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GEISINGER QUALITY OPTIONS, INC. (Called the PPO ) REQUIRED OUTLINE OF COVERAGE ( Outline )

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GEISINGER QUALITY OPTIONS, INC. (Called the PPO ) a Pennsylvania for-profit corporation whose home office is 100 North Academy Avenue, Danville, Pennsylvania COMPREHENSIVE MAJOR MEDICAL PREFERRED
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GEISINGER QUALITY OPTIONS, INC. (Called the PPO ) a Pennsylvania for-profit corporation whose home office is 100 North Academy Avenue, Danville, Pennsylvania COMPREHENSIVE MAJOR MEDICAL PREFERRED PROVIDER POLICY WITH PREVENTIVE SERVICES FOR INDIVIDUAL COVERED PERSONS WITH NO REFERRAL Identified as the Geisinger Choice PPO with No Referral (Non-Group) MyChoice Complete REQUIRED OUTLINE OF COVERAGE ( Outline ) A. Read Your Policy Carefully. This Outline provides a brief description of the important features of your Comprehensive Major Medical Preferred Provider Policy with Preventive Services For Individual Covered Persons with No Referral (the Policy ), marketed as the Geisinger Choice PPO with No Referral (Non-Group) MyChoice Complete. This is not the insurance contract and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY! B. Comprehensive Major Medical Expense Coverage. Policies of this category are designed to provide insured persons with coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board; miscellaneous hospital services; surgical services; anesthesia services; inhospital medical services; and out-of-hospital care; subject to any Deductibles, Coinsurance and Copayment provisions or other limitations which may be set forth in the Policy. Coverage is not provided for unlimited hospital or medical-surgical expenses. Coverage is provided for most benefits at Preferred and Non-Preferred benefit levels with Cost Sharing options such as Deductibles, Coinsurance, Copayments and annual Benefit Limits and Lifetime Benefit Maximums. However, benefits for certain services are only available if received from a Preferred Provider. Benefits are subject to medical management review procedures and Precertification processes with penalties and possible loss of benefits for non-compliance. Benefits for Emergency Services and for Covered Services which are not available from a Preferred Provider are provided at the Preferred Provider benefit level, and, in such cases, the Covered Person will not be liable for a greater out-of-pocket expense than if the insured used a Preferred Provider. C. A brief description of the benefits contained in the Policy is as follows: 1) Daily Hospital Room and Board, which includes a semi-private room and board or a private room, when Medically Necessary, and general nursing care. 2) Miscellaneous Hospital Services, which includes the use of the following facilities, services and supplies as prescribed by a physician Provider: use of operating room and related facilities; use of intensive care unit or cardiac care unit and services; radiology, laboratory, and other diagnostic tests; drugs, medications, and biologicals; anesthesia and oxygen services; physical therapy, occupational therapy and speech therapy; pulmonary rehabilitation therapy; radiation therapy; inhalation therapy; renal dialysis; administration of whole blood and blood plasma; medical social services and cancer chemotherapy and cancer hormone treatments and to the extent Medically Necessary, services which have 1 been approved by the United States Food and Drug Administration for general use in treatment of cancer. Hospital benefits may be provided at a hospital Provider on either an inpatient or outpatient basis or an Ambulatory Surgical Center. Inpatient benefits are provided for as long as the hospital stay is determined to be Medically Necessary by the PPO and not determined to be Custodial, Convalescent or Domiciliary Care, except for mastectomy Covered Services as set forth in the Policy. 3) Surgical Services, which include pre- and post-operative services and special surgical procedures including: transplant services, certain oral surgery, restorative or reconstructive surgery, mastectomy and breast reconstruction surgery. 4) Anesthesia Services. Coverage is provided for the administration of anesthesia ordered by the attending professional Provider and rendered by a professional Provider other than the surgeon or assistant at surgery. Benefits are provided for the administration of anesthesia for certain oral surgical procedures in an outpatient setting provided that Precertification is obtained from the PPO before the procedure is conducted. 5) In-Hospital Medical Services, which includes inpatient medical care visits, intensive medical care, concurrent care, consultation and routine newborn care. 6) Out-of-Hospital Care, which includes (a) preventive services such as (i) periodic health assessments (including physical examinations, annual gynecological and pelvic examinations, breast exam, chlamydia screening, screening Pap smear, annual screening mammograms for women forty (40) years of age and older and for any Provider recommended mammograms for women under age forty (40), DEXA scan, cholesterol screening and lipid panel); (ii) well-child care; (iii) adult and pediatric immunizations; (iv) diabetes care and (v) colorectal screening; (b) diagnostic and other outpatient facility services; (c) physical, occupational and speech therapy services; (d) cardiac rehabilitation services; (e) enteral feeding/food supplements; and (f) diabetes treatment for all types of diabetes. 7) Other Benefits, which include diagnostic services; injectable drugs; skilled nursing facility services; home health care; transportation services; implanted devices; foot care services; hospice; diabetic medical equipment, supplies, prescription drugs and services; disease and weight management programs; ostomy supplies; urological supplies; voluntary family planning services; pulmonary rehabilitation; rehabilitative devices; diagnostic imaging, dental services, manipulative treatment services and vision services. 8) Emergency Services. Coverage is provided for the treatment of a sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the Covered Person, or with respect to a pregnant woman, the health of a woman or her unborn child, in serious jeopardy; or (b) serious impairment to bodily functions; or (c) serious dysfunction to any bodily organ or part. In the event that the Covered Person requires Emergency Services, benefits will be provided at the Preferred Provider services benefit levels. The Covered Person will not be responsible for any difference between the PPO payment and the Provider s charge. D. Benefit Amounts, Durations, Limits, Deductibles, Coinsurance and Copayments for Benefits under the Policy 2 1) Benefit Period is the initial twelve (12) month period of time the Policy is in effect as indicated on the Schedule of Benefits and the subsequent twelve (12) month periods thereafter. 2) The Schedule of Benefits, which is incorporated as a part of the Policy, is a summary of coverage for a Covered Person that identifies the Covered Persons and the Maximum Age for dependent coverage together with the applicable Deductible, Copayments, Copayment Maximums, Coinsurance, Coinsurance Maximums, Benefit Limits and Lifetime Benefit Maximum amounts for Covered Services, and any Riders in force for the Policy. If there is a change in any of the information printed on the Schedule of Benefits (for example, an item has been printed incorrectly or the wrong Schedule of Benefits has been provided), the PPO will issue a new Schedule of Benefits to replace all prior Schedule of Benefits. 3) Payment of Benefits. Subject to the provisions of the Policy, a Covered Person is responsible for payment of any Cost Sharing amounts due to the Provider after the amounts paid by the PPO hereunder. 4) Preferred / Non-Preferred Providers. The amount of reimbursement that will be provided by the PPO for Covered Services provided to a Covered Persons is based upon the contractual arrangement between the PPO and the Provider. i) Preferred Provider means a physician, medical group, pharmacy, hospital or other provider of health services, licensed, certified or otherwise regulated under any applicable law, that has an agreement with the PPO pursuant to which negotiated rates are established on a Preferred Provider basis for payment of Covered Services to Covered Persons under the Policy. ii) iii) iv) Preferred Provider Fee Schedule Amount means the amount of reimbursement that will be provided by the PPO for Covered Services rendered by a Preferred Provider based on the contractual arrangement between the PPO and the Preferred Provider which shall constitute payment in full for the Covered Services. Any Deductibles, Coinsurance and Copayments shall be the responsibility of the Covered Person. Non-Preferred Provider includes a physician, medical group, pharmacy, hospital or other provider of health services, licensed, certified or otherwise regulated under any applicable law that does not have an agreement with the PPO. Non-Preferred Provider Fee Schedule Amount means the amount of reimbursement that will be provided by the PPO for Covered Services rendered by a Non-Preferred Provider which is generally a percentage of Medicare reimbursement. A Covered Person may obtain information regarding his/her outof-pocket cost when using a Non-Preferred Provider by contacting the PPO s Customer Service Department at the telephone number on the back of his/her Identification Card. Generally, Covered Services provided by a Non-Preferred Provider will subject the Covered Person to significant out-of-pocket expenses due to higher Cost Sharing and because such expenses are based on the PPO s Non-Preferred Provider Fee Schedule Amounts, except for Emergency Services or when Covered Services are not available from a Preferred Provider; in such case, the Covered Person will not be liable to the Non- Preferred Provider for any amounts beyond what the Covered Person would have been liable to pay a Preferred Provider. 3 5) Cost Sharing means the Deductible, Copayment, Copayment Maximums, Coinsurance and any amounts exceeding the Coinsurance Maximums, Benefit Limits or Lifetime Benefit Maximums that a Covered Person will incur as an expense for Covered Services. Specific Cost Sharing amounts for Covered Services can be found on the Schedule of Benefits and as to Benefit Limits, also in the Policy and any Riders supplementing the Policy. i) Coinsurance is a form of Cost Sharing (indicated as a percentage amount on the Schedule of Benefits) which requires the Covered Person to pay a specified portion of the Preferred Provider Fee Schedule Amount or the Non-Preferred Provider Fee Schedule Amount, as set forth on the Schedule of Benefits, after the Deductible has been paid by the Covered Person or Family Unit. ii) iii) iv). Copayment is a form of Cost Sharing which requires the Covered Person to pay a fixed amount of money for the cost of Covered Services. Copayment amounts are set forth on the Schedule of Benefits and are due at the time and place such services are received by a Covered Person. Copayment amounts do not accrue toward satisfaction of any Coinsurance Maximum or Deductible amounts. The Copayment charge will never exceed the billed cost of the service. Once the Copayment Maximum has been reached by the Covered Person within a Benefit Period, the Covered Person will not be responsible for any additional Copayments above the Copayment Maximum amount during that Benefit Period. Deductible means a specified dollar amount for the cost of Covered Services that must be incurred and paid by a Covered Person or Family Unit before the PPO will assume any liability for all or part of the cost of Covered Services. The Deductible applies to each Covered Person subject to any family Deductible set forth on the Schedule of Benefits. Distinct Deductible amounts apply to Covered Services obtained from either Preferred or Non-Preferred Providers as set forth on the Schedule of Benefits. Amounts paid toward satisfaction of the Deductible amounts for Covered Services obtained from either Non-Preferred Providers or Preferred Providers do not accrue toward each other. Deductible amounts must be met every Benefit Period before the corresponding Coinsurance amount applies. Copayment amounts do not accrue toward satisfaction of any Deductible amounts. When a Family Dependent is added to the Policy during the last ninety (90) days of a Benefit Period, if that Family Dependent has not satisfied his/her Deductible prior to the end of the Benefit Period, amounts paid toward satisfaction of that Family Dependent s Deductible during that period shall carry over and accrue toward satisfaction of the Deductible for the next Benefit Period. The only in-network Covered Service subject to a Deductible under the Policy is Dental Services as set forth on the Schedule of Benefits. Benefit Amounts. Please note that for services listed with a Copayment below, Coinsurance and Deductible do not apply unless specifically noted otherwise. For services listed below with a Coinsurance, the Deductible applies but there is no Copayment unless specifically noted otherwise. In addition, please note that amounts applied to each Covered Person s single Deductible also apply to the family Deductible (for a Policy with Family Coverage). However, a Covered Person s covered expenses in excess of the single Deductible do not continue to apply to the family Deductible once a Covered Person s single Deductible has been reached. 4 BENEFIT PREFERRED PROVIDER NON-PREFERRED PROVIDER DEDUCTIBLE $0 SINGLE $ 4,000 SINGLE $0 FAMILY $ 8,000 FAMILY COINSURANCE MAXIMUM N/A SINGLE $ 10,000 SINGLE (does not include Select Injectable Drugs N/A FAMILY $ 20,000 FAMILY see separate Coinsurance Maximum for Select Injectable Drugs below) COPAYMENT MAXIMUM $ 2,500 SINGLE N/A $ 5,000 FAMILY CARDIAC REHABILITATION $20 Copayment 40% of Non Preferred Provider Fee (Benefit Limit of 36 sessions per Covered Person per Benefit Period) CHEMOTHERAPY ADMINISTRATION $25 Copayment services limited to Preferred Providers (per course of treatment) DENTAL SERVICES ($750 limit per benefit period) $50 SINGLE $150 FAMILY DEDUCTIBLE - Preventive/Palliative Services $0 Copayment per visit services limited to Preferred Providers - Basic Services 20% Coinsurance services limited to Preferred Providers DIABETIC EQUIPMENT, SUPPLIES, DRUGS & SERVICES - prescription drug Copayment per outpatient services limited to a Preferred Provider pharmacy prescription drug rider or 25% Coinsurance for Covered Persons with no prescription drug rider - diabetic foot orthotics $15 Copayment per billed item services limited to Preferred Providers - diabetic medical equipment $45 Copayment per billed item services limited to Preferred Providers - blood glucose test strips Copayment per outpatient services limited to a Preferred Provider (Copayment/Coinsurance per 100 strips) prescription drug rider or 25% Coinsurance for Covered Persons with no prescription drug rider - Diabetic training & outpatient education $10 Copayment services limited to Preferred Providers DIABETIC EYE EXAMINATION $45 Copayment services limited to Preferred Providers DIAGNOSTIC AND OTHER $10 Copayment 40% of Non Preferred Provider Fee OUTPATIENT SERVICES DIAGNOSTIC IMAGING $75 Copayment 40% of Non-Preferred Provider Fee DURABLE MEDICAL EQUIPMENT $15 Copayment per billed item services limited to Preferred Providers ($2,500 Benefit Limit per Covered Person per Benefit Period) 5 BENEFIT PREFERRED PROVIDER NON-PREFERRED PROVIDER EMERGENCY SERVICES $100 Copayment $100 Copayment - hospital emergency room (Copayment waived if admitted) ENTERAL FEEDING $150 Copayment services limited to Preferred Providers HOME HEALTH CARE - Primary Care Physician visits $20 Copayment 40% of Non Preferred Provider Fee - Specialist visits $45 Copayment 40% of Non Preferred Provider Fee - other professional visits $35 Copayment 40% of Non Preferred Provider Fee HOSPICE SERVICES $35 Copayment 40% of Non Preferred Provider Fee ($10,000 Benefit Limit per Covered Person per lifetime) HOSPITAL AND AMBULATORY SURGICAL CENTER SERVICES - inpatient Physician services $0 Copayment 40% of Non Preferred Provider Fee - inpatient hospital facility services $250 Copayment per day 40% of Non Preferred Provider Fee (limited to 90 days per Covered Person per Benefit Period) - outpatient Ambulatory Surgical Center $150 Copayment 40% of Non Preferred Provider Fee and hospital services IMPLANTED DEVICES - drug delivery /contraception $75 Copayment services limited to Preferred Providers - all other implanted devices $75 Copayment 40% of Non Preferred Provider Fee INJECTABLES $75 Copayment services limited to Preferred Providers MANIPULATIVE TREATMENTS $20 Copayment services limited to Preferred Providers (Benefit Limit of 15 visits per Covered Person per Benefit Period) MASTECTOMY AND BREAST CANCER RECONSTRUCTIVE SURGERY - post-mastectomy reconstructive surgery - inpatient hospital facility services $250 Copayment per day services limited to Preferred Providers - outpatient Ambulatory $150 Copayment services limited to Preferred Providers Surgical Center and hospital services - breast prosthesis - surgically implanted $40 Copayment services limited to Preferred Providers - external $40 Copayment services limited to Preferred Providers ORTHOTIC DEVICES $20 Copayment per billed item services limited to Preferred Providers 6 BENEFIT PREFERRED PROVIDER NON-PREFERRED PROVIDER OSTOMY SUPPLIES $15 Copayment per billed item services limited to Preferred Providers OUTPATIENT MENTAL HEALTH AND SUBSTANCE ABUSE PROFESSIONAL SERVICES (Benefit Limit of 10 visits per Covered Person per Benefit Period for individual and Group therapy) - individual therapy $25 Copayment per visit services limited to Preferred Providers - group therapy $10 Copayment per visit services limited to Preferred Providers - Short Term Acute Outpatient Opioid $20 Copayment per visit services limited to Preferred Providers Detoxification Treatment (Benefit Limit of 1 uninterrupted 4 month period of treatment per Covered Person per lifetime) PHYSICIAN OFFICE SERVICES - Primary Care Physician office visits $0 per initial 3 visits 40% of Non Preferred Provider Fee per Covered Person per Benefit Period $20 Copayment per each subsequent visit - Specialist office visits $45 Copayment 40% of Non Preferred Provider Fee - Services/Procedures $15 Copayment 40% of Non Preferred Provider Fee (excludes diagnostic services) PREVENTIVE SERVICES: $0 Copayment services limited to Preferred Providers - SEE EXHIBIT 4 TO POLICY FOR A LIST OF PREVENTIVE SERVICES $0 Copayment services limited to Preferred Providers - PERIODIC HEALTH ASSESSMENTS - Chlamydia screening $0 Copayment services limited to Preferred Providers (limited to women ages 16 25) - pap smear $0 Copayment services limited to Preferred Providers - annual mammogram $0 Copayment services limited to Preferred Providers - DEXA scan $0 Copayment services limited to Preferred Providers - cholesterol screening $0 Copayment services limited to Preferred Providers - lipid panel $0 Copayment services limited to Preferred Providers - WELL CHILD CARE - hemoglobin and hematocrit $0 Copayment services limited to Preferred Providers (Benefit Limit of one service under the age of 24 months) - PEDIATRIC IMMUNIZATIONS $0 Copayment services limited to Preferred Providers (not subject to Deductible) - ADULT IMMUNIZATIONS $0 Copayment services limited to Preferred Providers 7 BENEFIT PREFERRED PROVIDER NON-PREFERRED PROVIDER - DIABETES CARE - HbAlc test $0 Copayment services limited to Preferred Providers - LDL-C screening $0 Copayment services limited to Preferred Prov
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