guide to your healthcare benefits 2017 - Board of Pensions

steward plan resources for the benefit of all those who serve the Church . We hope you'll take .... covered under the PPO or EPO and the type of service you ...
4MB Sizes 5 Downloads 111 Views
Benefits through the stages of your life.

GUIDE TO YOUR HEALTHCARE BENEFITS 2017 For Active Medical Plan Members

TABLE OF CONTENTS 1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 A Network-Driven Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 PPO Medical Option . . . . . . . . . . . . . . . . . . . . . . . . . 2 EPO Medical Option . . . . . . . . . . . . . . . . . . . . . . . . . 2 Non-network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Your service providers . . . . . . . . . . . . . . . . . . . . . . . 3 Emergency and urgent care services . . . . . . . . . . . . . . . . 4 Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Alternatives to the ER . . . . . . . . . . . . . . . . . . . . . . . . 4 2. Eligibility and Coverage Contributions . . . . . . . . . . . . . 6 Installed Pastors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Other Teaching Elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Other Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Medical Continuation Coverage . . . . . . . . . . . . . . . . . . . . 8 3. Your Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Carry Your ID Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Get Advance Approval When Required . . . . . . . . . . . . . 9 Report Qualifying Life Events . . . . . . . . . . . . . . . . . . . . . . 10 Understand Your Share of the Costs . . . . . . . . . . . . . . . . 10 Protect Plan Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4. Medical Plan Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Medical Necessity Standard . . . . . . . . . . . . . . . . . . . . . . . 12 What’s Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Limits to coverage . . . . . . . . . . . . . . . . . . . . . . . . . 13 Women’s health protection . . . . . . . . . . . . . . . . . 13 Behavioral health services . . . . . . . . . . . . . . . . . . 15 Routine eye exam coverage . . . . . . . . . . . . . . . . 16 Specialized therapies . . . . . . . . . . . . . . . . . . . . . . 16 Organ transplants . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Habilitative services for developmental disabilities . . . . . . . . . . . . . . . 17 Pre-Certification Requirements . . . . . . . . . . . . . . . . . . . . 18 Emergency admission . . . . . . . . . . . . . . . . . . . . . . 18 If you don’t obtain advance approval . . . . . . . 18 What’s Not Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

5. Your Medical Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Your Share of the Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Preventive care benefit . . . . . . . . . . . . . . . . . . . . . 21 Routine medical costs . . . . . . . . . . . . . . . . . . . . . . 22 Routine vision exam . . . . . . . . . . . . . . . . . . . . . . . . 24 Hospital and emergency room visits . . . . . . . . 24 How To Get Reimbursed . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Medical and Hospital Services . . . . . . . . . . . . . . . . . . . . . 25 Claims Summaries and Explanation of Benefits Statements . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Online claims seminars . . . . . . . . . . . . . . . . . . . . . 25 Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . 25 Reviewing your claims . . . . . . . . . . . . . . . . . . . . . . 25 6. Your Prescription Drug Benefits . . . . . . . . . . . . . . . . . 27 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Deciding on the Right Prescription for You . . . . . . . . . 27 Brand vs. generic drugs . . . . . . . . . . . . . . . . . . . . . 27 Listing of covered drugs . . . . . . . . . . . . . . . . . . . . 28 Costs for formulary and non-formulary drugs . . . . . . . . . . . . . . . . . . . .