SUMMARY OF BENEFITS
CHARTER
10 POINT OF SERVICE
PACE UNIVERSITY
AS ADMINISTERED
BY HEALTH NET, FORMERLY PHS HEALTH PLANS
EFFECTIVE
DATE: January 1, 2003
Customer Service # 1-800-205-0095
www.health.net
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BENEFITS
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IN-NETWORK 1
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OUT-OF-NETWORK 2
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Financial
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Deductible:
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None
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$300
Single, $600 Two Person, $900
Family
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Max.
Out-of-Pocket Cost:
(Does
not include charges in excess of allowed amount or non-covered
benefits)
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$1,000
Single, $2,000 Family
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$1,800
Single, $3,600 Family
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Max.
Lifetime Benefit Per Member
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$2,000,000
combined in-network/out-of-network lifetime maximum
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Prescription Drugs
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Coverage
(Note: oral contraceptives, contraceptive devices and Norplant
are covered as part of the member’s prescription drug coverage,
subject to the applicable copayment)
Mail
Order, for a 90 day supply:
Member must use Walgreens Healthcare Plus Mail Order
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Retail
$10 Copayment per Generic
per prescription
$10 Copayment
per Brand Name prescription plus difference unless the physician
indicates Dispense as Written (DAW)
Mail
Order
$10 Copayment per Generic prescription
$15 Copayment
per Brand Name prescription plus difference unless the physician
indicates Dispense as Written (DAW)
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Outside
Service Area: Covered as in-network if the member uses the Advanced
Paradigm, Inc. (API Network).
If the member uses a non API pharmacy, prescriptions
will be covered, subject to the medical deductible and co-insurance.
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Preventive Care
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Routine
Physical Exams - Children Through Age 18
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$10 Copayment in accordance with HEALTH NET’s
schedule of covered well exam
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Covered
In-Network Only
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Adults
Age 19 and Over
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$10 Copayment in accordance with HEALTH NET’s schedule
of covered well exam
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Covered
In-Network Only
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Routine
Preventive Immunizations
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$10 Copayment per Visit
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Covered
In-Network Only
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Routine
Gynecological Care
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$10 Copayment per Visit, members age 15 and older are covered
for one pap test and one pelvic exam per calendar year
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Covered
In-Network Only
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Maternity Care
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Pre-Natal
& Post-Natal (from effective date of HEALTH NET’S coverage).
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No Cost
after 1st Visit with a $10 Copayment
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70% of
UCR
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Hospital
Services for Mother & Child (includes all newborn costs
even if mother is discharged and newborn requires continued
hospitalization)
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No
Cost
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70% of
Hospital Charges
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Family
Planning and Infertility Services (includes in-vitro fertilization
and GIFT)3
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$10 Copayment per Visit
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Covered
at 70% of UCR
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Outpatient Care
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Physician
Office Visits
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$10 Copayment per Visit
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70% of
UCR
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X-rays
& Laboratory Tests
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No Cost
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70% of
UCR
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Physical
& Occupational Therapy, Including Chiropractic Care3
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$10 Copayment per Visit
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70% of
UCR
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Cardiac
Rehabilitation
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$10 Copayment per Visit
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70% of
UCR
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Speech
Therapy, for up to 90 consecutive days3
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$10Copayment
per Visit
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70% of
UCR
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Allergy
Services
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$10 Copayment per Visit
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70% of
UCR
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Diagnostic
Procedures and/or Surgery Performed in a Hospital or Outpatient
Surgical Care3
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No Cost
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70% of
Hospital Charges
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BENEFITS |
IN-NETWORK 1 |
OUT-OF-NETWORK 2 |
| Vision Care |
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| Routine
Eye Exams |
$10 Copayment per Visit; One Visit per Member per 24 Months |
Not Covered |
| Eyeglasses,
including frames, lenses, etc. |
$200
combined allowance |
$200
combined allowance |
| Medical
Care for Illness or Injury to the Eye |
$10 Copayment per Visit |
70% of
UCR |
| Inpatient Care |
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| Semi-Private
Room and Board3 |
No Cost
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70% of
Hospital Charges |
| Physicians',
Surgeons’ and Nursing Services and Medications3 |
No Cost
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70% of
UCR |
| Special-Duty
Nursing3 |
No Cost
for up to 70 shifts per member per year |
70% of
UCR |
| Restorative
Physical & Occupational Therapy3 |
No Cost
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70% of
Hospital Charges |
| Mental Health, Drug/Alcohol Addiction |
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| Outpatient
Visits, up to 30 Outpatient Visits per Member per Year Combined
- All Services4 |
$20 Copayment per Visit
Mental
Health services require Prior Authorization after the 6th
visit3 |
50% of
charges per Visit/Session
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| Inpatient
Days Exchangeable with Partial Hospitalization Sessions up to
30 Days per Member per Year4 |
No Cost
Mental
Health services require Prior Authorization 3 |
70% at
HEALTH NET Approved Facilities |
| Home Health or Hospice Care |
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| Physician
House Calls |
$10 Copayment per Visit |
70% of
UCR |
| Home
Health Care When Skilled Services are Required3 |
No Cost;
200 Visits per Calendar Year |
70% in
Lieu of Hospitalization |
| Inpatient
Hospice Care3 |
No Cost
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70% of
UCR |
| Other Services |
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| Durable
Medical Equipment 3 |
No Cost |
70% of
Cost of Covered Item |
| Prosthetics
(maximums are combined in and out of network)
- Internal
- External, to a maximum
of $5,000 for the first appliance |
No Cost
No Cost |
70% of
UCR
70% of UCR
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| Gym Membership |
Discount |
Covered
In Network Only |
| Massage |
Discount |
Covered
In Network Only |
| Acupuncture,
for up to 20 visits per year |
$20 Copayment per Visit |
Covered
In Network Only |
| Emergency Care |
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| At Physicians
Office |
$10 Copayment per Visit |
$10 Copayment per Visit |
| Urgent
Care at an Urgent Care Center |
$10 Copayment per Visit |
$10 Copayment per Visit |
| At Hospital
Emergency Room |
$15 Copayment per Visit |
$15 Copayment per Visit |
| Limiting Age |
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| Dependents
are covered to the end of the month in which the eligible dependent
reaches age 19. If the
eligible dependent is 19 or over, and is a full-time student,
coverage will extend to the earlier of the end of the month
in which the eligible dependent graduates, ceases to be a full-time
student, or reaches age 25. |
1 In Network services
are services and benefits provided or arranged by a HEALTH NET participating
provider.
2 Out of Network
services require a member to pay a deductible and coinsurance.
3 When medically
necessary and approved in advance by HEALTH NET.
4. Substance Abuse
- when medically necessary and approved in advance.
Copayment Maximum: All
of your in-network copayments will be applied
to the annual copayment maximum of $1,000
per member or $2,000 per family per calendar year.
Out-of-Network Benefits: When using Out-of-Network benefits, precertification
is required for all inpatient and outpatient hospital admissions,
all elective ambulatory surgical procedures, and most diagnostic procedures
received in a non-plan hospital or free-standing surgical center. To obtain precertification,
please contact the HEALTH NET Customer Service Department at 1-800-205-0095.
A $200 penalty is applied to Out-of-Network reimbursement when
the member does not complete the precertification process.
General Exclusions: This
plan does not cover physical exams for employment, insurance, school,
premarital requirements or summer camp (unless substituted for a normal
physical exam); prescription drugs and some injectables
dispensed by a physician in his or her office; prescription drugs
prescribed for a non-covered service; dental services; routine foot
care; some transplant procedures; cosmetic or reconstructive surgery,
unless medically necessary; custodial services; weight-reduction programs;
marriage counseling; or psychiatric treatment which is above and beyond
the guidelines as determined to be clinically acceptable.
The services, exclusions and limitations listed above
do not constitute a contract and are a summary only. The Pace University plan documents are the final
arbiter of coverage under the plan.
If you have any questions, please call the HEALTH NET Customer Service Dept. at 1-800-205-0095 or contact
the Pace University Employee Benefits Office at 1-914-923-2763.
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