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Baker College, G-316
Enhanced Plan
Standard Plan
Benefit Description
In-Network
Out-of-Network
In-Network
Out-of-Network
Out-Of-Pocket Maximum per Benefit Year (Includes *Does not include co-payments of any type, including prescription drug co-payments, or expenses that constitute a penalty for non-compliance, exceed the usual and customary charge, exceed the limits of the Plan, or are otherwise excluded. Co-payments specified below continue to apply even after the Out-of-Pocket Maximum is satisfied in a Benefit Year. Annual Maximum Paid per Covered Person per Outpatient Physician Services (Includes Office Visits, Immediate Care Center Visits, and Second Surgical Opinions) All Other Charges Billed in Connection with the Paid the same as any other Paid the same as any other Illness; benefit percentage Illness; benefit percentage depends upon the type of service depends upon the type of service Physician’s Fee for an Examination Routine X-Rays and Labs Flu Shots and Other Routine Immunizations FDA-Approved Contraceptive Methods and Sterilization Procedures for Women with Reproductive Capacity Mammograms, Colonoscopies, and Other Routine Services Special Notes About Routine Preventive Care:
1. Co-insurance or an office visit co-payment may be imposed on preventive care services if either the visit is billed separately from the preventive care service or the services are provided during an office visit whose primary purpose is not preventive care (and the services are not billed separately). 2. The Routine Preventive Care Benefit will provide coverage for certain evidence-based items (with A or B ratings) in the recommendations of the United States Preventive Services Task Force; immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; evidence-based preventive care and screenings for infants, children, and adolescents provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and additional women’s preventive care and screenings in comprehensive guidelines supported by the HRSA. Physician’s Fee for an Examination in the All Other Charges Billed by the Physician in Connection with the Emergency Room Treatment Hospital’s Fee for the Use of the Emergency Room This brochure represents only a summary of your group health benefits Plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description for ERISA purposes and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding Plan provisions. Enhanced Plan
Standard Plan
Benefit Description
In-Network
Out-of-Network
In-Network
Out-of-Network
All Other Services Billed by the Hospital or Any Other Provider in Connection with the Emergency Room Visit Retail Prescription Drug Co-payments (30-Day Mail-Order Prescription Drug Co-payments (90- Special Notes About Prescription Drug Coverage:
1. The pharmacy will dispense generic drugs unless the prescribing physician requests “Dispense as Written” (DAW) or a generic equivalent is not available. If the covered person refuses an available generic equivalent and
the prescribing physician has not requested DAW, the covered person must pay the applicable co-payment plus the difference in price between the brand-name drug and its generic equivalent.
2. Over-the-counter forms of Claritin, Prilosec, Zyrtec, Tagamet HB, Zantac, Pepcid AC & Complete, Prevacid 24HR, Zegerid, and Allegra will be covered under the Plan and shall be subject to the generic co-payments shown above. A physician’s prescription for these products is required. 3. Prescription drugs prescribed for the treatment of infertility are eligible for coverage under the Plan, subject to the co-payments stated above. However, the Plan will only cover one 60-day supply per covered person per lifetime. 4. All generic contraceptives and all brand contraceptives that do not have a generic equivalent are covered at 100% with no co-payment. All brand contraceptives that do have a generic equivalent are covered at the co-payments stated above. 5. A 90-day supply of a prescribed medication can be purchased at a participating pharmacy (retail level), subject to the mail order co-payments stated above. Required for all inpatient hospital admissions, observational stays at the hospital, and certain outpatient services listed at the end of this Room and Board, Surgical Services, and Ancillary Services Hospital Visits, Surgical Procedures, and Anesthesiology *Limited to One Surgical Procedure to Treat Morbid Obesity per Covered Person per Lifetime. Paid the same as any other surgery; however, benefits payable for transplant-related services that were performed by providers who do not participate with the designated transplant network will be limited to $100,000 per transplant. If you or a covered family member is identified as a transplant candidate, please contact ASR Health Benefits using the phone number listed on the back of your health plan identification card. After your care plan has been reviewed, the designated transplant network will assist you and your physician in selecting an appropriate hospital for your transplant. For additional information about the designated transplant network, contact ASR Health Benefits. Surgery and Surgery-Related Services Chemotherapy and Radiation Therapy Hemodialysis Diagnostic X-Ray and Lab Services This brochure represents only a summary of your group health benefits Plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description for ERISA purposes and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding Plan provisions. Enhanced Plan
Standard Plan
Benefit Description
In-Network
Out-of-Network
In-Network
Out-of-Network
Spinal Manipulations and Therapy Treatments Physician’s Fee for an Initial or Periodic Evaluation $750 Maximum Paid per Covered Person per Benefit Year for All Chiropractic Care (In-Network and Out-of-Network Services Combined) Physical Therapy, Speech Therapy, and Occupational Therapy Hearing Care Services (Includes Audiometric Exams; Hearing Aids; and Hearing Aid-Related Evaluations, Fittings, and Conformity Tests) Durable Medical Equipment, Prosthetics, and Behavioral Care (Includes Mental Health Care and Inpatient/Partial Hospitalization Services Outpatient/Intensive Outpatient Services $2,500 Lifetime Maximum Paid per Covered Person for All Eligible Infertility Treatment (In-Network and Out-of-Network Services Combined) Special Note About Infertility Treatment: Eligible prescription drugs prescribed for the treatment of infertility are not covered under this benefit, but may be eligible for coverage under the Plan’s Prescription Drug benefit.
Temporomandibular Joint Dysfunction (TMJ) $500 Lifetime Maximum Paid per Covered Person for All Non-Surgical TMJ Treatment (In-Network and Out-of-Network Services Combined); The Plan Will Also Allow Charges for Surgery if All Other Means of Generally Accepted Treatment Have Been Exhausted. Services Requiring Authorization:
Coordination with Other Coverage for Injuries Arising out of Automobile Accidents
1. Inpatient hospital confinements and observational stays
The following special coordination rule applies regarding automobile insurance. If a covered person has automobile insurance
2. Home and outpatient rehabilitative therapy
(including, but not limited to no-fault) that provides health benefits, the automobile insurance shall be the primary plan and this
3. Rental and purchase of durable medical equipment
Plan shall be the secondary plan for purposes of paying benefits.
4. Home health care
5. Purchase of custom-made orthotic or prosthetic appliances
If a covered person fails to maintain automobile insurance required by state law to be in effect, and subsequently incurs
6. Oncology treatment
automobile-related Injuries, no benefits for those or related injuries or illnesses will be payable under this Plan.
Special Provision for Working Spouses
If a covered person receives eligible treatment at an in-network facility, any anesthesiology, pathology, or radiology charges will
A participant’s spouse who is eligible for medical coverage under his or her own employer’s group health plan as a full-time or
be paid at the in-network benefit percentage, even if out-of-network providers performed those services.
part-time employee must enroll for that coverage if the spouse’s employer makes a contribution or else pay a surcharge for primary
coverage under this Plan.
This brochure represents only a summary of your group health benefits Plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description for ERISA purposes and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding Plan provisions. Vision Plan
Benefit Description
*co-payment is waived on routine vision exams rendered to covered persons under age 18 **Maximum Benefit Paid per Covered Person per Benefit Year for Frames and Lenses NOTE: For covered persons aged 18 or older, only one vision exam will be covered by the Plan in any Benefit Year.
Dental Plan
Benefit Description
Type II - Minor Restorative Dental Services Type III - Major Restorative Dental Services Type IV - Orthodontic Services (for dependent children under age 19 only) Maximum Benefit Paid per Covered Person per Benefit Year for Types I, II, and III Dental Claims for Type I Preventive Dental Services incurred by covered persons under age 18 are not subject to the Benefit Year dollar maximum. Lifetime Maximum Benefit Paid per Dependent Child for Type IV Orthodontic Services Summary of Dental Procedures
Services:
Special Limitations:
Type I: Preventive Dental Services
Covered Persons under Age 18: No special limitations.
Covered Persons Age 18 or Older: Limited to two times in any 12-consecutive-month period.
Limited to two times in any 12-consecutive-month period. Limited to one time in any 36-consecutive-month period. This brochure represents only a summary of your group health benefits Plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description for ERISA purposes and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding Plan provisions. Summary of Dental Procedures
Services:
Special Limitations:
Type I: Preventive Dental Services, cont.
D. Occlusal, Extraoral, and Individual Periapical X-Rays Limited to two times in any 12-consecutive-month period. Covered Persons under Age 18: No special limitations.
Covered Persons Age 18 or Older: Not covered.
Paid as a separate benefit only if no other service, except x-rays, was rendered during the visit. Paid as a separate benefit only if no other service, except x-rays, was rendered during the visit. Type II: Minor Restorative Dental Services
Limited to one time in any three-consecutive-month period. Limited to one time in any three-consecutive-month period. Limited to one time in any 24-consecutive-month period. Re-cement Inlays, Onlays, Crowns, and Bridges Limited to two times per quadrant of the mouth in any 12-consecutive-month period. Limited to one appliance in any 36-consecutive-month period. Repairs to Full Dentures, Partial Dentures, and Bridges Limited to repairs or adjustments done more than 12 months after the initial insertion. Limited to relining done more than 12 months after the initial insertion and then not more than one time in any 24-consecutive-month period. O. Surgical Extraction of Impacted Teeth Not covered as a dental expense if covered under the employer’s medical plan. Not covered as a dental expense if covered under the employer’s medical plan. Not covered as a dental expense if covered under the employer’s medical plan. Not covered as a dental expense if covered under the employer’s medical plan. Multiple restorations on one surface will be treated as a single filling. W. Silicate, Plastic, and Composite Restorations (fillings) Limited to one appliance in any five-consecutive-year period. This brochure represents only a summary of your group health benefits Plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description for ERISA purposes and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding Plan provisions. Summary of Dental Procedures
Services:
Special Limitations:
Type III: Major Restorative Dental Services
NOTE: For replacement of items A., C., E., F., G., and H. below, see the subsection entitled "EXCLUSIONS AND LIMITATIONS FOR DENTAL BENEFITS" in the Plan document.
Covered only when the tooth cannot be restored by silver fillings. An expense is considered incurred at the time the tooth or teeth are initially prepared. Covered only if the tooth cannot be restored by a filling or by other means. An expense is considered incurred at the time the tooth or teeth are initially prepared. E. Replacement of Teeth to Bridges and Dentures An expense is considered incurred at the time the tooth or teeth are initially prepared. Type IV: Orthodontic Services (Dependent Children Under Age 19 Only)
Orthodontic Diagnostic Procedures, Surgical Therapy, and Appliance Therapy This brochure represents only a summary of your group health benefits Plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description for ERISA purposes and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Health Benefits Plan. Please refer to the Health Benefits Plan Document for specific information regarding Plan provisions.

Source: http://www.baker.edu/bakeredu/assets/File/13HANDOUT-Non-Union-v3.pdf