Emerald Cover & Outline

National Business Advocates

Presents

Emerald Cover

For employer groups

This plan is available as a full benefit plan

Hospitals, Doctors, Lab, X-Ray, Rx ……..

Network GHI PPO for New York

No referral needed

Outside New York PHCS

Out of Network Benefits

*Deductible: $1500/3000

Max Out of packet 7350/14700)

Maximum Benefits: Unlimited

Preventive Services: 100%

Office Visit copay: 30/50

Rx: covered

Lab X-Ray: covered

Mental Health: covered

MONTHLY RATES:

AGE: 16-64 (rates include health benefits contribution, union dues and advocate fees) there is a onetime processing fee of $125 per employee

MONTHLY RATES: 16-64

EMPLOYEE…………..$869.00

H/W……………….$1699.00

I/C……………….$1650.00

FULL FAMILY………..$2275.00

National Business Advocates

Presents

Emerald Outline

PLAN BENEFITS OUT-OF-NETWORK

DEDUCTIBLE

Single/$6,000 Family

LIFESTYLE DEDUCTIBLE

Single/$1,000 Family

(Reduced Deductible based on wellness points earned)

CO-INSURANCE

CO-INSURANCE MAXIMUM

Single/$10,000 Family

OUT-POCKET-LIMIT

(Deductible + Co-Insurance Max)

$16,000 Single/$24,000 Family

(OOP Limit does not include copays and Rx copays)

ACA MAXIMUM OUT-OF-POCKET

Unlimited

PREVENTIVE SERVICES

PHYSICIAN SERVICES

-Primary Care Office Visit

Deductible/Co-insurance

-Specialist Office Visit

Deductible/Co-insurance

-Physician & Surgeon Professional Services

Deductible/Co-insurance

-Anesthesia Services (Physician/CRNA)

Deductible/Co-insurance

TELEPHONIC PHYSICIAN CONSULTATION

Copay

OUTPATIENT LAB

Deductible/Co-insurance

OUTPATIENT RADIOLOGY AND IMAGING

certification required to

scheduling for MRI, CT, PET

Nuclear Imagin

-Physician Office/Freestanding Imaging Ctr

Deductible/Co-insurance

-Hospital Outpatient

Copay, then Deductible/

insurance

DIABETIC SUPPLIES

Deductible/Co-insurance

ALERGY TREATMENT

Deductible/Co-insurance

OUTPATIENT REHAB & THERAPY

Deductible/Co-insurance

CHIROPRACTICE SERVICES

Deductible/Co-insurance

EMERGENCY SERVICES

Copay waived if admitted

-Hospital ER (Facility Charge Only)

copay then deductible

insurance

-Urgent Care/ER Professional Services

Deductible/Co-insurance

-Ambulance

Deductible/Co-insurance

-Air Ambulance

$2,500 Copay then

Deductible/Co-insurance

OUTPATIENT SURGICAL PROCEDURES

certification required prior to

scheduling

-Physician Office/Freestanding Surgery Ctr.

Deductible/Co-insurance

-Hospital Outpatient

$1,000 Copay per visit then

Deductible/Co-insurance

-Implant Device

Deductible/Co-insurance***

IMPATIENT HOSPITALIZATION

-Medical Facility Services

Copay then Deductible/

insurance

-Anesthesiologist & Surgeon Fees

Deductible/Co-insurance

INPATIENT SURGICAL PROCEDURES

Deductible/Co-insurance

-Implant Device

Deductible/Co-insurance***

HOME HEALTH, SKILLED NURSING & HOSPICE CARE

Deductible/Co-insurance

MENTAL HEALTH & SUBSTANCE ABUSE

Deductible/Co-insurance

DURABLE MEDICAL EQUIPMENT

Deductible/Co-insurance

PRESCRIPTION DRUG BENEFITS

-Generic

covered

-Brand/Non-Preferred Brand/Specialty

covered

-International Mail Order-Brand

covered

IN-NET WORK

$1,500 Single/$2,000 Family

$500 Single/$1,000 Family

20%

$2,500 Single/$5,000 Family

$4,000 Single/$8,000 Family

$7,350 Single/$14,700 Family

100%

$30 Copay then 100% to $250 per visit*

$50 Copay then 100% to $250 per visit**

Deductible/Co-insurance

$0 Copay

100% if prefered vendor, otherwise

Deductible/Co-insurance

Pre-certification required prior to scheduling

for MRI, CT, PET and Nuclear imaging

Deductible/Co-Insurance

$500 copay, then Deductible/Co-insurance

100% if preferred vendor, otherwise

50% cost through Rx Benefit

$25 Copay, then 100% to $100 per visit

Deductible/Co-insurance

Copay waived if admitted

$250 Copay then Deductible/Co-insurance

$50 Copay, then 100% to $500 per visit

then Deductible/Co-insurance

Deductible/Co-insurance

$2,500 Copay then Deductible/Co-insurance

Pre-certification requiered prior to scheduling

Deductible/Co-insurance

$1,000 copay per visit then Deductible/

Co-insurance

Deductible/Co-insurance***

$500 Copay then Deductible/Co-insurance****

Deductible/Co-insurance

Deductible/Co-insurance***

Deductible/Co-insurance

Refer to Preferred Formulary & SPD for details

$1 Copay/$15 copay

$50 Copay/$80 Copay/50%

$0 Copay if preferred vendor*****

$3,000

$500

50%

$5,000

$8,000

100%

Pre-

and

$500

Co-

$250

Co-

Pre-

$500

Co-

Not

IMPORTANT NOTES:

*$30 Copay then 100% TO $250 per visit for all services provided during visit except Lab services, then Deductible/Co-insurance **$50 Copay then 100% to $250 per visit for all services provided during visit except Lab services, then Deductible/Co-insurance ***Deductible/Co-insurance (benefit Max of 200% of manufactures invoice or scheduled benefit pricing, whichever is greater) ****$500 Copay per confinement. All non-emergency confinements must be pre-certified and emergency confinements must be reported with 48 hours of when

confinement begings.

*****Participation in Mall Order Program is voluntary

This outline is intended as a brief of the actual plan and representative benefit levels. Certain procedures requiere pre-certification prior to scheduling in order to qualify for benefits. Failure to do so will result in penalties and/or non coverage of servies. Please refer to your Summary Plan Dcomuent (SPD) for the actual benefits. Limitations and exclutions if there is any inconsistency between this outline and the SPD, the SPD shall govern. You may request a SPD from Lifestyle Health Plans or your sales representative. Certain procedures requiere pre-certification prior to scheduling in order to quality for benefits. Failure to do so will result in penalties and/or non coverage of services.