,639 9,663
Vermont 2 62 241 644
Virginia 6 1,206 2,359 6,460
Washington 26 1,048 3,581 16,944
West Virginia 10 359 807 2,406
Wisconsin 34 930 1,576 7,362
Wyoming 3 84 168 370
Unique Totals 1,311 63,677 103,286 383,433
®
optumrx.com is a fast, easy and secure way to get the information you need to make the most of your pharmacy benefit.
Website features and tools
Set up your online account at optumrx.com and:
• Compare medication prices at different pharmacies
• Locate a network pharmacies
• Manage medication for covered dependents and spouses
• View real time benefits and claims history
• You can save time, money and improve your health
• Save time — Skip the pharmacy line. Order medications youtake regularly online and make fewer trips to the pharmacy.
Our digital tools
My medication reminders
Manage text message reminders online.1
AMERICAN MEDICAL PLAN
optumrx.com
While on the go
Access your pharmacy benefits and manage your prescriptions from your smartphone or tablet with the OptumRx App.
• Find drug prices and lower-cost alternatives
• View your claims history
• Locate a pharmacy
• Access your ID card, if your plan allows
• Manage medication reminders
• Transfer retail prescriptions to home delivery
• Refill or renew home delivery prescriptions
Visit optumrx.com today.
Download the OptumRx App now from the Apple® App Store or Google Play™.
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.
All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.
© 2018 Optum, Inc. All rights reserved. 64538A-042018
AMERICAN MEDICAL PLAN
MINIMUM VALUE PLAN (MVP)
Understand the Value
The Minimum Value Plan (MVP) is a high deductible plan. The MVP plan does include the required MEC services and does prevent the employee from being taxed the “Individual Mandate” penalty tax by purchasing Minimum Essential Coverage through their employer. Unlike the plans being offered on the Exchange and individual market this MVP does have a list of services that are not covered by the plan. The MVP plan covers the following services after your $7,150 (individual) deductible is met; Emergency Room Services, Inpatient Hospital Services, Primary Care and Specialist visits, Imaging, Laboratory Services, X-rays and Diagnostic Imaging, and certain Generic and Preferred Brand drugs. Please pay close attention to the list of excluded benefit categories
* Please note: If you elect the MVP a Personal Health Questionnaire is required.
Group ID: FHINS
Claims Address:P.O. Box 1807Draper, Utah 84020Emdeon Payor ID: 88067Customer Service: 877-453-4201
Lifetime Max: None Network Providers Non-Network
Annual Deductibles
Does not include Co-pays.
In-network and Out-of-network are separate
accumulations and do not cross apply
Deductible applies to Out of Pocket
Individual: $7,150 Family: $14,300
Individual $14,300 Family $28,600
Annual Co-pay and Co-Insurance Out of Pocket
Maximums
(Medical and Rx Co-pays apply to the annual out
of pocket maximums)
Deductible applies to Out of Pocket
Individual: $7,150 Family: $14,300
Individual: Unlimited Family: Unlimited
Office Visits - Primary Care (exam or consultation) $50 Co-pay, Plan pays 60% Deductible, Plan pays 60% of allowed amount
Office Visits - Specialist (exam or consultation) $70 Co-pay, Plan pays 60% Deductible, Plan pays 60% of allowed amount
Office Services - basic services with exam (does not include pain management, chemo, surgical services) Plan pays 60% Deductible, Plan pays 60% of
allowed amount
Wellness Care - Adult Plan pays 100% Deductible, Plan pays 40% of allowed amount
Wellness Care - ChildrenPlan pays 100% Deductible, Plan pays 40% of
allowed amount
Ambulance
Birth Control / IUD Plan pays 100% Deductible, Plan pays 60% of allowed amount
Breast Pumps
* Chemical Dependency - Inpatient
Chemical Dependency Inpatient - All covered services other than facility charges Deductible, Plan pays 100% Deductible, Plan pays 60% of
allowed amount
Chemical Dependency - Outpatient
Chemotherapy / Radiation Therapy
Chiropractic Services
Colonoscopy (For Medical Reasons)Diagnostic Services - Basic labs/x-rays (related to office visit, LabCorp, etc.) Deductible, Plan pays 100% Deductible, Plan pays 60% of
allowed amount
Diagnostic Services - Major (Facility Charges) (MRI, CT, PET, Nuclear Medicine,etc.)
Diagnostic Services - Major (Physician Charges) (MRI, CT, PET, Nuclear Medicine,etc.) Deductible, Plan pays 100% Deductible, Plan pays 60% of
allowed amount
Diagnostic Services - Minor (Facility Charges) (ultrasounds, bone density, ecography,etc)
Diagnostic Services - Minor (Physician Charges) (ultrasounds, bone density, ecography,etc) Deductible, Plan pays 100% Deductible, Plan pays 60% of
allowed amount
Diabetic Education
Dialysis
Insurance Staffers
Basic Minimum Value (Basic MVP) & Preventative Services Coverage PlanSchedule of Medical Benefits
Option ID: INS9F
This Plan provides Minimal Value Coverage for Medical Care.
If the service is not listed on this Schedule of Benefits it is not covered.
* Pre-Certification: Arizona Foundation - FoundationUM (AZF) 833-291-2519
PPO Provider Network:
Physicians: PHCS- Specific Services Network
Facilities: 150% of Medicare
Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination.Minimum weekly hours for full time: 30 hours/130 per month
Benefit Limits Per Calendar Year
All benefits and accumulations are on a calendar year.
Beginning on January 1 and ending on December 31
Plan pays 100% once Deductible is met for in-network providers.
Wellness Care includes, but not limited to: pap smear, mammogram, prostate screening, gynecological exam, routine physical exam, routine vision screening for children, routine hearing screening for children, immunizations and related laboratory blood tests, colonoscopies. Other preventive services as identified by the Patient Protection and Affordable Care Act (PPACA) will be covered. Covered services incurred at a facility will be allowed at the Data iSight amount.
No Benefit
Plan pays 100% One per delivery. Purchase Breast Pump at a local retail store and submit the receipt for reimbursement
Deductible, Plan pays 100% up to 150% of Medicare allowed amount
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
No Benefit
No Benefit
No Benefit
No Benefit
Deductible, Plan pays 100% up to 150% of Medicare allowed amount
Deductible, Plan pays 100% up to 150% of Medicare allowed amount
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
No Benefit
No Benefit
Durable Medical Equipment (includes orthotics & prosthetics)
Emergency Room Facilities
Emergency Room - All covered services other than facility charges Plan pays 100% Plan pays 100% of allowed
amount
Gastric Bypass Surgery / Lap Banding
Home Health Care
Hospice Care
* Hospital Facility and Inpatient Services
Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement Deductible, plan pays 100% Deductible, Plan pays 60% of
allowed amount
Hospital - Outpatient Services (any charge billed from a hospital)
Infertility Services
Maternity - Prenatal Office Visits Only (billed separately from total delivery) Plan pays 100% No Benefit
Maternity (Labs, x-rays, ultrasounds and related covered services) Deductible, Plan pays 100% Deductible, Plan pays 60% of
allowed amount
* Maternity - Facility and Inpatient Services
Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement Deductible, Plan pays 100% Deductible, Plan pays 60% of
allowed amount
Medical Supplies (Including but not limited to: Insulin, Diabetic test strips, Insulin pumps, etc.) These supplies may also be covered under Prescription Benefit.
* Mental Health - Inpatient
Mental Health Inpatient - All covered services other than facility charges Deductible, Plan pays 100% Deductible, Plan pays 60% of
allowed amount
Mental Health - OutpatientOutpatient TherapyPhysical, Speech and Occupational
Outpatient Surgery performed in an office or urgent care facility
Included with office visit or urgent care Co-pay
Deductible, Plan pays 60% of allowed amount
Skilled Nursing
Sleep Studies
Sterilization for Women Plan pays 100% Deductible, Plan pays 60% of allowed amount
Sterilization for Men
TMJ and Orthognathic
* Transplant Facility
Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement Deductible, Plan pays 100% Deductible, Plan pays 60% of
allowed amount
Urgent Care Center & 24 Hour Clinic $70 Co-pay, Plan pays 60% Deductible, Plan pays 60% of allowed amount
Covered Prescription Drugs - OptumRx
Customer Service: 1-844-265-1719
Pre-Auth Line: 1-844-265-1719
Rx Bin:610011
Rx PCN: IRX
Rx GROUP: FH2FHTT
Generic Prescriptions <$9.99 = 100% coinsurance
Generic Prescriptions >$10 = 45% coinsurance
Brand Name Prescriptions = No Benefit
No Benefit
No Benefit
Deductible, Plan pays 100% up to 150% of Medicare allowed amount
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
No Benefit
No Benefit
No Benefit
Deductible, Plan pays 100% up to 150% of Medicare allowed amount
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
No Benefit
No Benefit
Prenatal office visit is covered for all females covered under the plan
Deductible, Plan pays 100% up to 150% of Medicare allowed amount
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
Percertifiation required if stay is in excess of 48 hours (or 96 hours)
No Benefit
Deductible, Plan pays 100% up to 150% of Medicare allowed amount
** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment
No Benefit
No Benefit
Maximum of $300 per visit
No Benefit
No Benefit
No Benefit
No Benefit
Deductible, Plan pays 100% up to 150% of Medicare allowed amount
Transplant Services Limited to Inpatient hospitalization only** Patient may be balance billed if provider does not accept 150%
of Medicare Allowable Payment
Prescription Benefits
Specialty Medications: No Benefit
All prescriptions are limited to 31 day supply
Sherpaa
All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a guarantee of payment.
Claims are determined upon receipt of the claim and any additional information required to make a benefit determination.
Rural Area is defined as 30 miles. If covered services are not available in the network within 30 miles the provider No Pre-existing for employees or dependents. Out of Country services will be paid as a in-network for covered medical emergencies only, to a maximum of $15,000 of billed charges.We believe this coverage is a non grandfathered health plan under the Patient Protection and Affordable
Care Act. (PPACA)
Visit www.talltreehealth.com to view the Plan Document, Schedule of Benefits, enrollment information, your claims history, link to the PPO network and more.
Telemedicine
Plan pays 100% Go to www.sherpaa.com for more information.Effective: 1/1/2019
* Pre Certification Required. Failure to obtain Pre Certification may result in a reduction of $250 or denial of benefits.
** Payment will be capped at 150% of the Medicare Allowable Payment. If provider does not accept the Medicare Allowable Amount, patient may
be balance billed.
Note: Any non-allowed or not covered amounts or services are the responsibility of the patient and are not included in the Out-of-Pocket Maximum.Dependents are covered to age 26 regardless of student or marital status.Timely Filing - Claims must be filed within 6 months from the date of service. Coordination of benefits - Non duplicating meaning this Plan will not pay in excess of the normal plan benefit in absence of other insurance.