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Overview of Medical Benefits - E.P.O. Plan ( E xclusive P rovider O rganization ) Effective 4/01/2013

Overview of Medical Benefits - E.P.O. Plan ( E xclusive P rovider O rganization ) Effective 4/01/2013. Monterey Bay Public Employees Trust Overview of Medical Benefits Exclusive Provider Organization (EPO) Plan. Annual Deductible $400.00 per person; maximum of $1200.00 per family.

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Overview of Medical Benefits - E.P.O. Plan ( E xclusive P rovider O rganization ) Effective 4/01/2013

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  1. Overview of Medical Benefits - E.P.O. Plan (Exclusive ProviderOrganization) Effective 4/01/2013

  2. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Annual Deductible • $400.00 per person; maximum of $1200.00 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 has been met, the Plan will pay 100% of covered charges for that calendar year.

  3. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Annual Out-of-Pocket Limit • In-P.H.A.-network: $1,000.00 per individual. $3,000.00 per family. The deductible does not count towards the out-of-pocket maximum. • Out-of-P.H.A.-network: No coverage for services provided by non-network providers except for emergency treatment for life-threatening illnesses or injuries. • NOTEMental/Nervous and Substance Abuse expenses are not included in determining annual limit.

  4. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan NONE • Lifetime Maximum • Lifetime Maximum: No lifetime maximum.

  5. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Life Insurance • Life Insurance: $25,000.00 term life insurance for active participants only.

  6. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Physician (Surgery, Home, Office, Hospital) • In-P.H.A.-network: 80% of contracted rates for surgeon/anesthetist. 80% of contracted rates for hospital visits and home visits. • Out-of-P.H.A.-network: None.

  7. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Access to Specialists • In-P.H.A.-network: 80% of contracted rates for specialists. (Must be referred by Primary Care Provider – no direct access.) • Out-of-P.H.A.-network: None.

  8. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Anesthesia • In-P.H.A.-network: 80% of contracted rates. • Out-of-P.H.A.-network: None.

  9. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Hospital Services(slide 1 of 3) • 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.

  10. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Hospital Services(slide 2 of 3) • M.B.P.E.T. Centers of Excellence: 80% of contracted rates; must be pre-authorized by Pacific Health Alliance. (Stanford Medical Center, University of California, San Francisco Medical Center, and other pre-approved facilities for specialized procedures or treatments).

  11. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Hospital Services(slide 3 of 3) • Out-of-Area Referral Hospitals: 80% of contracted rates; must be pre-authorized by Pacific Health Alliance.

  12. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Skilled Nursing Facility • In-P.H.A.-network: 80% of contracted rates up to one-hundred (100) days per calendar year. Pre-certification required; otherwise, penalties apply. • Out-of-P.H.A.-network: None.

  13. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • X-Ray and Laboratory Services • In-P.H.A.-network: 80% of contracted rates • Out-of-P.H.A.-network: None.

  14. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Maternity and Interrupted Pregnancy • In-P.H.A.-network: Covered as any other medical condition. • Out-of-P.H.A.-network: None.

  15. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Vasectomy • In-P.H.A.-network: Covered as any other medical condition. • Out-of-P.H.A.-network: None.

  16. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Emergency Room • Network Hospitals of Distinction: 90% of contracted rates after a $200.00 co-payment. • Out-of-P.H.A.-network: 80% of U.C.R. charges after a $200.00 co-payment only for life-threatening emergencies.

  17. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Wellness / Well Baby • In-P.H.A.-network: 100% of contracted rates for exams and immunizations as determined by the Affordable Health Care . Protection Act. There is no deductible or coinsurance. • Out-of-P.H.A.-network: None.

  18. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Flu Immunizations • In-P.H.A.-network: 100% of contracted rates as listed under the Affordable Health Care Protection Act. There is no deductible or coinsurance. • Out-of-P.H.A.-network: None.

  19. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Physical Exams and Mammograms • In-P.H.A.-network: 100% of contracted rates for mammograms and routine physicals. Coverage as provided under the Affordable Health Care Protection Act. There is no deductible or coinsurance. • Out-of-P.H.A.-network: None.

  20. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Allergy Testing / Administration of Serum • In-P.H.A.-network: 80% of contracted rates for testing, and 80% of contracted rates for administration of allergy serum (not subject to annual deductible). • Out-of-P.H.A.-network: None.

  21. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Home Health Care • In-P.H.A.-network: 80% of contracted rates. • Must be pre-certified Pacific Health Alliance. • Out-of-P.H.A.-network: None.

  22. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Hospice Care • In-P.H.A.-network: 80% of contracted rates. • Two (2) visits for bereavement counseling. • Pre-certification required; otherwise, penalties apply. • Out-of-P.H.A.-network: None.

  23. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Durable Medical Equipment / Prosthetics • In-P.H.A.-network: 80% of contracted rates. • Out-of-P.H.A.-network: None.

  24. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Acupuncture • In-P.H.A.-network: None. • Out-of-P.H.A.-network: None.

  25. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Hearing Services • In-P.H.A.-network: 80% of contracted rates. No hearing aid coverage except as required by surgery. • Out-of-P.H.A.-network: None.

  26. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Podiatry • In-P.H.A.-network: 80% of contracted rates. • Out-of-P.H.A.-network: None.

  27. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Chiropractic Care • In-C.H.P.C.-network: $10.00 co-payment per visit up to forty-five (45) visits per calendar year. • Out-of-C.H.P.C.-network: None.

  28. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Prescription Drugs – Retail Store(slide 1 of 3) • Generic: $10.00 co-payment for up to a thirty (30) day supply (co-payment waived only at CVS Pharmacy Stores); • 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.

  29. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Prescription Drugs – CVS Pharmacy Stores • (slide 2 of 3) • Generic: $0 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 regular mail in program except there is a zero co-pay for generics.

  30. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Prescription Drugs - Mail (slide 3 of 3) • Generic: $20.00 co-payment for up to a ninety (90) day supply; • Formulary Brand: $60.00 co-payment for up to a ninety (90) day supply; • Non-Formulary Brand: $100.00 co-payment for up to a ninety (90) day supply.

  31. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Rates for active employees(effective 4/01/2013) • Single: $814.56 per month. • Two-Party: $1,204.46 per month. • Family: $1,734.20 per month.

  32. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Rates for retirees under 65(effective 4/01/2013) • Single: $814.56 per month. • Two-Party: $1,204.46 per month. • Family: $1,734.20 per month.

  33. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Rates for retirees 65 and older(effective 4/01/2013) • Single: $528.35 per month. • Two-Party: $736.72 per month. • Family: not available

  34. Monterey Bay Public Employees TrustOverview of Medical BenefitsExclusive Provider Organization (EPO) Plan • Disclaimer • This presentation provides only a general overview of the Medical benefits for the E.P.O. Plan; • For complete information, consult your copy of theSummary Plan Description or callHealth Services & Benefit Administrators. • (1-831-757-1711 or 1-888-742-3380).

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