Fallon community health plan, inc

Benefit Summary—College of the Holy Cross Effective: January 1, 2012 – December 31, 2012 Choosing a primary care provider (PCP) Your relationship with your PCP is very important With FCHP Select Care, you get everything you because he or she will work with FCHP to provide need to live a healthy life. This plan features or arrange most of your care. As a member of comprehensive medical benefits for lower monthly FCHP Select Care, you must select a PCP. To do premiums and slightly higher out-of-pocket this, just complete the section on your FCHP expenses compared to our other plans. There are membership enrollment form. If you need help no deductibles, but you do have a copayment on choosing a PCP, please visit the “Find a Doctor” tool on fchp.org or call Customer Service. • A fitness reimbursement of up to $400 for families ($200 for individual contracts) that can be When you want to visit a specialist, talk with your used for gym memberships at the gym of your PCP first. He or she will help arrange specialty care choice with no limitations, school and town sports for you. The following services do not require a fees, exercise classes, ski lift tickets, and more! referral when you see a provider in the FCHP Select • $0 copayments for routine physical exams and Care network: routine obstetrics/gynecology care, other preventive services, including mammograms, screening eye exams and behavioral health cholesterol screenings and immunizations services. For more information on referral procedures for specialty services, consult your $0 copayments for routine annual eye exams FCHP Select Care Member Handbook/Evidence of • Nurse Connect: A free 24/7 nurse call line • Member discounts on products and services to keep you healthy and features you won’t find Emergency services do not require referral or authorization. When you have an emergency medical condition, you should go to the nearest With FCHP Select Care, you can choose to get your emergency communications system (police, fire care from doctors, specialists, hospitals and health department or 911). For more information on care facilities in the FCHP Select Care network. You emergency benefits and plan procedures for can be seen at physician practices, community emergency services, consult your FCHP Select Care Member Handbook/Evidence of Coverage. Massachusetts and Southern New Hampshire, giving you a wide choice of health care providers. For a complete list of FCHP Select Care providers, visit the “Find a Doctor” tool on fchp.org. Fallon Community Health Plan, Inc. • fchp.org • 1-800-868-5200 The benefit period, sometimes referred to as a “benefit year” is the 12-month span of plan coverage, and the time during which the deductible, out-of-pocket maximum and specific The out-of-pocket maximum is the total amount of inpatient admissions copayments, same day surgery copayments and coinsurance you are responsible for in a benefit period. The out-of-pocket maximum does not include your premium charge or any amounts you pay for $2,000 family services that are not covered by the plan. Benefits Routine physical exams (according to MHQP preventive guidelines) Office visits (limited service clinics, e.g., Minute Clinic) Short-term rehabilitative services (60 visits per benefit period) Tests, immunizations and services geared to help screen for diseases and improve early detection when symptoms or diagnosis are not present Tests, immunizations and services that are intended to diagnose, check the status of, or treat a disease or condition Imaging (CAT, PET, MRI, Nuclear Cardiology) Chiropractic care (12 visits per benefit period calendar year) Prescription drugs, including oral contraceptives, insulin and insulin syringes Prescription medication refills obtained through the mail order program Prilosec OTC, Prevacid 24HR, omeprazole OTC (prescription required) Room and board in a semiprivate room (private when medically necessary) Fallon Community Health Plan, Inc. • fchp.org • 1-800-868-5200 Same-day surgery in a hospital outpatient or ambulatory care setting Services in a general or psychiatric hospital It Fits!, an annual benefit period fitness reimbursement (including school and town sports programs, gym memberships, Weight Watchers®, aerobics, Pilates and yoga classes) $400 family Oh Baby!, a program that provides prenatal vitamins, a convertible car seat and other “little extras” for expectant parents—all at no additional cost. Free online access to health and wellness encyclopedia CVS Caremark ExtraCare Health Card – provides 20% discount on CVS/pharmacy FCHP Family Fun – provides discounts at Massachusetts and New Hampshire Fallon Community Health Plan, Inc. • fchp.org • 1-800-868-5200 Exclusions Hearing aids and the evaluation for a hearing aid Experimental procedures or services that are not generally accepted medical practice Dental services not described in the FCHP Select Care Member Handbook/Evidence of Coverage Custodial confinement Some services may require prior authorization. A complete list of benefits and exclusions is in the FCHP Select Care Member Handbook/Evidence of Coverage, available by request. This is only a summary of benefits and exclusions. Questions? If you have any questions, please contact Fallon Community Health Plan Customer Service at 1-800-868-5200 (TDD/TTY: 1-877-608-7677), or visit our Web site at fchp.org. This health plan meets minimum creditable coverage standards and will satisfy the individual mandate that you have health insurance. As of January 1, 2011, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18) years and older, must have health coverage that meets the minimum creditable coverage standards set by the Commonwealth Health Insurance Connector. Benefits may vary by employer group. Weight Watchers® is a registered trademark of Weight Watchers International, Inc. Fallon Community Health Plan, Inc. • fchp.org • 1-800-868-5200

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