Healthcare Benefit
Healthcare Benefit Plan
July 1, 2011
For more information and
understanding of benefits please
Avera for benefits– 888-322-2115
South Dakota School District Benefits Fund Healthcare Plan SOUTH DAKOTA SCHOOL DISTRICT BENEFITS FUND BENEFIT SERVICES ADMINISTRATOR Avera Health Plans Benefit Administrators Eligible Employees of Employers of South Dakota School District Benefits Fund Sponsoring School District participating in the South This document includes all amendments through July 1, 2011 http://www.hmpsd.com PREFERRED PROVIDER ORGANIZATION 1-800-546-5677 http://www.pti-nps.com/ CLERICAL ERROR Any clerical errors shall not change the rights or obligations of any enrollee If an overpayment occurs, the Plan retains a contractual right to the over- payment. The provider will be required to return the overpayment, or if the of the overpayment will be deducted from In case of discrepancy between the Articles that follow and the schedule of Benefits, PIERRE SCHOOL DISTRICT 32-2
Plan option changes are allowed only at the beginning of each calendar year.
Coinsurance Percentage per calen- 80% of $5,000 per indi-
80% of $5,000 per indi- 75% of $5,000 per individ- ble, then 100% thereafter to the end ily, of eligible expenses. ily, of eligible expenses. Prescription Drug Co-Pay
Plan option changes are allowed only at the beginning of each calendar year.
Coinsurance Percentage per calen- 80% of $5,000 per indi-
ble, then 100% thereafter to the end ily, of eligible expenses. Prescription Drug Co-Pay
Health Savings Account - Plans - Qualified Pre-
scription drugs will be subject to deductible and then $5 Co-pay Generic, $25 Co-pay Brand Name Subject to Deductible and Coinsurance.
Dr. Co-pay Does not apply to
Health Saving Account Plan
All benefits are subject to the following de
ductibles, coinsurance and maximums unless otherwise stated.
Preferred Provider Network
Various discounts can be applied to eligible claims submitted by participating pro- viders. Please refer to the Plan Specifications Page for contact information. Pre-Notification:
When the participant’s doctor suggests that hospitalization is necessary, or for or- gan transplants, or for any procedure that will, or is expected to, total more than $25,000.00 a pre-authorization and/or second opinion procedure may be required. The Plan covers physician consultation services when incurred as a result of volun- tary second surgical opinions or other requirements for follow up care. The Plan Administrator may require second opinions for certain covered services (such as non-emergency surgical procedures) when there is cause to believe there is an ef- fective and equivalent alternative to the original medical/surgical opinion. Non- emergency surgical procedures include, but are not limited to, sinus surgery, or anterior/lateral disc fusion. Second opinions are also required for surgical proce- dures that must be redone because the patient did not follow physician instructions. The procedure below will need to be followed. If pre-authorization review and/or the second opinion process indicate that a medi- cally necessary procedure can be beneficially performed at a facility that has con- tracted with the Plan Administrator, payment will be limited to the contracted fee at that facility. If the Covered Person chooses another facility, he or she will be re- sponsible for the cost over the contracted fee amount. These charges will not apply to the individual’s annual medical out-of pocket limit. To be eligible for maximum benefits under this Plan, the participant is required to take a few simple steps before admission to a hospital. When the participant’s doc- tor suggests that hospitalization is necessary for the participant or a covered mem- ber of the participant’s family, the participant will need to follow the steps outlined below. The company named on the back of the participant’s identification card may negotiate and approve allowable hospital or facility charges. If admission is necessary on an urgent basis, notification is requested within 48 hours or on the first business day following weekend or holiday admissions. Pre-Notification and
Second Opinions:
When the participant’s physician says that the participant or a covered member of the participant’s family must go into the hospital for a non-emergency (elective) procedure, the participant or the participant’s physician must call the Pre- Notification Company at least 30 days before the participant or the participant’s
dependent will be entering the hospital. It is the participant’s responsibility to ad- vise the participant’s doctor of this notification requirement and to provide him with adequate information. A notification of less than 7 days could result in a pen- Urgent Hospital Admission
Please note that Benefits towards Hospital Expenses may result in a reduction
of 50%
if you have not pre-certified your Hospital stay within the specified time
limits. Benefits also will be denied for any Hospital admission or stay which was
not determined to be Medically Necessary.
All benefits are subject to the following deductibles, coinsurance and maximums unless otherwise stated.
Urgent Hospital Admission
In the case of an urgent Hospitalization for you or a covered member of your Family, your doctor, the Hospital, or a family member must telephone the Pre-Certification company within 48 hours of admission or on the first business day following week- end or holiday admissions. You should be prepared to provide the following infor- ⇒ Name, address, social security number and age of patient ⇒ Admitting diagnosis, planned procedure or treatment and proposed length of stay ⇒ Employer’s group name and plan number ⇒ Name, address and telephone number of the attending physician and the hospital Pregnancy Review:
Failure to enroll and comply with the Pre-Notification Company’s recommendations in the “Our Healthy Baby Program: will result in a 50% penalty (no maximum amount) to all related charges from birth to discharge, for the eligible dependent newborn child. The 50% penalty will not apply to deductible or coinsurance. Penalty for Non-Compliance
Failure to comply with the Pre-Notification Program may result in a reduction of 50% applied toward outpatient surgery, non-emergency (elective) procedures, and hospital confinement, including hospital, doctor and diagnostic x-ray and lab expenses. Continued Stay Review:
The Plan provides for Continued Stay Review which is a complimentary Hospital stay review service. The Pre-Certification company will monitor all Hospital stays by being in contact with the Physician until the patient is discharged from the Hospi- tal. This service is automatically provided to all patients who have been certified under the Pre-Admission Certification program. Organ Transplants:
As a result of the pre-authorization review the Covered Person will be asked to con-sider obtaining transplant service from a participating Center of Excellence facility arranged by the Plan Administrator. The purpose of designating Centers of Excel-lence networks is to perform necessary transplants in the most appropriate setting for the procedure, to improve the quality and probability of a successful outcome, and reduce the average cost of the procedures. There is no obligation for the patient to use a participating transplant network facility. However, benefits for the transplant and its related expenses may vary depending on whether services are provided in or out of the transplant network. If a transplant is performed out of the network, but the Covered Person has received approval from the Plan Administrator for out of the network services, then network benefits will apply to the transplant and related expenses. If, however, pre-authorization review and/or the second opinion process indicate that a medically necessary procedure can be beneficially preformed at a facility that has contracted with the Plan Administrator, payment will be limited to the contracted fee at the facility. If the Covered Person chooses another facility, he or she will be responsible for the cost over the contracted fee at the facility. If the Covered Person chooses another facility, he or she will be responsible for he cost over the contracted fee amount. These charges will not apply to the individual’s annual medical out-of-pocked limit. All benefits are subject to the following deductibles, coinsurance and maximums unless otherwise stated.
Professional services for local air or ground. Covers schizophrenia and other psychotic disorders; bipolar disorder; major depression, and obsessive-compulsive disorder. Covered separate from the Mental Health Benefit. Expenses other than for Hospital and Surgery will be limited to a maximum benefit of $2,000 annually. Benefits include surgical treatment, appliance ther- apy, anesthesia, medications, Orhognatic surgery, x- ray, and laboratory tests when recommended by both a dentist and a medical doctor. All treatment for TMJ must be approved by the Claims Administrator. The following information must be provided prior
to approval: A) a dentist’s evaluation of the prob-
lem to include diagnosis, present or planned treat- ment, and prognosis, and B) a medical doctor’s evaluation of the problem to include diagnosis, pre- sent or planned treatment, and prognosis. If treat- ment is provided prior to approval the charges will be paid at 50% (subject to deductible, coinsurance Outpatient therapy, including but not limited to ma- nipulations, adjustments, therapeutic ultrasounds and other related expenses with a limit of one visit per The plan pays for certain Elective Sterilization pro- cedures such as tubal ligation and vasectomies. SCHEDULE OF BENEFITS (Cont.)
Limited to 100 visits per calendar year. Please contact Our Health Baby program as soon
as you know your are pregnant at the following # Healthy newborn charges are covered as charges
of the mother. Includes nursery room and board,
Prior approval is recommended. In addition to
the standard organ transplant benefit an enhanced benefit may be available when a covered person participates in the Special Transplant Program. Call the Benefit Services Administrator for details. Limited to $30,000 per transplant procedure. SCHEDULE OF BENEFITS (Cont.)
Limited to $5,000 per transplant procedure; Includes transportation, lodging & meals. Lodging and meals up to $150 per day for individual(s) accompanying the covered recipient. No payment for treatments, services or supplies that are educational or provided primarily for re-search. This is for the Doctors office visit only and will not cover any x-ray or lab which will be subject to HSA PLANS— Do not have Co-pay
Note: For Plans F - subject to deductible and
Second Surgical Opinion
Paid at 100% if second opinion obtained prior to - PLAN A, B, C & D
surgery. Then subject to deductible and coinsur- Second Surgical Opinion is subject to deductible and then paid at 100% if done prior to the surgery. $300 then $300 then First $300 per accident, if claim is incurred within 72 hours of accident Remainder subject to deducti- SCHEDULE OF BENEFITS (Cont.)
Well Child Office Visit Only - up to age 7 Annual Physical Exam Office Visit Only - age 7 Annual Well Woman - Includes office visit, pap smear, hemoglobin and urinalysis Routine Immunizations Mammogram - 1 baseline between age 35-39 and annual starting at age 40 Prostate Cancer Screening—Annual starting at age 50; age 45-49 if high-risk or history of prostate cancer Colorectal Screening Starting age 50 - option of annual fecal occult blood, choice of double con-trast barium enema and/or flexible sigmoidoscopy every 5 years or screening colonoscopy every 10 years Lipid Screening - 1 every 5 years Glucose Screening - 1 every 3 years Osteoporosis Testing -1 baseline starting at age 50 Please visit www.AveraHealthPlans.com for a complete list of covered preventive services. MEDICAL PLAN’S MAXIMUM LIABILITY
Annual Maximum All Benefits
(National Pharmaceutical Services
Limited to a 30-day supply for one co-payment. Limited to a maximum 90 day supply from a retail pharmacy. www.pti-nps.com
⇒ Drugs or medicines authorized to be distributed by prescription; ⇒ Compounded medication of which at least one ingredient is a prescription Legend Plan A, B, C & D
⇒ Insulin and diabetic supplies (test strips, needles and lancets or the supplies that are needed to monitor diabetes). This does not include glucose monitors; and PLANS F (H S A)
⇒ Home injectable kits —including Avonex, Copaxone, Enbrel, Neupogen, Epogen, Health Savings Account - Plans -
Procrit, Betaseron, Lupron, Low Molecular Weight Heparins, Methotrexate, Excludes:
Drugs or medicines, except for insulin, which are lawfully obtainable without the prescription of a physician, whether or not such drugs are actually obtained by ⇒ Refilling of a prescription in excess of the number specified by the Physician, or any refill dispensed after one (1) year from the date of order of the Physician; ⇒ Charges in connection with rest or custodial care, personal comfort items, health club dues or fees for weight loss clinics; ⇒ Infertility drugs with no other approved indication; ⇒ Drugs for weight loss and appetite suppressants; ⇒ Therapeutic devices or appliances, including hypodermic needles, syringes (except diabetic supplies), support garments and other non-medical substances, except as indicated for diabetes ⇒ Prescription drugs which may be properly received without charge under local, state, or federal governmental programs, including Worker’s Compensation or similar laws; ⇒ Medication which is to be taken by or administered to the covered person, in whole or in part, while a patient in a hospital, rest home, sanitarium, extended care facility, skilled nursing facility or similar institution which operates on its premises, or allows to be operated on it premises, a facility dispensing pharmaceuticals; ⇒ Mailing and delivery charges;
⇒ Drugs which were distributed by the manufacturer as samples;
⇒ Drugs for cosmetic purposes, such as Minoxidil (Rogaine), Eflornithine (Vaniqa), and Tretinoin (retin A). Retin A for non-cosmetic purposes requires prior authorization for covered persons over age 26; ⇒ Unapproved uses of drugs,, I.e., uses that are not approved by the United States Food and Drug Administration or peer-reviewed medical journals; ⇒ Prescription medications determined to be “less than effective” by the Drug Efficacy Study Implementation program (DESI); and ⇒ Drugs labeled: “Caution—limited by federal law to investigational use,” or experimental drugs, even though a charge is made.
Refer to the Exclusion section of the Plan for additional limitations.

Medicare Qualifying Participants
This Plan is a Supplement to Medicare for non-employee participants and and Dependents
their dependents. This plan is Primary for employees and their dependents. Coverage Effective Date and
Effective date is the first day of the month following date of hire and proper Waiting Period
Participant Eligibility Requirement Must work at least twenty-five (20) hours per week.
Dependent Child Maximum Age
Dependents under the age of 26 are eligible. Dependents 26 years of age through 29 years of age are eligible if enrolled in and attending an accredited college, university, trade, or secondary school on a full time basis. He or she must remain a continuous full-time student through the age of 29 and not have other creditable coverage. Termination of Coverage
Date of termination of employment or loss of eligibility, with an option to Retirement
Retired employees and/or participating dependents are treated the same as any other terminating employee unless the Sponsoring School District formally adopts Retiree Coverage criteria. Dependent Coverage
Shall include the following: Natural Children, Stepchildren, Legally Medically Necessary
The fact that a Physician or provider may prescribe, order or recommend a service or supply does not make it Medically Necessary or make the charge allowable, even though the service is not specifically listed as an exclusion. Your Plan Sponsor has the final determination if a service or supply is cov-ered. Free Choice of Physician
Participants and dependents shall have free choice of any licensed physician or surgeon, and the physician-patient relationship shall be the decision of the participant or dependent. An exception to this is that a close relative of the participant or dependent shall not be an approved provider of care. Annual Election of Deductible
Your School District has more than one deductible plan option. During the month of December you will be able to change your deductible plan, if so desired. The change must be made and reported during the 31 days of De-cember for January 1 effective date. This will be the only time when de-ductible plan option changes can be made throughout the year.

Source: http://www.pierre.k12.sd.us/media/pierreschoolsfactor360com/uploads/Administration/StaffResources/2011ScheduleBenefitsPierre.pdf

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