BENEFITS SUMMARIES. The Board shall maintain a copy of the then current master plan agreements for all policies and carriers referred to in subsection E and F of this Article at the Administration Building and shall provide then current copies of the benefits summaries for the above-referenced plans in the office of each school building and to each teacher.
BENEFITS SUMMARIES. Anthem (SISC) PPO Plan (110-A$10, Rx $5/20) Medical Plan Benefits SEIU Anthem (SISC) PPO Plan In Network Out-of-Network Calendar Year Deductible Individual/Family Embedded/Aggregate None (N/A) Annual Out-of-Pocket Maximum Individual/Family Embedded/Aggregate $1000/$3000 Embedded No Limit Embedded Physician Office Visit $10 copay; copay waived for visits 1-3 in a benefit period Member pays difference between max allowed and actual charges Specialist Copay $10 copay Member pays difference between xxx allowed and actual charges Preventative Care No charge Not covered Diagnostic Services (Lab and X- ray) No charge Not Covered Lab and X-ray Advanced Diagnostic Imaging (e.g. CT, MRI, PET scans) Other Lab and x-ray tests No charge No charge Member pays all billed amounts exceeding $800 per test* Not covered Hospitalization Inpatient Outpatient (Freestanding Surgical Center) No charge No charge All billed amounts exceeding $600 per day for non-emergency admissions* All billed amounts exceeding $350 per day* Emergency Room Facility Services $100 copay (waived if admitted) Emergency Room Doctor and Other Services No charge Urgent Care Services $10 copay Member pays difference between xxx allowed and actual charges Durable Medical Equipment No charge Not covered Prescription Drugs Rx Copay Out-of-Pocket Maximum Retail- 30 Day Supply Mail Order- 90 Day Supply Generic/Brand $1500/$2500 $5/$20 (at a network pharmacy provider) $0/$50 (Costco Mail Order) *When using non-network providers, the plan will pay the lesser of the benefit maximum or the maximum allowed amount. If the maximum allowed amount is less than the listed benefit maximum, the plan will not exceed the maximum allowed amount. Anthem (SISC) PPO 2 Plan (80-E$20, Rx $5/20) Medical Plan Benefits SEIU Anthem (SISC) PPO 2 Plan In Network Out-of-Network Calendar Year Deductible Individual/Family Embedded/Aggregate $300/$600 Annual Out-of-Pocket Maximum Individual/Family Embedded/Aggregate $1000/$3000 No Limit/No Limit Physician Office Visit $20 copay; copay waived for visits 1-3 in a benefit period Member pays difference between max allowed and actual charges?* Specialist Copay $20 copay (ded. waived) Member pays difference between xxx allowed and actual charges?* Preventative Care $0 (ded. waived) Not covered? Diagnostic Services (Lab and X- ray) 20% Not covered? Lab and X-ray Advanced Diagnostic Imaging (e.g. CT, MRI, PET scans) Other Lab and x-ray tests 20% Member pays all billed amounts exceeding $800 per tes...
BENEFITS SUMMARIES. Medical and
