The physician office visit benefit applies to doctor office visits for the medically necessary diagnosis or treatment of an injury or sickness. Office visits for routine physical exams are covered under the Wellness Benefit. A fixed benefit amount (see Plans & Rates table) is payable for each visit up to five (5) visits per covered person per plan year*. Note that the amount payable by the plan is not a “co-pay”. The covered person may be billed for any balance due by the physician’s office. Physician visits to patients who are in a hospital are not covered.

A fixed benefit amount (see Plans & Rates table) is payable for each visit to a physician’s office or an outpatient facility for the purpose of diagnostic lab tests or x-ray screenings. Up to three (3) diagnostic test visits are payable per plan year*.

The plan will pay a fixed benefit amount (see Plans & Rates table) for one (1) physician visit per plan year* for a routine physical. The wellness visit benefit includes a history, physical examination, x-ray and lab tests provided during the visit. The wellness visit benefit is payable in addition to the physician office visit benefits for treatment of injury or sickness.

A fixed benefit amount per day is payable for medically necessary confinement in a hospital for treatment of an injury or sickness (see Plans & Rates table for Regular Inpatient Accident & Sickness Stay). Benefits are payable for a maximum of thirty (30) days per covered person per plan year*.

Twice the daily hospital benefit amount is payable for medically necessary confinement in an intensive or critical care unit of a hospital for a maximum of ten (10) days per covered person per plan year*.

Half the daily hospital benefit amount is payable for medically necessary confinements related to mental or nervous conditions for a maximum of ten (10) days per covered person per plan year*.

Half the daily hospital benefit amount is payable for medically necessary confinements related to substance abuse for a maximum of ten (10) days per covered person per plan year*.

Benefits are also payable for medically necessary confinement in a skilled nursing facility. Half the daily hospital benefit amount is payable for a maximum of twenty (20) days per covered person per plan year*. Admission to the skilled nursing facility must occur within three (3) days of a hospital confinement.

Inpatient and outpatient surgery benefits are payable for medically necessary treatment of an injury or sickness up to the maximum indicated on the Plans & Rates table per covered person per plan year*. Inpatient surgery must be performed in the operating room of a hospital. Outpatient surgery must be performed in the outpatient department of a hospital or in an ambulatory surgery center. In addition, 25% of the surgical benefit paid is available as an anesthesiologist benefit.

For treatment related to an accident, an Accident Medical Expenses benefit of up to the amount shown on the Plans & Rates table is payable per accident. There is no maximum limit on the number of accidents per plan year*. Benefits are not limited to hospital emergency rooms only. Care can be received in an emergency room, a physician’s office, or an urgent care center.

A fixed benefit amount (see the Plans & Rates table) is payable for one (1) visit to a hospital emergency room per covered person per plan year* for a medical emergency caused by sickness.

If a covered person suffers accidental loss of life or dismemberment within 365 days of a covered accident, the percentage of the Principal Sum shown below will be paid. The Principal Sum is the amount for which the employee or family member is covered as shown in the Certificate of Insurance. The Principal Sum amounts of insurance under this plan are also indicated on the Plans & Rates page of this website. If multiple losses occur, only one benefit amount, the largest, will be paid for all losses due to the same covered accident.

Definitions for the above terms will be included in the Certificate of Insurance.

The amount payable will be reduced if an employee is age 70 or older on the date of the accident causing the loss. The amount payable for the loss is a percentage of the amount that would otherwise be payable as shown below:

The plan will pay a fixed benefit amount of twenty-five dollars ($25) for one (1) eye exam every plan year* and fifty dollars ($50) once every two (2) plan years* for eyeglasses or contacts.

Through participating pharmacies, covered employees and their families have access to discounts of up to 40% on the purchase of generic or brand name prescription drugs. Note that this is a discount benefit, not insurance, that can help participants lower the cost of their prescription drugs. There is also an optional benefit available under this plan that provides insured generic drugs and discounts on brand name medications. See Insured Generic Prescripton Drug Benefit Available on the Plans & Rates page.

To find a participating pharmacy, visit www.regencerx.com, (this will open in a new window) click on Meet RegenceRx and then click on “Our Pharmacy Network”. Follow the onscreen instructions to find a participating local pharmacy or to view a list of all participating pharmacy chains.

On the RegenceRx website, covered employees and their families can also look up information about prescriptions drugs. Click on “Learn About Medications” and follow the onscreen instructions to get information about generic and brand name prescriptions as well as a pricing guide. Assistance is also available by calling toll-free 1-888-437-1508.

MEDICAL INFORMATION HOTLINE

The doctor’s office isn’t open 24 hours a day. In addition to the medical benefits provided by the plan, covered employees and their families also have access, without charge, to toll-free 24-hour telephone service providing medical information and the opportunity to talk directly with a medical professional, generally a registered nurse.

This service can help with questions about a new prescription drug, concerns about a recently diagnosed medical condition, options for a diagnostic test or surgical procedure and emergency advice when someone falls ill in the middle of the night.

The ID card will include information on how to access the medical information hotline. Please note that the service does not diagnose or provide treatment.

The toll-free number also provides access to an audio library on a broad range of health topics.

This is a value-added service, not an insured benefit.

BEECH STREET PPO NETWORK ACCESS

Covered employees and their covered family members may go to any doctor or hospital for services under this plan. However, if a doctor or hospital that participates in the Beech Street PPO network is used, the charge may be reduced. Note that the plan pays the same amount in or out of the network.

Participating doctors and hospitals can be found by visiting the Beech Street website – www.beechstreet.com – or by calling toll-free 1-800-432-1776.

Information about locating a doctor or hospital in the Beech Street PPO network will also be provided on each ID card.

This is a value-added service, not an insured benefit.

This is an optional benefit that requires additional premium. The choice is made at the group level, not by each insured employee.

If this option is elected, generic prescription drugs are covered under the insurance plan. Brand name drugs are discounted. The covered employee or covered family member visits a participating pharmacy and pays a $15 co-pay for each generic prescription drug purchased. The annual maximum benefit is $2,500 per covered person per plan year.*

Mail order service is available as well with a $45 co-pay for a three- month supply of generic prescriptions.

Brand name prescription drugs are not covered under the insurance plan but will be discounted through a participating pharmacy.

To find a participating pharmacy, visit www.regencerx.com, (this will open in a new window) click on Meet RegenceRx and then click on “Our Pharmacy Network”. Follow the onscreen instructions to find a participating local pharmacy or to view a list of all participating pharmacy chains.

On the RegenceRx website, covered employees and their families can also look up information about prescriptions drugs. Click on “Learn About Medications” and follow the onscreen instructions to get information about generic and brand name prescriptions as well as a pricing guide. Assistance is also available by calling toll-free 1-888-437-1508.

This is an optional benefit that requires additional premium. The choice can be made at the group level (i.e., automatically added to a GS Plan) or at the employee level (i.e., as an add-on to one of the GS Plans).

If this option is elected, scheduled benefit amounts (see schedule below) are payable up to $1,500 per covered person per Plan Year. In addition, all periodontics services are subject to a lifetime maximum of $500. All orthodontics services are subject to a separate $750 maximum per course of treatment; orthodontic services are available to adults & children.

You may use the dental provider of your choice.