WEST SUBURBAN HEALTH GROUP EPO HMO PLAN BENEFITS PLAN by herhero

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									 WEST SUBURBAN HEALTH GROUP - EPO/HMO PLAN BENEFITS                                                        --- Effective 7/1/08                last updated 3/2008          1
PLAN FEATURES                                          FALLON EPO                                                                   FALLON EPO
                                                       RATE SAVER
                                                DIRECTCARE & SELECTCARE*                                              DIRECTCARE & SELECTCARE *
Employee Contribution                     Directcare: Ind. $ 39.50 Fam. $ 213.00                                     Directcare: Ind. $ 46.40 Fam. $ 250.60
                                         Selectcare: Ind. $ 42.50   Fam. $ 229.20                                    Selectcare: Ind. $ 50.00 Fam. $ 269.60
PROVIDERS OF SERVICE:
SELECTCARE – An expansive network that includes physician practices, community-based hospitals and medical facilities across the
Commonwealth. The network encompasses more than 17,000 providers and 50 hospitals.

DIRECTCARE – A tailored network custom-built around several of the Commonwealth’s premier provider groups and community-based
hospitals. Unique to the marketplace, Fallon Direct Care offers members more coordinated care and is one of the lowest-cost HMO plans
available in Massachusetts today.

Primary Care Physician PCP)            Member must select                                                 Member must select
Pre-existing Conditions                No restrictions                                                    No restrictions
Hospital Services                      Semi-private room & board & ancillary                              Semi-private room & board & ancillary services, in
(Inpatient)                            services, $250 co-pay (out of pocket                               full
                                       maximum: 4 co-pays per year)
Out-of-Service Area                    $75 co-pay (waived if admitted)                                    $25 co-pay (waived if admitted)
Emergencies only
Physician Services                     In full                                                            In full
Outpatient Emergency                   $75 co-pay. (Inpatient copay applies if                            $25 co-pay. (waived if admitted)
Room. Services in the                  admitted)
Service Area
Inpatient Surgery                      In full                                                            In full.
Outpatient Surgery                     $125 co-pay                                                        In full.
Office Visits                          $20 co-pay per visit                                               $5 co-pay per visit
                                       $40 co-pay per visit to Specialist
Routine Physical Exams                 $20 co-pay per visit                                               $5 co-pay per visit
Dental Services                        Family dental coverage:                                            Family dental coverage:
                                       $10 co-pay for exam, cleaning, x-rays every                        $10 co-pay for exam, cleaning, x-rays every 6 mos.
                                       6 mos.                                                             Variable co-pays for minor restorative (fillings).
                                       Variable co-pays for minor restorative                             25-50% discount available for sealants, crowns and
                                       (fillings). 25-50% discount available for                          inlays, bridges, root canals, gingivectomies and
                                       sealants, crowns and inlays, bridges, root                         dentures.

     *SELECTCARE & DIRECTCARE benefits are the same. The difference between the two plans is in the
      Provider Networks (Doctors & Hospitals)
     The information provided here is an abbreviated description of health plan features. Details of coverage and exclusion are available from each health plan provider.
     Health plan representatives provided the information for this summary of benefits and the West Suburban Health Group is not responsible for its accuracy.
 WEST SUBURBAN HEALTH GROUP - EPO/HMO PLAN BENEFITS                                                        --- Effective 7/1/08                last updated 3/2008          2
                                       canals, gingivectomies and dentures.
                                       Must use participating dentists                                    Must use participating general dentists
PLAN FEATURES                                           FALLON EPO                                                           FALLON EPO
                                                        RATE SAVER
                                              DIRECTCARE & SELECTCARE*                                             DIRECTCARE & SELECTCARE *
Eye Examinations                       $20 co-pay; one visit every 12 months                              $5 co-pay; one visit every 12 months

Skilled Nursing Facility               In full up to 100 days per year                                    In full up to 100 days per year

Chiropractic Care                      $20 co-pay per visit                                               $5 co-pay per visit

                                       Up to 12 visits per calendar year not to                           Up to 20 visits per calendar year, for the treatment
                                       exceed $500 per calendar year.                                     of acute musculo-skeletal conditions

Inpatient - Mental &                   Covered in full in a general or psychiatric                        Covered in full in a general or psychiatric hospital.
Nervous                                hospital.

As required by law, coverage
for certain mental health
disorders (biologically-based
conditions, rape-related
conditions and any MH
condition for children to age
19) is the same as for other
medical conditions.
Outpatient - Mental &                  $20 co-pay per visit                                               $5 co-pay per visit
Nervous

As required by law, coverage
for certain mental health
disorders (biologically-based
conditions, rape-related
conditions, and any MH
condition for children to age
19) is the same as for other
medical conditions.

     *SELECTCARE & DIRECTCARE benefits are the same. The difference between the two plans is in the
      Provider Networks (Doctors & Hospitals)
     The information provided here is an abbreviated description of health plan features. Details of coverage and exclusion are available from each health plan provider.
     Health plan representatives provided the information for this summary of benefits and the West Suburban Health Group is not responsible for its accuracy.
 WEST SUBURBAN HEALTH GROUP - EPO/HMO PLAN BENEFITS                                                        --- Effective 7/1/08                last updated 3/2008          3
PLAN FEATURES                                           FALLON EPO                                                                  FALLON EPO
                                                        RATE SAVER
                                              DIRECTCARE & SELECTCARE*                                              DIRECTCARE & SELECTCARE *
Inpatient – Substance                  Covered in full for unlimited days for                             Covered in full for unlimited days for detoxification
Abuse                                  detoxification; and for up to 30 days per                          and for up to 30 days per calendar yr for
                                       calendar yr for rehabilitation.                                    rehabilitation.
Outpatient – Substance                 $20 co-pay unlimited visits.                                       $5 co-pay unlimited visits.
Abuse
Pre-Admission Testing                  In full                                                            In full.

Outpatient Surgical Facility           $125 co-pay                                                        In full.

Outpatient Diagnostic X-ray            In full                                                            In full.
& Lab
Emergency Transportation               In full when medically necessary                                   In full when medically necessary
Services
Private Duty Nursing (when             In full when medically necessary                                   In full when medically necessary
medically necessary only)
Home Health Care                       In full                                                            In full.

Hospice Care                           In full                                                            In full.
Maternity Care                         Prenatal: $20 co-pay first visit only;                             Prenatal: $5 co-pay first visit only; Postpartum: $5
                                       Postpartum: $20 co-pay per visit                                   co-pay per visit
Newborn Well Baby Care                 In full                                                            In full
(Inpatient)
Radiation Therapy                      In full                                                            In full
Chemotherapy                           In full when administered by a health care                         In full when administered by a health care
                                       professional                                                       professional
Physical Therapy                       $20 co-pay; up to 20 visits per illness or                         $5 co-pay; up to 20 visits per illness or injury per
                                       injury per calendar year                                           calendar year
Medical Supplies, including            Corrective appliances & DME up to limit of                         Corrective appliances & DME up to limit of $1,500
oxygen, and rental of                  $1,500 per calendar year, covered in full.                         per calendar year, covered in full.
durable medical equipment
(DME)

    *SELECTCARE & DIRECTCARE benefits are the same. The difference between the two plans is in the
     Provider Networks (Doctors & Hospitals)
     The information provided here is an abbreviated description of health plan features. Details of coverage and exclusion are available from each health plan provider.
     Health plan representatives provided the information for this summary of benefits and the West Suburban Health Group is not responsible for its accuracy.
 WEST SUBURBAN HEALTH GROUP - EPO/HMO PLAN BENEFITS                                                        --- Effective 7/1/08                last updated 3/2008          4
PLAN FEATURES                                           FALLON EPO                                                                  FALLON EPO
                                                        RATE SAVER
                                               DIRECTCARE & SELECTCARE*                                              DIRECTCARE & SELECTCARE *
Fitness Programs                       It Fits! Program reimburses families up to                         It Fits! Program reimburses families up to $300 per
                                       $300 per family contract ($150 for individual                      family contract ($150 for individual contracts) to
                                       contracts) to use toward health club                               use toward health club memberships, Pilates and
                                       memberships, Pilates and yoga classes,                             yoga classes, Weight Watchers® programs, and
                                       Weight Watchers® programs, and local &                             local & school sports programs. Other discounts
                                       school sports programs. Other discounts also                       also available. See plan materials for details.
                                       available. See plan materials for details.
Prescription Drugs –                   Retail Pharmacy:                                                   Retail Pharmacy:
Outpatient                             $10 co-pay for Tier-1/$25 for Tier-2/$45 for                       $5 co-pay for Tier-1/$15 for Tier-2/$35 for Tier-3
(Inpatient drugs paid in full          Tier-3 for up to a 30-day supply                                   for up to a 30-day supply

                                       Mail-Order:                                                        Mail-Order:
                                       $20 co-pay for Tier-1/$50 for Tier-2/$90 for                       $10 co-pay for Tier-1/$30 for Tier-2/$70 for Tier-3
                                       Tier-3 for up to a                                                 for up to a
                                       90-day supply                                                      90-day supply
                                       Emergency out of area:                                             Emergency out of area:
                                       $10 co-pay for Tier-1/ $25 for Tier-2/$45 for                      $5 co-pay for Tier-1/ $15 for Tier-2/$35 for Tier-3
                                       Tier-3 for a 14-day supply.                                        for a 14-day supply.




    *SELECTCARE & DIRECTCARE benefits are the same. The difference between the two plans is in the
     Provider Networks (Doctors & Hospitals)
     The information provided here is an abbreviated description of health plan features. Details of coverage and exclusion are available from each health plan provider.
     Health plan representatives provided the information for this summary of benefits and the West Suburban Health Group is not responsible for its accuracy.

								
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