Health and Welfare Plan BenefitTabs™

  • Self Funded PPO

  • Covered Features

    This is a Self Funded PPO Plan with coverage worldwide for medically necessary treatments.

  • Choice of Providers

    Choose any physician or hospital. Reduced charges are available from the Preferred Provider hospital and physician networks that have a contract with the Plan. Your out-of-pocket expenses will be higher when you use a provider or facility that is not a Preferred Provider.

  • PPO General Program Information

    The Plan contracts with the Blue Shield Shared Advantage Program for is Preferred Provider Organization (PPO) and medical case management services.

    • Using provider from the PPO network saves both you and the Plan money. To find a PPO provider, access
    • Prior Authorization/Pre-Admission Review: Before any non-emergency hospitalization, your physician should call 800-343-1691 to determine whether a procedure or treatment program is covered, or if an alternative service is recommended.
    • Life Referrals 24/7 (Employee Assistance Program) This program allows members to access a 24/7 help line (800-985-2405) to speak with a mental health counselor, life coach, or even financial advisors.
    • NurseHelp 24/7: This program allows members to contact a registered nurse for immediate and reliable answers to health questions, 24 hours a day, 7 days a week. Call 877-304-0504 or log in to
    • Effective August 1, 2011, PPO participants will have access to Blue Shield's disease management and personalized case management services. Members who qualify for these programs are identified from medical and pharmacy claims, as well as referrals from physicians. All information is kept confidential. These programs are member friendly and not intended as a substitute for patient/provider communications. Participation is voluntary and members may opt out at any time.

    The complex case management program provides a range of specialized services for individuals with multiple conditions, advanced date cancer and acute circulatory or digestive conditions, as well as support for individuals and their families who face end of life hospice care.

    The disease management program is designed to help members manage their chronic conditions, improve their qualify of life and minimize the cost of health care. Personalized at home support services are available for conditions including asthma, diabetes, chronic obstructive pulmonary disease, congestive heart failure and coronary artery disease. The services may include educational materials, a link to the website and, in some cases, phone calls from a registered nurse who can provide additional support and respond to questions.

  • Calendar Year Maximums per family member

    2011: $750,000
    2012: $1,500,000
    2013: $2,000,000
    2014: None

    Lifetime Maximum: None.

  • Calendar Year Deductibles

    $100 per person per calendar year, or
    $200 per family per calendar year

    Effective 8/1/2012
    $150 per person per calendar year, or
    $300 per family per calendar year

  • Benefits/Out-Of-Pocket Maximums

    After satisfying the deductible, benefits are paid at 80% of the PPO contract rate for services provided by a PPO Provider and 60% of usual and customary charges for services provided by a non-PPO provider. For each covered person, there is a $1,500 out-of-pocket maximum per calendar year. After a person has met the out-of-pocket maximum, covered charges for a PPO Provider will be paid at 100% of the PPO contract rate and 80% of the usual and customary charges for services provided by a non-PPO Provider. In no event will the out-of-pocket Covered Charges exceed the maximum amount allowable under the Affordable Care Act, which for 2014 is $12,700 per person.

    The benefits apply to the following Covered Services for reasonable and customary charges for services, treatment, and supplies for the care and treatment of an illness or injury:

    1. Hospital Room and Board and Miscellaneous charges
    2. Surgery
    3. Anesthesia
    4. Physician or other Licensed or Certified Health Care Provider visits
    5. Outpatient lab & x-rays
    6. Annual physical and immunization inoculations (up to $300 calendar year maximum)
    7. Ambulance services to move patient from place of injury or illness to nearest hospital equipped to provide necessary care
    8. Mother's outpatient maternity related care*
    9. Mother's and newborn baby's in patient hospital care for up to 48 hours following normal delivery and 96 hours following caesarian section.*

    *applies to members/spouses/domestic partners only.

    Other Covered Benefits include:

  • Mental Health and Substance Abuse Treatment Benefits

    Benefits for services provided by contracting PPO Providers will be reimbursed at 100% of the PPO Contract Rate; benefits for services provided by non-Contracting PPO Providers are reimbursed at 60% of usual and customary charges once the annual deductible of $150 per person/$300 per family is satisfied, and at 80% of usual and customary charges after reaching the $1,500 per person "out of pocket" maximum.

  • Certain Tests Covered at 100%

    100% of lesser of Contracted Rate, or Usual Reasonable & Customary Charges for:

    All preventative services mandated under the Patient Protection and Affordable Care Act when services are rendered by an in-network (contracting) provider or at an in-network (contracting) facility. Refer to SPD.

  • Other Preventive Services

    Colorectal Cancer Screening for adults over age 50 in accordance with Medicare guidelines.

    Prostate Cancer Screening for men over age 50 in accordance with Medicare guidelines.

    Pap smears and Pelvic Exams: once every 12 to 24 months. Refer to SPD.

    Mammogram Screenings: Refer to SPD for age based limitations. Refer to SPD.

  • Acupuncture and Chiropractic Services

    These services will each be limited to a maximum of 30 visits per calendar year effective January 1, 2009.

  • Prescription Drugs

    See the Prescription tab for information regarding the Self Fund PPO Plan prescription drug program administered by Catamaran.

  • Coverage for Alternative Treatment for Certain Suspected Physical Causes of Autistic Symptoms

    In general, the Plan does not cover charges for treatment that is not generally accepted by the medical profession or is considered experimental, under investigation, or limited to research. However, alternative treatment for physical symptoms that are suspected of being caused or related to autism are covered as follows.

    Coverage limited to $3,000 per Calendar Year is available for alternative treatment for a condition suspected of playing a role in the expression of symptoms of autism, including:

    • vitamin supplementation therapy;
    • oral secretin therapy;
    • chelation;
    • hyperbaric oxygen therapy;
    • cranio-sacral therapy;
    • fibroblast growth factor therapy;
    • live cell and stem cell therapy;
    • anti-fungal therapy;
    • antibiotic therapy; and
    • naltextrone therapy .
  • Work Related Conditions

    Charges incurred as a result of a work related injury or illness or for which a third party tortfeasor is responsible are not covered under the Plan. However, benefits may be advanced from the Plan pending determination by way of court or administrative determination of third party liability, or by way of settlement, whether or not the third party is responsible for payment of medical expenses.