Out-of-Area Plan: Plan Design
The Out-of-Area plan allows a participant to use any provider he or she wishes. Each participant must meet the $350 deductible. Then, whenever the participant receives medical services, the plan pays a percentage of the cost of services, up to the R&C limit. The participant pays the remaining percentage (coinsurance) plus any amount above the R&C limit.
Participants may be responsible for filing claims for reimbursement. Participants should check with their provider for information on their payment and claim filing policies.
Reasonable and Customary (R&C) Limit
The R&C limit is the maximum amount the plan will pay for a covered service, based on what providers in the participant's geographic area charge for similar services. Participants are responsible for paying any difference between the R&C limit and the amount billed. The determination of what the reasonable and customary limit is for a specific medical service is within the sole discretion of the Claims Administrator and is not subject to challenge or review.
Multiple and Bilateral Surgical Procedures
Multiple surgical procedures consist of more than one surgical procedure performed on the same date of service during the same surgical session. Bilateral surgeries consist of surgery performed during the same surgical session through separate incisions to matching parts of the body (e.g., both shoulders). When multiple or bilateral surgical procedures are performed during the same operative setting, the allowed amount of secondary and subsequent procedures is reduced.
Major (first) procedure - 100% of R&C
Second procedure - 50% of R&C
Subsequent procedure - 25% of R&C
If multiple or bilateral surgical procedures are performed by network providers, participants will not have to pay any more as a result of the reduced amount. Participants who choose out-of-network providers could incur additional costs if the provider chooses to bill the member for the remaining balance.
Multiple Scan/Images Procedure
When multiple images of adjacent body parts are taken during a single session, a reduction will be applied to the technical component of the services performed. Professional fees billed separately are not affected.
Initial scan/imaging - 100% of R&C Subsequent scan/imaging - 75% of R&C
If multiple or bilateral surgical procedures are performed by network providers, participants will not have to pay any more as a result of the reduced amount. Participants who choose out-of-network providers could incur additional costs if the provider chooses to bill the member for the remaining balance.
Prescription Drug Program
Prescription drugs are covered under the Out-of-Area plan when they are purchased from a network pharmacy or through the mail order program.
Retail Pharmacies
A participant who needs to take medication for a short period of time (up to 30 days) should locate the nearest network pharmacy.
To find a participating pharmacy, participants can log on to their PPO network web site.
Prescription drugs are not covered if they are purchased from out-of-network pharmacies.
Mail Order
A participant who needs to use a long-term, maintenance medication (usually a prescription for more than 30 days) can fill his or her prescription through the mail order program. By using the mail order program, participants can receive up to a 90-day supply of medication for two times the copay amount, and prescriptions are mailed directly to the participant's home.
Types of Prescriptions Available
The amount a participant pays for a prescription depends on the type of drug he or she purchases:
| Type of Prescription | At a retail pharmacy (up to a 30-day supply), you pay: | Through mail order (up to a 90-day supply), you pay: |
|---|---|---|
| Generic | $10 copay | $20 copay |
| Brand formulary | $20 copay | $40 copay |
| Brand non-formulary | $35 copay | $70 copay |
- Generic drugs have the same chemical composition and potency as brand-name equivalents, but are less costly.
- Brand formulary drugs are on a preferred list of prescriptions (called a formulary) due to significant discounts negotiated with the drug manufacturer and/or proven effectiveness.
- Brand non-formulary drugs are brand-name drugs that do not have a generic equivalent and are not included on the list of preferred drugs. Brand-name drugs that are not on the formulary require the highest copayment, since these drugs are the most costly to the plan.
The formulary is subject to change. For up-to-date formulary information, participants should visit the applicable web site or call the number on the back of their ID card.