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Benefits

Patriot Retirees VEBA
HealthSmart Group #5742 Anthem Network
Effective Date: 1/1/2014
Schedule of Benefits Summary
BENEFIT FEATURE IN-NETWORK OUT-OF-NETWORK
Annual Maximum Benefit Unlimited
• Plan Pays
• You Pay (after deductible)
90%
10%
70%
30%
Annual Deductible (Plan Year) – Does not include prescription deductible
• Individual $250 $250
• Family Maximum None None
Amounts applied to the In-Network Plan Year Deductible will apply to the Out-of-Network Plan Year Deductible and vice versa. In-network benefits apply if this plan is secondary to another health plan.
Annual Out-of-Pocket Maximum (Plan Year) –
• Includes deductible and physician office visit copays.
• Does not include prescription out-of-pocket.
• Individual (maximum per person) $800 $800
• Family Maximum
Cumulative maximum per family
$800 $800
Amounts applied to the In-Network Out-of-Pocket Maximum will apply to the Out-of-Network Out-of-Pocket Maximum and vice versa.
*=Subject to the Deductible
Physician Services
Non-Specialist Office Visits $20 copay, then 100% $20 Copay
Specialist Office Exam $35 Copay, then 100% $50 Copay, then 100%
All services by Specialist (does not include office exam) 90%* 70%*
• MRI’s, CT Scans, PET Scans, MRA’s, Nuclear Medicine, Chemotherapy and Chemotherapy Related Injections 90%* 70%*
• Other Diagnostic, X-Ray and Lab, Other Therapeutic Injections, Supplies, Surgery, Allergy Injections and Other Office Expenses 90%* 70%*
Inpatient Hospital Expenses – Pre-Certification of Admission is Required
• Inpatient Facility and Physician Fees 90%* 70%*
• Outpatient Facility and Physician Fees 90%* 70%*
• Diagnostic, X-ray and Lab (excludes MRI’s, CT Scans, PET Scans, MRA’s and Nuclear Medicine) 90%* 70%*
• MRI’s, CT Scans, PET Scans,
MRA’s and Nuclear Medicine
and all other complex x-rays
90%* 70%*
• All Other Expenses 90%* 70%*
Emergency Services
Emergency Room Expenses – True Emergency Facility and Physician Fees 90%* 90%*
Emergency Room – Non-Emergency Facility and Physician Fees $150 penalty, then 90%* $150 penalty, then 90%*
• Urgent Care Expenses (facility) $50 Copay, then 100% 70%*
• Ambulance Expenses 90%* 70%*
Preventive Care Expenses
Immunizations/Flu Shots 100% 80% up to $500 per calendar year
Mammograms 100% 80% up to $500 per calendar year
Colonoscopies 100% 80% up to $500 per calendar year
All Other Covered Routine Expenses (adult/child) 100% 80% up to $500 per calendar year
Other Services
Independent Diagnostic, X-Ray and Lab Facility Expenses 90%* 70%*
Durable Medical Equipment 90%* 70%*
Extended Care Services
• Home Health Care – 60 visits per plan year
NOTE: subject to medical necessity extensions
90%* 70%*
• Skilled Nursing Facility – 120 days per plan year 90%* 70%*
• Hospice Services 90%* 70%*
• Occupational, Physical and Speech Therapy Expenses 90%* 70%*
• Cardiac Rehabilitation 90%* 70%*
• Pulmonary Rehabilitation Therapy 90%* 70%*
Prescription Drugs Schedule of Benefits
Pharmacy Benefits Provided by Caremark/CVS
Prescription Drug Annual Out-of-Pocket Maximum (Plan Year) –
Does not include medical out-of-pocket
IN-NETWORK OUT-OF-NETWORK
• Individual and Family Maximum $800 $800
Amounts applied to the In-Network Out-of-Pocket Maximum will apply to the Out-of-Network Out-of-Pocket Maximum and vice versa.
Retail Only (30-day Supply)
• Generic $5 Copay Member pays 100%
then files a claim for
reimbursement.
• Preferred Brand $25 Copay or 30%,
whichever is greater,
up to a $50 maximum
Member pays 100%
then files a claim for
reimbursement.
• Non – Preferred Brand $75 Copay or 50%,
whichever is greater,
up to a $200 maximum
Member pays 100%
then files a claim for
reimbursement.
Mail Order Benefit (90-day Supply)
• Generic $10 Copay Not Applicable
• Preferred Brand $50 Copay or 30%, whichever is greater, up to a $100 maximum Not Applicable
• Non – Preferred Brand $150 Copay or 50%, whichever is greater, up to a $400 maximum Not Applicable
Note: This is a summary of benefits and is not in any way a guarantee of coverage. This summary provides a general description of your medical benefits. It does NOT list all benefits. The plan contains limitations and restrictions that could reduce the benefits payable under the Plan. The Summary Plan Description will take precedence over all other documents as of 1/1/2014.
Customer Service
Anthem Provider Locator/Lookup www.Anthem.com
Anthem Provider Locator 1-800-810-2583
HealthSmart Customer Service 1-800-500-4277
HealthSmart Precertification 1-877-202-6379 ext. 2530
Caremark/CVS Prescriptions 1-800-328-5340
www.caremark.com
Patriot Retirees VEBA website www.patriotveba.org

Contact Numbers:

Healthsmart Customer Service:
1-800-500-4277
7 am – 7 pm EST

Healthsmart Precertification:
1-877-202-6379 ext. 2530

Anthem Provider Locator:
www.Anthem.com
1-800-810-2583

Anthem Provider Eligibility/Benefits:
1-800-676-2583

Caremark Pharmacy:
1-800-328-5340