Annual Deductible
Individual
In-network and out-of-network are not combined; they do not cross apply.
Family
Medical Out-of-Pocket Maximum
All Coverage Levels
The annual deductible, prescription drug and preventive care expenses do not count toward the out-of-pocket maximum. In addition, amounts over Reasonable & Customary (R&C) and non-covered services do not accumulate to the out-of-pocket maximum.
Lifetime Maximum
$5,000,000 lifetime maximum per covered member; in network and out of network combined
Internists, general physician, family practitioner, pediatrician and specialist care.
Plan pays 85%, after deductible You pay 15%, after deductible
Plan pays 65%, after deductible You pay 35%, after deductible
Specialty Care/Office Visits.
Plan pays 85%, after deductibleYou pay 15%, after deductible
Plan pays 65%, after deductibleYou pay 35%, after deductible
Walk-in Clinic Immunizations and routine consults performed by Nurse Practitioners outside of traditional office visit setting.
Retail (Up to a 30-day supply) First 3 purchases of any medication.*
Generic
You pay 10%**, up to $25 maximum, for each prescription or refill
Plan pays 50%, no deductible You pay 50%, no deductible
Brand Name
Preferred brand name. (listed on formulary)
You pay 30%, up to $75 maximum, for each prescription or refill, no deductible
Non-preferred brand name. (not listed on formulary)
You pay 50%, up to $175 maximum, for each prescription or refill, no deductible
Mail Order (Up to a 90-day supply)
You pay 10%, up to $50 maximum, for each prescription or refill, no deductible
No Coverage
Brand NamePreferred brand name. (listed on formulary)
You pay 30%, up to $150 maximum, for each prescription or refill, no deductible
Brand NameNon-preferred brand name. (not listed on formulary)
You pay 50%, up to $350 maximum, for each prescription or refill, no deductible
*After the third purchase of a long-term medication, you pay an additional co-payment of up to $25 per additional fill of that medication at retail. To avoid this charge, visit a CVS location or use mail order.
**You pay 0% for in-network generic prescription contraceptive medications that are covered at 100% as part of the Affordable Care Act.
Performed as part of physician office visit and billed by physician, covered same as physician office visits.
Performed in outpatient hospital or other outpatient facility setting, including independent lab.
Emergency Room
Non-emergency use of an Emergency Room
Plan pays 50%, after deductibleYou pay 50%, after deductible
Ambulance
Urgent Care Facility
Non-urgent use of an Urgent Care Facility
MRA/MRS, MRI, CT Scan, PET Scan. Precertification required for outpatient services.
Adults, age 18 and older Routine physical exam, immunizations, flu shots 1 physical exam per year.
Plan pays 100%, deductible waived
Plan pays 100% up to Reasonable & Customary (R&C), deductible waived
Colorectal Screenings For all members age 45 and over: Fecal occult blood test every year, Sigmoidoscopy (1 every 5 years), double contrast barium enema (1 every 5 years), Colonoscopy (1 every 10 years).
Gynecological 1 routine GYN exam per year with 1 pap smear and related lab fees.
Hearing Exams Covered only as part of routine physical exam.
Mammograms Routine mammogram. 1 baseline age 35-40. 1 annual mammogram age 40+.
Prostate Specific Antigen (PSA) Test and Digital Rectal Exam (DRE) 1 annual (PSA and DRE) exam for males ages 40 to 75; not covered age 76 and over.
Vision Screenings Covered only as part of routine physical exam.
Well Child Care Routine immunizations, flu shots. Child to age 18: 7 exams in the 1st 12 months of life. 3 exams in the 13-24th months of life. 3 exams in the 25-36th months of life. 1 exam per 12 months thereafter.
OB Visits Hospital/facility delivery charges are covered under Hospital Services.
Inpatient Inpatient surgery expenses, room & board & misc. fees, physician expenses, routine nursery care, prescription drugs, and all inpatient care; Precertification required.
Bariatric Surgery, Cardiac Care, Orthopedic Care Inpatient and outpatient. Precertification required.
Plan pays 85%, after deductibleYou pay 15%, after deductible Plan pays 90%, after deductibleYou pay 10%, after deductible if services performed in Institute of Quality (IOQ) facility
Second Surgical Opinion
Outpatient Hospital Expenses Hospital and other facilities.
Outpatient Surgery Performed in Office Setting
Inpatient services; no maximum inpatient days per year; Precertification required.
Outpatient services; no visit maximum for medically necessary care; Precertification required (generally not required for outpatient therapy visits).
Inpatient rehabilitation and detoxification in a hospital or treatment facility; no maximum inpatient days per year; Precertification required.
Outpatient services in an office or other outpatient setting; no visit maximum for medically necessary care; Precertification required (generally not required for outpatient therapy visits).
Allergy Testing and Treatment Office Visit.
Allergy Injections
Autism/Pervasive Development Delays Covers diagnosis, Applied Behavioral Analysis (ABA) and Outpatient Short-Term Rehabilitation.
Chiropractic Care All visits/services at a chiropractor count toward 20 visit annual maximum.
Contraceptive Devices, Implants and Injections Plan covers associated office visit for injection of Depo-Provera and Lunell, Diaphragm fitting, and cervical cap and IUD devices.
Convalescent Facility/Skilled Nursing Facility Semi-private room rate. Prior hospital confinement not required. Precertification required; up to 120 days per calendar year (combined in-network and out-of-network limit).
Durable Medical Equipment Precertification required for amounts in excess of $5,000.
Hearing Aids Limited to $1,000 per ear every 3 years.
Home Health Care Prior hospital confinement not required. Each visit by a Home Health Aide of up to 4 hours equals 1 visit. Each visit by a Nurse or Therapist equals 1 visit. Limited to 120 visits per year (Home Health Care and Private Duty Nurse visits combined); Precertification required for some services.
Inpatient Hospice Care; Precertification required.
Inpatient Hospice Lifetime Maximum.
Unlimited
Outpatient Hospice Care.
Outpatient Hospice Lifetime Maximum.
Infertility Covers diagnosis and treatment of underlying cause only.
Mouth, Jaws, Teeth Oral surgery procedures; Precertification required. Covers accident related injury to teeth, and medical in nature oral and jaw surgery.
Organ and Tissue Transplants Requires preauthorization by National Medical Excellence.
Plan pays 90%, after deductible You pay 10%, after deductible if services performed in Institute of Quality (IOQ) facility
Outpatient Short-Term Rehabilitation Limited to 60 visits per year, combined for speech, physical and occupational therapies. Short-Term Rehabilitation at an outpatient hospital setting is included in the 60 visits maximum. No limits on coverage for Autism/Pervasive Developmental Delays.
Private Duty Nursing (PDN) Outpatient care provided by a Registered Nurse or LPN, if member’s condition requires skilled nursing care and visiting nursing care is not adequate; Precertification required. Limited to 120 visits per year (Home Health Care and Private Duty Nurse visits combined).PDN maximum: 1 shift equals up to 8 hours.
Prosthetic Devices (Artificial limbs, breast prosthesis) Precertification required for amounts in excess of $5,000.
Sexual Disorders Excludes treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling that do not have a physiological or organic basis.
Inpatient Hospital Precertification required for treatment facilities, skilled nursing facilities and inpatient mental health / substance abuse.
Precertification required; provider responsible - no penalty
You are responsible for precertification; $500 penalty for failure to precertify
Outpatient Hospital Precertification required for home health care, private duty nursing and some other outpatient services; generally not required for outpatient therapy visits.
You are responsible for precertification; $300 penalty for failure to precertify
Pre-existing Conditions
No restrictions
Plan covers eligible dependent children from birth to age 26.
Medical Administered by:
Aetna P.O. Box 981106 El Paso, TX 79998-1106
Prescription Administered by:
CVS CaremarkP.O. Box 52136Phoenix, AZ 85072-2136
In some locations in the United States, employees may have limited or no access to a provider network. If the medical claims administrator determines you reside in one of these locations, you are eligible for out-of-area benefits. Once the determination is made, it will be valid for the remainder of the year. Out-of-area coverage is the same as out-of-network coverage except that the plan reimbursement is generally 80% (not 65%) of the reasonable and customary charge* (after the deductible) for most covered medical expenses. The deductibles and out-of-pocket maximums are the same as the in-network deductibles and out-of-pocket maximums. If you receive medical care from a network provider, covered expenses are reimbursed at the in-network level.
* The reasonable and customary charge is the charge most often made for a given health care service or supply in a geographical area. Benefits paid by the LM HealthWorks Plan for out-of-network or out-of-area care are based on reasonable and customary charges.
This document is not intended as a summary plan description or plan document. If there is any conflict between this summary and the official plan documents, the official plan documents will govern.
The information provided in this "Benefits Summary" is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Consult the formal plan documents to determine governing plan provisions, including procedures, exclusions and limitations relating to the plan. While this information is believed to be accurate as of the plan effective date (January 1, 2023), it is subject to change.
* Benefits paid by the LM HealthWorks Plan for out-of-network and out-of-area care are based on Reasonable and Customary charges. Reasonable and Customary charges are those most often made for a given health care service or supply in a geographical area.
Please note that plan provisions and eligibility for union represented employees are based on the terms of the collective bargaining agreement.
