Nebo school district dual utppq100 4000-b-r0_0_0-c100 nsb 090113.doc

ALTIUS PEAK PLUS QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN
UTPPQ100 4000-B-R0_0_0-C100 NSB
Nebo School District
Participating
Non-Participating
September 1, 2012
Providers
Providers
DEDUCTIBLE, OUT-OF-POCKET & LIMITS
Plan Year Deductible – (Individual / Family) Deductible applies to Out-
of-Pocket Maximum. Cumulative across benefit levels. Out-of-Pocket Maximum – (Individual / Family) All copays and
coinsurance apply. Cumulative across benefit levels. Lifetime Maximum
OUTPATIENT SERVICES
Designated Preventive Care Services – Certain covered office
visits, minor diagnostic tests and x-rays, and outpatient hospital/facility services
received through participating providers are not subject to deductible when provided
in conjunction with a preventive diagnosis, as determined by Altius and in
accordance with Section 223 of the Internal Revenue Code.
Services include the following: Annual adult physical examinations, annual gynecological examinations, well child care, preventive childhood and adult immunizations, preventive blood screening, bone density screening, mammograms, prostate cancer screening, and colorectal cancer screening. Some services you receive during a preventive office visit may not qualify as Designated Preventive Care Services and will be subject to deductible. Other preventive services that are covered by this benefit plan are subject to deductible. Office Visits – Primary Care
Office Visits – Specialty Care
After-Hours Care / Urgent Care – Care received in a primary care
physician’s office or urgent care facility. Chiropractic Office Visits – Limited to 20 visits per member, per Plan
Eye Exams – Optometrist
Major Diagnostic Laboratory Tests and Radiology –
Including, but not limited to CT scans and MRIs. Minor Diagnostic Laboratory Tests and X-Rays
Outpatient Hospital / Facility Services – Including, but not limited
to, outpatient surgery, observation, chemotherapy, radiation therapy, dialysis,
cardiovascular services, infusion therapy, endoscopy, and pulmonary services.
Includes physician charges. Cardiac rehabilitation and pulmonary rehabilitation limited to a combined benefit of 18 outpatient facility visits per member, per Plan year. Physiotherapy Services at a Provider's Office – Physical,
occupational and speech therapy provided on an outpatient basis. Limited to a
combined benefit of 20 provider's office and/or outpatient facility visits of each type per member, per Plan year. Physiotherapy Services at an Outpatient Facility – Physical,
occupational and speech therapy provided on an outpatient basis. Limited to a
combined benefit of 20 provider's office and/or outpatient facility visits of each type per member, per Plan year. Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 * Applies to out-of-pocket maximum (OOPM), AD = after deductible PQCMPOS3500 Rev. 12-11
ALTIUS PEAK PLUS QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN
UTPPQ100 4000-B-R0_0_0-C100 NSB
Nebo School District
Participating
Non-Participating
September 1, 2012
Providers
Providers
EMERGENCY CARE
Emergency Room Care – When medically necessary, as determined by
Altius. Includes all services provided in an Emergency Room setting. Inpatient
benefit applies when admitted. Outpatient hospital benefit applies when transferred to an operating room. Urgent Care –
When medically necessary, as determined by Altius. Ambulance / Paramedics – (including Air Ambulance) When medically
INPATIENT SERVICES
Inpatient Hospital / Facility Services
Inpatient Physiotherapy Services – Physical, occupational and
speech therapy provided on an inpatient basis. Limited to 60 days per member, per
Plan year for all therapy types combined. Physician, Surgeon, Assistant Surgeon,
Anesthesiologist
Organ Transplant Services – Organ and tissue transplant services,
including, but not limited to, cornea, kidney, heart, lung, heart-lung, liver, pancreas,
and bone marrow transplants and related services. MATERNITY SERVICES
Pre-Natal and Post-Natal Care – Obstetrician or Certified
Nurse Midwife – Routine pre-natal office visits, delivery (including surgeon
and assistant surgeon), and post-natal care. Regular benefits apply for complications of pregnancy. Inpatient Hospital / Facility Services
Adoption Indemnity Benefit – Indemnity benefit for a child placed for
adoption with the subscriber within 90 days of birth. The maximum benefit amount
is $4,000, and will be reduced by any applicable deductible, copay, and/or INJECTABLE OR IMPLANTABLE MEDICATIONS
Injectable or Implantable Medications – Non-Facility –
Injectable or implantable medications received in a physician’s office or through a
home health provider. (Preferred / Non-Preferred) Injectable or Implantable Medications – Pharmacy
PRESCRIPTION DRUGS
If you receive a Tier 2 or Tier 3 brand name drug when a Tier 1 generic equivalent can be substituted, you will pay the difference in cost between
the generic and the brand name drug, any applicable deductible, and/or the Tier 1 copay. Regular benefits apply if a Tier 1 generic cannot be
substituted.
Prior Authorization / Step Therapy: Standard

Prescription Drugs – Up to a 30-day supply. This benefit also includes the
following injectable medications when provided by an Altius participating
pharmacy: insulin, Imitrex, Symlin, Byetta, glucagon, Lovenox, and epinephrine kits (such as Epi-Pen). (Tier 1 / Tier 2 / Tier 3) Prescription Drugs Mail Order – 90-day supply of maintenance
MENTAL HEALTH / SUBSTANCE ABUSE
Inpatient Services
Outpatient Services
Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 * Applies to out-of-pocket maximum (OOPM), AD = after deductible PQCMPOS3500 Rev. 12-11
ALTIUS PEAK PLUS QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN
UTPPQ100 4000-B-R0_0_0-C100 NSB
Nebo School District
Participating
Non-Participating
September 1, 2012
Providers
Providers
ALLERGY CONDITIONS
Serum and Treatment
Injections
OTHER BENEFITS
Accident Related Dental Services – Dental services required as the
result of an accidental injury. Services include, but are not limited to, crowns, caps,
bridges, and root canals. Limited to a combined lifetime maximum of $1,000 per Durable Medical Equipment (DME) – Including corrective
Home Health Care – Limited to a combined benefit of 60 visits per
Hospice Care – Care for a terminally ill member through a licensed hospice
Implantable Contraceptives and Intra-Uterine Devices
Infertility Services – Evaluation, testing, and diagnostic services. Includes
services that are provided for the purpose of ruling out infertility. Limited to $750 per member, per Plan year, up to a lifetime maximum of $5,000. Medical Supplies – Disposable medical supplies and accessories as
determined medically necessary by Altius. Skilled Nursing Facility – Limited to a combined benefit of 60 days per
Temporomandibular Joint Dysfunction (TMJ) – Evaluation,
testing and diagnostic services. Limited to a combined lifetime maximum of $1,000. GENERAL INFORMATION
Plan Year Deductible – You must satisfy an individual or family deductible each plan year before most benefits will be provided under this
benefit plan. All deductibles, copays and coinsurance amounts count towards the out-of-pocket maximum.
Out-of-Pocket Maximum – All deductibles, copays and coinsurance amounts apply to the Out-of-Pocket Maximum. When you or your family
fulfill out-of-pocket maximums during a plan year, then no further out-of-pocket expenses will be required for the remainder of that plan year. This
provision does not apply to non-covered services or charges that exceed eligible medical expenses. You are required to keep receipts for out-of-pocket
expenses and furnish such proof to the Altius Claims Department when you reach your maximum.
Securing Benefits and Payment for Services Through Altius - In order for a medical service to be eligible for coverage, it must
be defined as a covered benefit and properly coordinated through Altius. Prior authorization is required for certain services (excluding emergency care) in
order to verify that the services to be provided are covered by your benefit plan and are medically necessary and appropriate. It is your responsibility to
determine that providers and facilities have obtained prior authorization from Altius prior to receiving care. If prior authorization from Altius is not
obtained, coverage may be denied.
Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses in addition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 * Applies to out-of-pocket maximum (OOPM), AD = after deductible PQCMPOS3500 Rev. 12-11
specified in the Altius formulary; medications for athletic and mental performance; compounding fees; non-covered ingredients When required by federal law, limitations and exclusions will not apply used in a compounded medication; medications for cosmetic to injuries resulting from an act of domestic violence or a medical indications; hair growth products and medications; homeopathic condition (including both physical and mental health conditions). medications; hypodermic needles; impotence medications; medications for the treatment of infertility; skin patches for motion The following benefits are limited under this benefit
sickness; medications for the treatment of nail fungus; progesterone cream and suppositories; smoking cessation products, including any medications prescribed for smoking cessation; medications required Physiotherapy services (occupational, physical and speech) are exclusively for foreign travel; oral vitamins (except prescription limited to medically necessary services for conditions resulting from prenatal vitamins); medications for shift work sleep disorder; illness or injury where therapy can be provided in a short-term medications or nutritional supplements for weight loss, or for weight rehabilitation program that is likely to significantly improve the member’s condition, as determined by Altius. Replacement of lost, stolen, or damaged prescription drugs. • Altius reserves the right to include only one manufacturer’s product • Immunizations required exclusively for foreign travel. on the Altius formulary when the same or similar drug (that is, a drug with the same active ingredient), supply, or equipment is made Food supplements, food substitutes, medical foods, and formulas by two or more different manufacturers. The product or products not when taken orally, except when related to inborn errors of amino listed on the Altius formulary will be excluded from coverage. • Altius reserves the right to include only one dosage or form of a drug on the Altius formulary when the same drug is available in In-vitro fertilization, GIFT, ZIFT, artificial insemination, and similar different dosages or forms (for example, dissolvable tablets, services. This includes any related services such as prescription capsules, etc.), from the same or different manufacturers. The medications, embryo transport, collection, and preparation costs. product or products in other forms or dosages that are not listed on the Altius formulary will be excluded from coverage. • Amniocentesis and ultrasonography for sex determination. • Implantable contraceptive capsules such as Norplant and Implanon are limited to one implantation and removal during the maximum • Predictive diagnostic testing and screenings, and other preventive implantation period of the product, as determined by the product services performed in the absence of illness or injury, other than those procedures or tests specifically recommended by Altius, the • Neuropsychological evaluation and treatment is limited to those United States Preventive Services Task Force (USPSTF), the services that diagnose or treat an underlying medical condition and Centers for Disease Control (CDC), and local government public is covered only when there is clinically significant brain health authorities. Preventive services performed more often than, or outside of the guidelines of Altius, the USPSTF, CDC, and local • Accident-related dental services are covered only when required as a government health authorities, are excluded. result of an accidental injury to sound, natural teeth. Dental services • Elective home delivery for childbirth. must be received within two years following the accidental injury. • Procedures, services, drugs, and supplies related to elective abortions, • A determination by Altius that a service is infertility-related may be except when the life of the woman would be endangered if the fetus based on medical records or other documented evidence, and is not were carried to term or when the pregnancy is the result of an act of dependent on whether Altius actually receives a claim with a Surgical treatment for obesity (including morbid obesity) and/or • Certain medications, including those that are administered by a medical complications therefrom, including a reversal of these surgeries. professional, are covered only when they are purchased through • Sex change operations or related health care services. designated specialty pharmacies. To obtain a current list of these • Treatment, services, devices, and supplies related to sexual medications, visit the Altius web site or call customer service. dysfunction[, except as provided herein]. This exclusion does not • Cochlear implants are covered only for those members who meet all apply to implantation of a penile prosthesis or use of an external of the following criteria: member has been diagnosed with bilateral device for impotence caused by an organic disease such as diabetes profound sensorineural hearing loss; member has a functioning mellitus or hypertension, or caused by surgery for genitourinary auditory nerve; member is less than 18 years old; member has the cognitive ability to communicate effectively with restored hearing; Surgery performed in order to prevent the possible onset of a hearing cannot be restored adequately with conventional hearing condition or disease with which the member has not been diagnosed. aids; and member and family are willing and able to participate in • Services, supplies, or treatment in connection with cosmetic or reconstructive procedures which alter appearance but do not restore or improve impaired physical function, or which are performed for The following are excluded from coverage under this
psychological or emotional purposes. This exclusion does not apply benefit plan:
to: (1) reconstructive surgery required as the result of an accidental Services provided outside the United States of America and its injury, infection, or cancer. Services must be rendered (or a planned, territories, except as required for an emergency or urgent condition. staged series of services, as specifically documented in the member’s medical record, must be initiated) within 12 months of the New procedures, services, supplies, and medications until they are cause or onset of the injury, infection, or cancer; (2) circumcision reviewed for safety, efficacy and cost effectiveness and approved by for a newborn child up to three months of age; or (3) reconstruction of the breast(s) following a medically necessary mastectomy. Experimental or investigational treatment, procedures, tests, equipment, or facilities, or any health care service which is still Treatment of hyperhidrosis (perspiration/sweating) or sialorrhea Services, drugs, and supplies that are not medically necessary, as Medication amounts in excess of maximum quantity and/or dosage Health education services not closely related to the care and levels indicated by the drug manufacturer and the FDA. treatment of an illness or injury, except as specifically recommended by the USPSTF and provided within USPSTF guidelines. Experimental medications; medications for non-approved FDA indications or non-approved indications determined by Altius Health Services provided by an athletic trainer or a personal trainer. Plans; over-the-counter medications and products, except those Telephone consultations, electronic mail communication, and specifically listed in the Altius formulary and those for which communication services that do not require direct face-to-face coverage is required by law; prescription medications that have an contact between the patient and the provider. over-the-counter equivalent or alternative, unless otherwise • Charges for failure to keep a scheduled appointment. PQCMPOS3500 Rev. 12-11
• Interest or finance charges, except as specifically required by law. • Services related to the treatment of sensory processing dysfunction • Prolotherapy (the use of injections to strengthen tendons and or sensory integration disorder. This exclusion does not apply to the initial assessment for diagnosis of the condition or to the medical • Services for crossmatching and/or harvesting organs when the organ management of an underlying medical illness which may be • Routine foot care. This exclusion does not apply to members with • Psychotherapy, counseling or other services in connection with marital or family problems; social, occupational, religious, or other social • Treatment of weak, strained or imbalanced feet. maladjustments; conduct disorders; chronic adjustment disorders; • Foot orthotics, wedges or shoe inserts, unless herein provided. This psychosexual disorders; chronic organic brain syndromes; personality exclusion does not apply to foot orthotics or shoe inserts for disorders; developmental disorders; learning disabilities; or mental retardation. This exclusion does not apply to the initial assessment for • Corrective appliances, prostheses, artificial aids and durable medical diagnosis of the condition, nor to the medical management of an equipment, including supplies and accessories, are excluded when underlying medical illness which may be contributing to the disability. determined to be primarily for convenience, comfort, non- • Electrosleep or electronarcosis therapy, rapid detoxification programs, therapeutic purposes, or in the absence of illness or injury. • Helmet therapy for benign positional plagiocephaly. • Psychiatric treatments or services performed in the absence of a • Routine periodic servicing, such as cleaning and regulating, of durable medical equipment, corrective appliances, and prostheses is • Treatment for mental disorders that are irreversible or for which there not covered. Replacement is not covered unless the existing device is little or no reasonable expectation for improvement. has become inoperable through normal wear and tear and cannot be • Substance abuse maintenance therapy, such as methadone clinics repaired, or replacement is prescribed by a physician because of a change in the member’s physical condition. • Evaluation, testing, and treatment provided by public or private • All shipping, handling, or postage charges, except as incidentally • Charges in connection with a work-related injury or sickness for Any devices used to aid hearing, including, but not limited to, which coverage is provided or would be provided under any cochlear implants for members 18 years of age and older and workers’ compensation, employer’s liability, or occupational disease hearing aids, including the fitting of such devices and related law. When the employer is required by law to have such coverage, this exclusion applies whether or not such coverage is in effect. Routine periodic servicing, repairs, batteries and accessories for any • Services, supplies, or treatment for which coverage is provided under any motor vehicle no-fault plan. When the member is required by law to have no-fault insurance, this exclusion applies to charges • Eyeglasses, contact lenses, and examinations for contact lenses. This up to the minimum coverage required by law whether or not such exclusion does not apply to: (1) the first pair of contact lenses or eyeglasses following the initial diagnosis of aphakia or the surgical • Expenses for which the member has no legal responsibility to pay or removal or surgical replacement of an organic lens; or (2) for which the member would not ordinarily be charged in the hydrophilic contact lenses used as a corneal bandage to treat absence of coverage under this benefit plan. conditions involving the cornea. In the event that eyeglasses are • Care for military service connected disability to which the member covered, the following are excluded: additional charges for deluxe is legally entitled, and for which facilities are reasonably available to frames or lens enhancements, including but not limited to blended lenses, oversize lenses, progressive lenses, tinted lenses, lens • Care or treatment of an illness or injury caused by war or any act of coatings, or other lens options not related to the correction of war (whether declared or undeclared), hostilities, or voluntary participation in a riot or civil insurrection. • Eye surgeries performed primarily to correct refractive errors. • Care for conditions which state or local law requires to be treated in Examples include, but are not limited to: PRK (photorefractive keratectomy), LASIK (laser-assisted in-situ keratomileusis), RL • Services and treatments provided in connection with, or to comply (refractive lensectomy), ICRS (intracorneal ring segments), Intacs, with, involuntary admissions, police detentions, and similar phakic intraocular lenses (unless related to post-cataract surgery), and astigmatism correction (Limbal Relaxing Procedure). This • Examinations and services obtained for administrative purposes, exclusion does not apply to cornea transplants. such as treatment, care, reports or appearances obtained for, or • Non-emergency follow-up care provided in an emergency room. pursuant to, legal proceedings, court orders, employment, continuing • Charges for transportation, including ambulance, unless determined or obtaining insurance coverage, governmental licensure, travel, or • Travel expenses, including hotel, motel and other non-medical room • Oral surgery, including but not limited to orthognathic surgery, unless determined medically necessary by Altius for treatment of • Private hospital rooms, unless medically necessary. obstructive sleep apnea or direct treatment of an invasive tumor or • Hospital take-home drugs and personal, comfort, or convenience • Services related primarily to the treatment of Temporomandibular Joint Syndrome (TMJ). This exclusion does not apply to diagnosis • Custodial care, domiciliary care, rest cures, and independent living • Dental or orthodontic splints or dental prostheses, unless determined • Home health services requested for the convenience of the patient or medically necessary by Altius for treatment of obstructive sleep family that do not require the training and technical skills of a nurse. apnea or necessitated by accidental injury. Hospice services that are not reasonable and necessary for palliation Services related to the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth, unless herein provided or necessitated by accidental injury. Physiotherapy services (occupational, physical and speech) for psychosocial and/or developmental delays, including, but not limited • Alternative medicine programs such as hypnosis, massage therapy • Physiotherapy services (occupational, physical and speech) for work hardening or for recreational purposes, including, but not limited to • Recreational therapy, wilderness therapy, or residential treatment PQCMPOS3500 Rev. 12-11
• Injury or illness resulting from voluntary participation in an illegal • Services for which a provider waives the member’s copay, • Services provided by a member of the patient’s immediate family or • Expenses related to non-covered services, including pre- and post- operative evaluation, diagnostic testing, and complications resulting from non-covered services, supplies, and/or medications. When a non-covered procedure is performed as part of the same operation or process as a covered service, then only eligible charges relating to the covered service will be covered. Pre-existing conditions during the pre-existing condition waiting • Benefits and services not specified as covered in the Group Service ALTIUS HEALTH PLANS
PQCMPOS3500 Rev. 12-11

Source: http://www.nebo.edu/sites/nebo.edu/files/Altius%20Dual%20HDHP%20Plan.pdf