Microsoft word - plan iii schedule of benefits booklet 2014.docx
Schedule of Benefits Booklet
The Benefits and coverages described herein are provided through a Trust Fund, The Health
Plan Trust for the Members of the Oklahoma Lumbermen’s Association, established by a
group of employers, members of the Oklahoma Lumbermen’s Association. The Trust Fund is
not subject to any insurance guaranty association. Other related financial information is
available from your employer or from the Oklahoma Lumbermen’s Association. Excess
insurance is provided by a licensed insurance company to cover certain claims which exceed
certain amounts. This is the only source of funding for these benefits and coverages. The
benefits and coverage described herein are funded by contributions from employers and
employees who are eligible for coverage.
SUMMARY SCHEDULE OF BENEFITS BOOKLET
Verification of Eligibility
Call the numbers listed below to verify eligibility for Plan benefits. Verification of Benefits is not binding
on the Plan. All benefits are subject to Plan’s provisions at the time treatment is provided.
(800) 842-4351 or (405) 290-5612
All benefits described in this schedule of benefits booklet are subject to the exclusions and limitations
described in the Plan Document, which is incorporated herein by reference. This includes, but is not
limited to, the Plan Administrator's determination that: care and treatment is Medically Necessary; that
charges are Usual and Reasonable or within provider contract allowable; that services, supplies and care are not Experimental and/or Investigational. The meanings of these capitalized terms are in the Defined
PRE-SERVICE notification for the Covered Person is required to make sure the Plan is
notified within 2 business days prior to the beginning of a Covered Person’s hospital
inpatient stay, Long Term Acute Care Facility stay, skilled nursing facility stay, home health
care, outpatient surgery or purchase or rental of durable medical equipment in excess of
$1,000. Please review this part carefully to avoid a benefit reduction. The telephone
number for Pre-service notification is (855) 253-7283.
Pre-service notification is not required for a maternity length of stay that is 48 hours or less
for a vaginal delivery or 96 hours or less for a cesarean delivery. Please see the Cost
Management section in this booklet for details.
Penalty for failure to comply: Benefit payment will be reduced one hundred dollars
($100.00) per occurrence for non-compliance with Pre-service notification. Penalty does not
apply to Wellness procedures.
Selecting your Medical Care Professionals and Facilities
This Plan is a plan that has a Participating Provider Organization (PPO) feature. The current PPO for the
Plan is First Health. This is subject to change by the Plan without notice. The PPO has entered into an
agreement with certain hospitals, physicians and other health care providers, which are called
Participating Providers. Because these Participating Providers have agreed to charge reduced fees to
persons covered under the Plan, the Plan can afford to reimburse a higher percentage of their fees.
Consult “ERISA Disclosures and Information” section or your identification card to identify your PPO. The Employee is free to choose any provider for their own and their Dependent’s care. The benefits
provided to reimburse for services are maximized when the Covered Person selects providers in the PPO.
The lowest level of benefits applies to services provided by out-of-network providers. Therefore, when a
Covered Person uses a PPO provider, that Covered Person may receive a higher payment from the Plan than when an out-of-network provider provides treatment. It is the Covered Person’s choice as to which
PPO benefits apply only to charges for services performed by providers actively participating in the PPO
network on the date services were received. Not all providers at participating hospitals are in the
network. Some services during an episode of care, may be covered at the out-of-network level. For example, if a Participant has surgery at a PPO hospital using a participating surgeon, your anesthesiology
or pathology, or other services may be from out-of-network providers. If this happens, the
anesthesiology and pathology services would be treated as out-of-network benefits.
Additional information about this option, as well as a list of Participating Providers will be made available
to Covered Persons and updated as needed.
Medical Emergency Provision.
If care is provided in the event of a Medical Emergency as defined by
the Plan, benefits will be paid at the in-network level, limited to the in-network Allowable Charge or Usual
and Reasonable charge, whichever is lower.
Global maximum out-of-pocket amount. Applies to PARTICIPATING PROVIDER
ORGANIZATION (PPO), Tier 1 – Tier 2 Specialty Drug and Tier 1 – Tier 2 Organ Transplant
claims only. Does not apply to Prescription Drug copays. To the extent a Covered Person
has claims for in-network, Allowable Charges under the Plan; and the Covered Person is
responsible to pay a portion of these charges because of deductibles, copays or other
applicable Plan provisions; the maximum amounts for a Calendar Year are:
Per Covered Person
OUT OF NETWORK
DEDUCTIBLE PER CALENDAR YEAR *
*The Deductible amounts for each benefit are separate and do not apply to the next higher Deductible. For example, deductible amounts applied to the PPO level do not apply to the out-of network (OON) level deductible.
MAXIMUM OUT-OF-POCKET AMOUNT (OOP), PER
The plan will pay the designated percentage of covered charges until the out-of-pocket amounts are reached, at which
time the plan will pay 100% of the remainder of covered charges for the rest of the Calendar Year unless stated
otherwise. In-network (PPO) out-of-pocket accumulates to out-of-network (OON) out-of-pocket. The following charges do not apply to the out-of-pocket maximum and are never paid at 100% until the
global maximum out-of-pocket amount is reached.
Emergency room care when there is no medical emergency
Participating Providers (PPO) transplant care benefits
Non-covered charges, such as amounts that exceed Allowable Charge or Usual and Reasonable charge limits
Inpatient Care (OON room limited to $500 per day)
Intensive Care Unit (OON ICU room limited to $1,250 per day)
Emergency Room Care when there is no medical emergency.
50% copay - does not apply to out-of-pocket
Physician Services –
except as otherwise described in the
Allergy & Hormone Injections - does not include office visit
Other covered physician services unless limited in this summary Plan pays 80% after
OUT OF NETWORK
All Other Covered Outpatient Services
Including CT scans &
MRI’s and laboratory and radiology services performed outside the
Total Parenteral Nutrition (TPN)
Well Child Care
Services mandated to be covered by the Patient Protection and Plan pays 100%
Adult Preventative Care:
Services mandated to be covered by the Patient Protection and Plan Pays 100%
Prostate cancer screening – limited to one physician office visit
and PSA lab test annually, for participants age 40 and older
Skilled Nursing Facility
Home Health Care
Emergency Only, to nearest facility that can treat
$30 copay per visit then Plan pays 60% after
24 Outpatient visits maximum per Calendar Year
Spinal Manipulation/Chiropractic –
Durable Medical Equipment
Prosthetics and Orthotics
OUT OF NETWORK
Prescription Drugs –
Retail –30 day maximum supply except for insulin which has a
Patient pays a $125 copay for single-source brand name drugs that do not have an exact generic equivalent but have a viable generic therapeutic alternative. If the generic therapeutic alternative is purchased, the generic copay applies.
Specialty Drug Benefit
Any deductible or out-of-pocket is separate Dispensed and billed by Dispensed and billed by OUT OF NETWORK
from any other deductible or out-of-pocket Script Care specialty
$125 per specialty drug $175 per specialty drug Not covered
The Plan will pay 80% The Plan will pay 80%
OUT OF NETWORK
Allowable Charges after Allowable Charges after
Allowable Charges after Allowable Charges after
Cost Management Services – Penalty for failure to
comply (See the Cost Management Services section
Benefits will be reduced by $100 per occurrence
Penalty does not apply to wellness procedures.
2014 OLA Health Plan Plus Specialty Drug List
The drugs listed are considered specialty drugs. Benefits under this Part are excluded from the Outpatient Prescription Drug Benefit. OLA Health Plan
Plus has entered into an agreement with a provider called SCL Specialty Pharmacy. When the specialty pharmacy is used, a higher level of benefit wil
be received than when the listed drugs are obtained elsewhere. Please refer to the schedule of benefits booklet for the benefit tiers and benefit
maximums. To use the specialty pharmacy, the participant or the Physician submits a prescription to the specialty pharmacy to have the specialty drug
shipped. All claims are handled by the specialty pharmacy.
Benefits subject to established plan provisions and copay amounts. OLA Health Plan Plus’ Specialty Drug List is reviewed annually and updated accordingly.
M NOTE: These medications are subject to manufacturer availability. Please contact SCL Specialty Pharmacy at 866-443-1991 for more information.
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