2013 Benefit Enrollment Guide - Troy University
2013 Benefit Enrollment Guide - Troy University 2013 Benefit Enrollment Guide - Troy University
BlueCard PPO: Troy University Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: _________ | Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.behavioralhealthsystems.com or by calling 1-800-245-1150. Important Questions Answers Why this Matters: What is the overall deductible Are there other deductibles for specific services Is there an out–of– pocket limit on my expenses What is not included in the out–of–pocket limit Is there an overall annual limit on what the plan pays Does this plan use a network of providers Do I need a referral to see a specialist Are there services this plan doesn’t cover $ Does not apply to mental health and substance abuse care. $ $ Does not apply to mental health and substance abuse care. Yes. For a list of mental health or substance abuse in-network providers, call Behavioral Health Systems at 800-245- 1150. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Questions: Call 1-800-245-1150 or visit us at www.behavioralhealthsystems.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.behavioralhealthsystems.com or call 1-800-245-1150 to request a copy. 1 of 2
BlueCard PPO: Troy University Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: _________ | Plan Type: PPO Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services Your Cost If You Use an In-network Provider $13-30 copay/visit for office visits, 20% coinsurance for other outpatient services $100 deductible /admission and 20% coinsurance for inpatient, 20% coinsurance for intensive outpatient and partial hospitalization $13-30 copay/visit for office visits, 20% coinsurance for other outpatient services $100 deductible /admission and 20% coinsurance for inpatient, 20% coinsurance for intensive outpatient and partial hospitalization Your Cost If You Use an Out-of-network Provider Not covered Not covered Not covered Not covered Limitations & Exceptions Office visits limited to 25 visits/year. Overall deductible does not apply. No coverage for services by out-ofnetwork providers. No coverage for inpatient, partial hospitalization, intensive outpatient, ECT, or psychological testing unless pre-authorized by Behavioral Health Systems. Questions: Call 1-800-245-1150 or visit us at www.behavioralhealthsystems.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.behavioralhealthsystems.com or call 1-800-245-1150 to request a copy. 2 of 2
- Page 1 and 2: 2013 Benefit Enrollment Guide an ov
- Page 3 and 4: introduction Enrollment Current Emp
- Page 5 and 6: Healthcare Benefits Medical (Blue C
- Page 7 and 8: Healthcare Benefits Pre-Tax Cafeter
- Page 9 and 10: Healthcare Benefits BlueCard Worldw
- Page 11 and 12: Voluntary Life Insurance Voluntary
- Page 13 and 14: travel assistance MEDEX ® Travel A
- Page 15 and 16: flexible spending Flexible Spending
- Page 17 and 18: etirement Mandatory Retirement Plan
- Page 19 and 20: important notices Summary Plan Desc
- Page 21 and 22: Troy University-54395/000 Coverage
- Page 23 and 24: Common Medical Event If you need dr
- Page 25 and 26: Excluded Services & Other Covered S
- Page 27: Questions and answers about the Cov
BlueCard PPO: <strong>Troy</strong> <strong>University</strong> Coverage Period: 01/01/<strong>2013</strong> – 12/31/<strong>2013</strong><br />
Summary of <strong>Benefit</strong>s and Coverage: What this Plan Covers & What it Costs Coverage for: _________ | Plan Type: PPO<br />
Common<br />
Medical Event<br />
If you have mental<br />
health, behavioral<br />
health, or substance<br />
abuse needs<br />
If you are pregnant<br />
Services You May Need<br />
Mental/Behavioral health outpatient services<br />
Mental/Behavioral health inpatient services<br />
Substance use disorder outpatient services<br />
Substance use disorder inpatient services<br />
Prenatal and postnatal care<br />
Delivery and all inpatient services<br />
Your Cost If<br />
You Use an<br />
In-network<br />
Provider<br />
$13-30 copay/visit<br />
for office visits,<br />
20% coinsurance<br />
for other outpatient<br />
services<br />
$100 deductible<br />
/admission and<br />
20% coinsurance<br />
for inpatient,<br />
20% coinsurance<br />
for intensive<br />
outpatient and<br />
partial<br />
hospitalization<br />
$13-30 copay/visit<br />
for office visits,<br />
20% coinsurance<br />
for other outpatient<br />
services<br />
$100 deductible<br />
/admission and<br />
20% coinsurance<br />
for inpatient,<br />
20% coinsurance<br />
for intensive<br />
outpatient and<br />
partial<br />
hospitalization<br />
Your Cost If<br />
You Use an<br />
Out-of-network<br />
Provider<br />
Not covered<br />
Not covered<br />
Not covered<br />
Not covered<br />
Limitations & Exceptions<br />
Office visits limited to 25 visits/year.<br />
Overall deductible does not apply.<br />
No coverage for services by out-ofnetwork<br />
providers.<br />
No coverage for inpatient, partial<br />
hospitalization, intensive outpatient,<br />
ECT, or psychological testing unless<br />
pre-authorized by Behavioral Health<br />
Systems.<br />
Questions: Call 1-800-245-1150 or visit us at www.behavioralhealthsystems.com.<br />
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary<br />
at www.behavioralhealthsystems.com or call 1-800-245-1150 to request a copy.<br />
2 of 2
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