Insurance

Pickerington Local Schools

Blue Access^SM (PPO) – PPO Plan $500 Ded

Summary of Benefits, Effective 09/01/2015

Benefits Covered	Network	Non-Network
Deductible (Single/Family)	$500/$1,000	$1,000/$2,000
Out-of-Pocket Limit (Single/Family)	$1,500/$3,000	$3,000/$6,000
Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/Specialty Care Physician (SCP) Including Office Surgeris and allergy serum: • allergy injections (PCP and SCP) • allergy testing • routine and non-routine mammograms (regardless of outpatient setting) • diabetic education (regardless of outpatient setting) • certain medical nutritional therapy (regardless of outpatient setting) • MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies and non-maternity related Ultrasounds	$25/$35     10% 10% No copayment/coinsurance   No copayment/coinsurance No copayment/coinsurance   10%	30%     30% 30% 30%   30% 30%   30%
Preventive Care Services Services include but are not limited to: Routine Exams, Pelvic Exams, Pap testing, PSA tests, Immunications1, Annual diabetic eye exam, Routine Vision And Hearing exams • Physician Home and Office Visits (PCP/SCP) • Other Outpatient Services @ Hospital/Alternative Care Facility	No copayment/coinsurance No copayment/coinsurance	30% 30%
Emergency and Urgent Care • Emergency Room Services @ Hospital (facility/other covered services) (copayment waived if admitted) • Urgent Care Center Services	$150     $35	$150     $35
Inpatient and Outpatient Professional Services Include but are not limited to: • Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams	10%	30%
Inpatient Facility Services Unlimited days except for: • 60 days Network/Non-Network combined for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) • 60 days Network/Non-Network combined for skilled nursing facility	10%	30%
Outpatient Surgery Hospital/Alternative Care Facility • Surgery and administration of general anesthesia	10%	30%
Other Outpatient Services (including but not limited to): • Non Surgical Outpatient Services for example: MRIs, C-Scans, Chemotherapy, Ultrasounds • Home Care Services • Durable Medical Equipment, Orthotics and Prosthetic Devices • Physical Medicine Therapy Day Rehabilitation programs • Hospice Care • Ambulance Services	10%   10% 10% 10% 10% 20%	30%   30% 30% 30% 10% 20%
Benefits Covered	Network	Non-Network
Outpatient Therapy Services (Combined Network & Non-Network limits apply) • Physician Home and Office Visits (PCP/SCP) • Other Outpatient Services @ Hospital/Alternative Care Facility Limits apply to: • Physical therapy: 20 visits • Occupational therapy: 20 visits • Manipulation therapy: 16 visits • Speech therapy: 20 visits	$25/$25 10%	30% 30%
Behavioral Health Services2 • Inpatient Facility Services • Inpatient Professional Services • Physician Home and Office Visits (PCP/SCP) • Other Outpatient Services. Outpatient Facility @ Hospital/Alternative Care Facility, Outpatient Professional These benefits have been tested and are compliant with Federal Mental Health Parity legislation.	10% 10% $25/$25 10%	30% 30% 30% 30%
Human Organ and Tissue Transplants3 • Acquisition and transplant procedures, harvest and storage.	No copayment/coinsurance	30%
Prescription Drugs4 Network Tier structure equals 1/2/3 (and 4, if applicable) • Network Retail Pharmacies:    (30-day supply) Includes diabetic test strip • Anthem Rx Direct Mail Service:    (90-day supply) Includes diabetic test strip Medicare Rx – Wrap	$100 Deductible (Network/ Non-Network Combined) $15/$30/$45     $30/$60/$90	$100 Deductible (Network/ Non-Network Combined) $15/$30/$45     Not covered

Notes:

• All deductibles, copayments and coinsurance apply toward the out-of-pocket maximum including prescription drugs. (Excludes Non-network Human Organ and Tissue Transplant (HOTT) Services).
• Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance. However, the deductible does not apply to Emergency Room Services @ Hospital where a pecentage (%) coinsurance applies to other covered services.
• Network and Non-network deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other.
• Dependent Age: to end of the month which the child attains age 26.
• Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OB/GYN’s and Geriatrics or any other Network Provider as allowed by the plan.
• Physicians Home and office visit copayment also applies if the office visit is billed with allergy injections.
• No copayment/coinsurance means no deductible/copayment/coinsurance up to the maximum allowable amount. 110% means no coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for any balance due after the plan payment.
• PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan.
• SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
• Certain diabetic and asthmatic supplies have no deductible/copayment/coinsurance up to the maximum allowable amount at network pharmacies except diabetic test strips.
• Benefit period = calendar year

¹These covered services are not subject to the deductible/copayment if you have a flat dollar copayment and if rendered without an office visit.

²We encourage you to contact Our Mental Health Subcontractor to assure the use of appropriate procedures, setting and medical necessity. Refer to Schedule of Benefits for limitations. Behavioral Health Services (Mental Health and Substance Abuse) benefits provided in accordance with Federal Mental Health parity.

³Kidney and Cornea are treated the same as any other illness and subject to the medical benefits.

⁴All prescription drug expenses except tier 1, (Network/Non-network, Retail/Mail-service combined) apply to the individual deductible. Once the deductible is met, the appropriate copayment applies. Also if applicable, the Prescription Drug out of pocket maximum applies to Network Retail and Mail-Service combined.

⁵Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips.

Precertification:

• Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services.

This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

 

 

Delta Dental PPO (Point-of-Service)

Summary of Dental Plan Benefits

For Group #1039-0001, 0002, 0003, 0099

Pickerington Local School District

 

This Summary of Dental Plan Benefits should be read in conjunction with your Dental Care Certificate. Your Dental Care Certificate will provide you with additional information about your Delta Dental plan, including information about plan exclusions and limitations. The percentages below will be applied to the lesser of the dentist’s submitted fee and Delta Dental’s allowance for each service. Delta Dental’s allowance may vary by the dentist’s network participation. PLEASE NOTE – if you choose a Nonparticipating Dentist, you will be responsible for any difference between the amount Delta Dental allows and the amount the Nonparticipating Dentist charges, in addition to any Co-payment or Deductible.

 

Control Plan – Delta Dental of Ohio

 

Benefit Year – January 1 through December 1

 

Covered Services	PPO Dentist	Premier Dentist	Non-participating Dentist
	Plan Pays	Plan Pays	Plan Pays*
Class	I
Diagnostic and Preventive Services – includes exams, cleanings, fluoride, and space maintainers	100%	100%	100%
Emergency Palliative Treatment – to temporarily relieve pain	100%	100%	100%
Sealants – to prevent decay of permanent teeth	100%	100%	100%
Radiographs – X-rays	100%	100%	100%
Class	II
Minor Restorative Services – fillings and crown repair	80%	80%	80%
Endodontic Services – root canals	80%	80%	80%
Periodontic Services – to treat gum disease	80%	80%	80%
Oral Surgery Services – extractions and dental surgery	80%	80%	80%
Other Basic Services – misc. services	80%	80%	80%
Relines and Repairs – to bridges and dentures	80%	80%	80%
Class	III
Major Restorative Services – crowns	60%	60%	60%
Prosthodontic Services – includes bridges and dentures	60%	60%	60%
Class	IV
Orthodontic Services – includes braces	60%	60%	60%
Orthodontic Age Limit	No Age Limit	No Age Limit	No Age Limit

 

*When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental’s Nonparticipating Dentist Fee that will be paid for those services. This Nonparticipating Dentist Fee may be less than what your dentist charges, which means that you will be responsible for the difference.

 

Maximum Payment – $2,500 per person total per benefit year on all services except orthodontics. $850 per person total per lifetime on orthodontic services.

 

Deductible – $25 deductible per person total per benefit year limited to a maximum deductible of $50 per family per benefit year. The deductible does not apply to diagnostic and preventive services, emergency palliative treatment, x-rays, sealants, and orthodontic services.