| The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-291-1425 or go to 3nrk.agemboutique.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at http://www.healthcare.gov/sbc-glossary or call 1-800-291-1425 to request a copy. |
| Important Questions | Answers | Why This Matters: | |
| What is the overall deductible? | $ 0 |
|
|
| Are there services covered before you meet your deductible? | Yes | This Plan does not have a deductible. But a copayment may apply. | |
| Are there other
deductibles for specific services? |
No | You don’t have to meet deductibles for specific services. | |
| What is the out-of-pocket limit for this plan? | $ 400 / family for PPL* physician visits
$ 600 / family for PPL prescription drugs $400 / family for non-PPL physician visits $600 / family for non-PPL drugs $600 / family for non-PPL hospital |
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met.
* PPL means Participating Provider List.
|
|
| What is not included in
the out-of-pocket limit? |
The extra cost of using brand name or non-preferred drugs,
balance-billing charges, and health care this plan doesn’t cover. (This plan has no premiums.) |
Even though you pay these expenses, they don’t count toward the out–of–pocket limit. | |
| Will you pay less if you use a participating provider? | Yes. See 3nrk.agemboutique.com
or call 1-800-291-1425 for a list of participating providers. |
This plan uses a Participating Provider List (PPL) network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. | |
| Do you need a referral to see a specialist? | No | You can see the specialist you choose without a referral. |
| All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. |
| Common Medical Event |
Services You May Need | What You Will Pay | Limitations, Exceptions, & Other Important Information | |
| Participating Provider
(You will pay the least) |
Non-Participating Provider
(You will pay the most) |
|||
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness | $20 copay / visit | $30 copay / visit | None |
| Specialist visit | $20 copay / visit | $30 copay / visit | None | |
| Preventive care/screening/
immunization |
$20 copay / visit | $30 copay / visit | Routine physical exams are covered for ages under 6 and over 54; annually or semi-annually by a gynecologist; or by a specialist as part of the specialist’s care of a medical condition.
Copayments apply. |
|
| If you have a test | Diagnostic test (x-ray, blood work) | No charge | No charge | None |
| Imaging (CT/PET scans, MRIs) | No charge | No charge | None | |
| If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at 3nrk.agemboutique.com.
|
Generic drugs or
Preferred brand drugs |
$15 copay per 30-day supply
$5 copay per 90-day supply for mail order |
$30 copay per 30-day supply
|
Maximum supply for non-mail order is 90 days.
|
|
Brand drugs where generic is available |
$15 copay per 30-day supply.*
$5 copay per 90-day supply for mail order.* *Plus the difference in cost between the generic and brand product. |
$30 copay per 30-day supply,
plus the difference in cost between the brand and generic product.
|
If the prescribing physician obtains a medical necessity authorization there will be no additional payment for the use of the brand drug. | |
| Non-Preferred brand drugs
|
$15 copay per 30-day supply.*
$5 copay per 90-day supply for mail order.* *Plus the differential payment that is approximately equal to the difference in cost between the Preferred and Non-Preferred product. |
$30 copay per 30-day supply,
plus the differential payment that is approximately equal to the difference in cost between the Preferred and Non-Preferred product. |
If the prescribing physician obtains a medical necessity authorization there will be no additional payment for the use of the Non-Preferred drug. | |
| Preferred Specialty drugs
Non-Preferred Specialty drugs
Specialty drugs not on the Specialty Drug List |
$5 per 30-day supply at CVS Specialty Pharmacy
$5 per 30-day supply at CVS Specialty Pharmacy
$5 per 30-day supply at CVS Specialty Pharmacy $15 per 30-day supply at any other Specialty pharmacy |
If Specialty drugs are obtained at a non-network Specialty pharmacy, a $30 per 30-day supply copay applies.
|
Pre-authorization is required for all Specialty drugs.
All drugs on the Specialty Drug List must be obtained from a CVS Specialty Pharmacy.
If a Non-Preferred Specialty drug within the classes on the Specialty Drug List is selected, the prescriber will be asked to consider a Preferred drug to be used before the Non-Preferred drug will be covered. |
|
| If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | No charge | No charge | None |
| Physician/surgeon fees | No charge | No charge | None | |
| If you need immediate medical attention | Emergency room care | $20 copay per visit | $30 copay per visit | Copay only applies to physician’s charge for the emergency room visit. |
| Emergency medical transportation | No charge | No charge | None | |
| Urgent care | $20 copay per visit | $30 copay per visit | Copay only applies to physician’s charge for the visit. | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | No charge | The plan pays 90% of Participating Provider rate. The Beneficiary is responsible for the remaining balance of charges up to the $600 annual out-of-pocket maximum. Hold Harmless provisions may not apply. | Private rooms are not covered unless patient’s condition requires isolation or no semi-private room is available. |
| Physician/surgeon fees | $20 copay per visit | $30 copay per visit | Copay only applies to physician’s charge for hospital visits. | |
| If you need mental health, behavioral health, or substance abuse services | Outpatient services | $20 copay per visit
|
$30 copay per visit
|
Alcoholism and drug rehabilitation programs must be provided by an accredited facility. |
| Inpatient services | No charge | The plan pays 90% of Participating Provider rate. The Beneficiary is responsible for the remaining balance of charges up to the $600 annual out-of-pocket maximum. Hold Harmless provisions may not apply. | Inpatient services must be provided by an accredited facility.
Plan payment for non-PPL hospital and related benefits is limited to 90% of the amount that would have been paid to a PPL hospital. |
|
| If you are pregnant |
Office visits |
$20 copay per visit
|
$30 copay per visit
|
Depending on the type of services, a copayment may apply. Copayment does not apply when childbirth/delivery is billed as a bundled service. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) |
| Childbirth/delivery professional services | No charge | No charge | Copayment does not apply when childbirth/delivery is billed as a bundled service.
|
|
| Childbirth/delivery facility services | No charge | The plan pays 90% of Participating Provider rate. The Beneficiary is responsible for the remaining balance of charges up to the $600 annual out-of-pocket maximum. Hold Harmless provisions may not apply.
|
Plan payment for non-PPL hospital and related benefits is limited to 90% of the amount that would have been paid to a PPL hospital. | |
| If you need help recovering or have other special health needs | Home health care | No charge | No charge | Must be medically justified with skilled care. |
| Rehabilitation services | No charge | No charge | Must be medically justified with skilled care. | |
| Habilitation services | No charge | No charge | Must be medically justified with skilled care. | |
| Skilled nursing care | No charge | No charge | Must be medically justified with skilled care. | |
| Durable medical equipment | No charge | Not covered | Most equipment must be purchased through a DME network provider. Some equipment must be prior approved. | |
| Hospice services | Not covered | Not covered | None | |
| If you need dental or eye care | Eye exam |
$46.77
|
Not Applicable
|
Covered once every 24 months. |
| Glasses | $23.39 per lens single vision
$35.09 per lens bifocal $46.77 per lens trifocal $58.47 per lens lenticular $35.09 per contact lens $33.13 frames |
Not Applicable | Covered once every 24 months.
Lenses will not be covered unless the new prescription differs from the most recent one by an axis change of 20 degrees or .50 diopter sphere or cylinder change and the lens must improve visual acuity by at least one line on the standard chart. |
|
| Dental check-up | Not covered | Not covered | None | |
Excluded Services & Other Covered Services:
| Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) | ||
| · Acupuncture
· Chiropractic care · Cosmetic surgery
|
· Dental care
· Long-term care · Private-duty nursing unless necessary to preserve life and ICU is unavailable
|
· Routine foot care
· Weight loss programs
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) | ||
| · Bariatric surgery
· Hearing aids
|
· Infertility treatment (artificial insemination only)
· Non-emergency care when traveling outside the U.S.
|
· Routine eye care
|
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: The UMWA Funds at 1-800-291-1425 or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-291-1425 (TTY: 711)
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-291-1425 (TTY: 711)
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-291-1425 (TTY: 711)
Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-291-1425 (TTY: 711)
––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
