Ngs-cofinity- 2010 medical plan final.pdf

OVERVIEW OF BENEFITS
The plan is designed to provide levels of benefits based on the choices you make. Benefits that are payable are subject to the terms and conditions of the plan. Non-Network
Deductible
Out-Of-Pocket
(Excluding deductible)
Lifetime Maximum
(Excludes prescription drugs and
separate $1,000,000 maximum per transplant) All transplant procedures and specified clinical trials must be pre-
Pre-Certification
certified. Failure to pre-certify a transplant procedure or specified
clinical trial may result in a reduction or denial in benefits.
MEDICAL EXPENSES
Non-Network
Hospital-Inpatient
80%, after deductible
80%, after deductible
Hospital Visits
80%, after deductible
Emergency Room
accidental injury)
accidental injury)
Urgent Care
80%, after deductible
Allergy Testing and Injections
80%, after deductible
Ambulance
Anesthesia
80%, after deductible
80%, after deductible
Cardiac Rehabilitation
80%, after deductible
Chemotherapy
80%, after deductible
Chiropractic Care
80%, after deductible
Manipulation, Adjustments, Physical Therapy and X-rays Livingston Educational Services Agency Medical Plan Non-Network
Colonoscopy
(Regardless of the diagnosis)
80%, after deductible
Consultations
80%, after deductible
80%, after deductible
Diabetes Management
80%, after deductible
Program - Outpatient
Dialysis
80%, after deductible
Fertility Testing
80%, after deductible
80%, after deductible
Home Health Care
Hospice
(Respite care limited to 5 days during
a 30 day period) (210 days in a lifetime) Implants
80%, after deductible
Injections
Including administration of a covered
80%, after deductible
Laboratory Testing
80%, after deductible
Mammogram
(Limited to1 per calendar year for
80%, after deductible
Medical Equipment and
Supplies
Including insulin pumps and blood glucose monitors Mental Disorders and/or
Substance Abuse Expenses
80%, after deductible
80%, after deductible
Nursing - Private Duty
50%, after deductible
Occupational Therapy
(Limited to 60 visits in a calendar
80%, after deductible
year combined with speech and
physical therapy)
Office Visits
80%, after deductible
during the physician’s office visit
80%, after deductible
Livingston Educational Services Agency Medical Plan Non-Network
Orthotics
Physical Therapy
(Limited to 60 visits in a calendar
80%, after deductible
year combined with occupational and speech therapy) Pregnancy Related Expenses-
80%, after deductible
80%, after deductible
Prescription Drugs
Certain OTC products (including OTC generic equivalents) are covered with a $0 co-pay. (Prescription required) For example, if you are given a Prescription Drug Over-the-
prescription for Clarinex, you can get only one over-the-counter allergy Counter-Incentive
medicine reimbursed for the full cost of the over-the-counter medication. Please refer to the section titled “What If I Need A Prescription Medication?” for additional information. Preventive Care
(Limited to $1,000 in a calendar year)
x PSA x Routine Gynecological Exam x Pap Smear x Sigmoidiscopy Livingston Educational Services Agency Medical Plan Non-Network
Preventive Care
(Limited to $1,000 in a calendar year)
NOTE: Immunizations received at the local health department will be covered at 100% Prosthetic Devices
(Specially designed prosthetic bras
Radiation Therapy
80%, after deductible
Skilled Nursing Facility
Specified Clinical Trials
80%, after deductible
Speech Therapy
(Limited to 60 visits in a calendar
80%, after deductible
year combined with occupational
and physical therapy)
Transplants

Human Organs (Cornea, Kidney,
Skin)
80%, after deductible
$10,000 maximum for transportation, meals and lodging for patient and 1 companion (2 if the patient is a minor) Livingston Educational Services Agency Medical Plan Non-Network
Transplants

80% after deductible
Transplants
Lung (Limited to a separate $1,000,000 maximum per transplant) $10,000 maximum for transportation, meals and lodging for patient and 1 companion (2 if the patient is a minor) Weight Management for Morbid
80%, after deductible
All Other Covered Expenses
80%, after deductible

NOTE: This is only a brief overview of benefits. Please refer to the sections of the plan for
complete information on the eligibility provisions, limitations and for all other terms of the plan. Any maximums listed are applicable to all plan levels. Livingston Educational Services Agency Medical Plan

Source: http://www.livingstonesa.org/cms/lib03/MI17000763/Centricity/Domain/45/Transparency%20Reporting/Health%20Care%20Benefits%20Plan/NGS-COFINITY-%202010%20Medical%20Plan.pdf