Overview of Medical Benefits - Medical Choice Plan Effective 04/01/2015.

Overview of

Medical Benefits -

Medical Choice PlanMedical Choice PlanEffective 04/01/2015

Monterey Bay Public Employees TrustOverview of Medical Benefits

Medical Choice PlanMedical Choice Plan

Annual Deductible• $750.00 per person; maximum of $2,250.00 per family.

• After annual deductible has been met, the Plan pays the percentage of covered charges as shown. When the annual out-of-pocket amount for network providers has been met, the Plan will pay 100% of covered charges for that calendar year. There is no out-of-pocket maximum for non-network providers.



Annual Out-of-Pocket Limit• In-P.H.A.-network: $3,750.00 per individual, $11,250.00 per family. Note: The calendar year deductibles are included in the out-of-pocket limits

• Out-of-P.H.A.-network: None.

Note: The prescription drug program has a separate individual and family out-of-pocket limit of $1,950.00



Lifetime Maximum• Lifetime Maximum: No Lifetime maximum per

person.



Life Insurance• Life Insurance: $25,000.00 term life insurance for active participants only.

Monterey Bay Public Employees Trust

Overview of Medical BenefitsMedical Choice PlanMedical Choice Plan

Physician (Surgery, Home, Office, Hospital)

• In-P.H.A.-network: 70% of contracted rates for surgeon/anesthetist. 70% for hospital visits and home visits. $20.00 co-payment for office visits (deductible does not apply).

• Out-of-P.H.A.-network: 50% of U.C.R. charges.



Access to Specialists• In-P.H.A.-network: 70% of contracted rates for specialists. (Direct access to specialists allowed.)

• Out-of-P.H.A.-network: 50% of U.C.R. charges. (Direct access to specialists allowed.)



Anesthesia• In-P.H.A.-network: 70% of contracted rates.




Hospital Services (slide 1 of 4)

• M.B.P.E.T. Hospitals of Distinction:• 90% of contracted rates. (Natividad Medical Center, George L. Mee Memorial Hospital, Hazel Hawkins Memorial Hospital, Salinas Valley Memorial Hospital, Watsonville Community Hospital and Community Hospital of the Monterey Peninsula.



Hospital Services (slide 2 of 4) •M.B.P.E.T. Centers of Excellence: 100% of contracted rates; $250.00 daily per diem for family expenses for each day of in-patient medically necessary care (must be pre-approved by Executive Director). (Stanford Medical Center and other pre-approved facilities for specialized procedures or treatments).




• Network Hospitals: 80% of contracted rates.

•Non-Network Hospitals- 60% of U.C.R. covered expenses.




• Non-Network Hospitals: 60% of U.C.R. charges



Skilled Nursing Facility• In-P.H.A.-network: 70% of contracted rates for the first ten (10) days and 60% of contracted rates for the next ninety (90) days - annual maximum of one-hundred (100) days. Pre-certification required; otherwise, penalties applied.




X-Ray and Laboratory Services• In-P.H.A.-network: 70% of contracted rates.




Maternity and Interrupted Pregnancy• In-P.H.A.-network: Covered as any other medical condition.

• Out-of-P.H.A.-network: Covered as any other medical condition.



Vasectomy• In-P.H.A.-network: Covered as any other medical condition.

• Out-of-P.H.A.-network: Covered as any other medical condition.



Emergency Room• In-P.H.A.-network: 70% of contracted rates after a $200.00 co-payment.

90% of contracted rates in Hospitals of Distinction after a $200.00 co-payment.

• Out-of-P.H.A.-network: 50% of U.C.R. charges after a $200.00 co-payment.



Wellness / Well Baby• In-P.H.A.-network: 100% of contracted rates. Well Baby Care is listed under the Affordable Care Act. There is no deductible or coinsurance.

• Out-of-P.H.A.-network: No coverage.



Immunizations• In-P.H.A.-network: 100% of contracted rates as listed by the Affordable Care Act. There is no deductible or coinsurance.




Physical Exams and Mammograms• In-P.H.A.-network: 100% of contracted rates for routine gynecological exams and routine health exams as listed under the Affordable Care Act. There is no deductible or coinsurance.




Allergy Testing / Administration of Serum

• In-P.H.A.-network: 70% of contracted rates for testing/treatment with allowance of up to $400.00 per year for allergy serum.

• Out-of-P.H.A.-network: 50% of U.C.R. charges for testing/ treatment with allowance of up to $400.00 per year for allergy serum.



Home Health Care• In-P.H.A.-network: 70% of contracted rates up to $6,000.00 annual maximum. Pre-certification required for more than ten (10) visits.

• Out-of-P.H.A.-network: 50% of U.C.R. charges up to $6,000.00 annual maximum. Pre-certification required for more than ten (10) visits.



Hospice Care• In-P.H.A.-network: 70% of contracted rates up to $7,500.00 lifetime maximum. Two (2) visits for bereavement counseling. Pre-certification required; otherwise, penalties apply.




Durable Medical Equipment / Prosthetics

• In-P.H.A.-network: 70% of contracted rates.




Hearing Services / Hearing Aids In-P.H.A.-network: 80% of contracted rates. Hearing Aid benefit up to $1,000.00 annual maximum provided once every thirty-six (36) months.

• Out-of-P.H.A.-network: 60% of U.C.R. charges. Hearing Aid benefit up to $1,000.00 annual maximum provided once every thirty-six (36) months.



Acupuncture• In-P.H.A.-network: 70% of contracted rates to a maximum allowance of $50.00 per visit for up to fifteen (15) visits per calendar year.

• Out-of-P.H.A.-network: 70% of U.C.R. charges to a maximum allowance of $50.00 per visit for up to fifteen (15) visits per calendar year.



Chiropractic Care• In-C.H.P.C.-network: $10.00 co-payment per visit up to forty-five (45) annual visits per calendar year.

• Out-of-C.H.P.C.-network: None.



Prescription Drugs – Retail Store (slide 1 of 3)

• Generic: $10.00 co-payment for up to a thirty (30) day supply;

• Formulary Brand: $30.00 co-payment for up to a thirty (30 day supply;

• Non-Formulary Brand: $50.00 co-payment for up to a thirty (30) day supply.



Prescription Drugs – CVS Pharmacy Stores

(slide 2 of 3)

• Generic: $0.00 co-payment for up to a thirty (30) day supply;

• Formulary Brand: $30.00 co-payment for up to a thirty (30) day supply;

• Non-Formulary Brand: $50.00 co-payment for up to a thirty (30) day supply.

Note: Ninety (90) day supply solely at CVS Pharmacy Stores at same co-payments as the prescription mail

order program except there is a zero co-pay for generics.



Prescription Drugs - Mail Order (slide 2 of 2)

• Generic: $20.00 co-payment for up to a ninety (90) day supply;

• Formulary Brand: $60.00 co-payment for up a to ninety (90) day supply;

• Non-Formulary Brand: $100.00 co-payment for up to a ninety (90) day supply.



Rates for active employees (effective 4/01/2014)

• Single: $879.58 per month.

• Two-Party: $1,285.26 per month.

• Family: $1,837.91 per month.



Rates for retirees under 65 (effective 4/01/2014)


• Two-Party: $1,285.25 per month.

• Family: $1,837.91 per month.



Rates for retirees 65 and older (effective 4/01/2014)


• Two-Party: $693.31 per month.

• Family: $853.75 per month.



Disclaimer• This presentation provides only a general overview of the Medical benefits for the Medical Choice Plan;• For complete information, consult your copy of the Summary Plan Description or call Health Services & Benefit Administrators (1-831-757-1711 or 1-888-742-3380).

Overview of Medical Benefits - Medical Choice Plan Effective 04/01/2015.

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