Benefits at a Glance - Medicare
Post-65 Retirees/Medicare primary members
View/Download Benefits at a Glance for Post-65 Retirees/Medicare primary members
Orange Ulster School Districts’ Health Plan Effective 1/1/25
The following information applies to post-65 retirees/Medicare primary member
CLAIMS PROCESSOR:
Luminare Health Benefits 1-866-893-4472
ONLINE PORTAL:
Our secure online portal lets you access your benefits and claims, view your EOBs, and more. Visit www.myLuminareHealth.com to register and log in.
MOBILE APP:
Need information about your health benefits while you’re on the go? You can find a doctor, connect with Luminare Health customer service, access your ID card, and much more using our mobile app. Download for free today from Apple’s App Store or Google Play.
PLAN ADMINISTRATOR:
Matt Bourgeois - Executive Director - (845) 781-4890
The benefits provided on this plan are secondary to Medicare. For covered expenses, the member responsibility after Medicare’s payment will be paid by this plan after the deductible has been met if your provider participates with Medicare. If you are treated by a physician or provider of service who does not participate with Medicare, the allowable charge will be reduced to the Usual and Customary (U&C) amount then processed secondary to Medicare’s payment. Members may be responsible for amounts in excess of U&C. The OU Health Plan follows Medicare guidelines for benefit coverage. Charges for Hearing Aids, Home Healthcare, Skilled Nursing Facilities, Wigs, Orthotics, Acupuncture and Routine/Well Adult Health Benefits not covered by Medicare may be considered up to the applicable OU Health benefit maximum.
MEDICAL SCHEDULE OF BENEFITS
| Deductible (Per Calendar Year) |
Individual $300 | |
|---|---|---|
| Coinsurance | Plan pays 100% | |
|
Medical - Out-of-Pocket Maximum (OOPM) Includes Medicare $257 and OUH $43 calendar year deductible |
||
|
Individual $300 |
||
| Prescription Out-of-Pocket Maximum |
Individual $2,000 Family $4,000 |
|
| Lifetime Maximum | Unlimited | |
| Covered Services | Plan Pays | |
|---|---|---|
| Acupuncture 50 visits per calendar year | 100% after Deductible | |
| Allergy Services Office visit & Testing |
100% after Deductible | |
|
Allergy Services |
100% after Deductible | |
| Ambulance Services Air & Ground Services |
100% after Deductible | |
| Ambulatory Surgical Facility | 100% after Deductible | |
| Anesthesia | 100% after Deductible | |
| Cardiac Rehabilitation (Outpatient) Physician |
100% after Deductible | |
| Cardiac Rehabilitation (Outpatient) Outpatient Facility |
100% after Deductible |
|
| Chemotherapy | 100% after Deductible | |
| Chiropractic | 100% after Deductible | |
| Covered Services | Plan Pays | |
|---|---|---|
| Diagnostic, X-ray and Lab (Outpatient) Outpatient Hospital |
100% after Deductible | |
| Diagnostic, X-ray and Lab (Outpatient) Inpatient Hospital |
100% after Deductible | |
| Diagnostic, X-ray and Lab (Outpatient) Independent Lab/Imaging Center/Office |
100% after Deductible | |
| Durable Medical Equipment Supplies (Includes orthotics) |
100% after Deductible | |
| Emergency Room Emergency Care |
100% after Deductible | |
| Emergency Room Non-Emergency Care |
100% after Deductible | |
| Cardiac Rehabilitation (Outpatient) Physician |
100% after Deductible | |
| Hearing Aid and Exam Hardware limited to one device up to $1,500 per ear every 3 calendar years |
100% after Deductible (Member can see a Medicare provider for hearing test and then purchase hearing aid(s) from any provider or Costco, Amazon, etc., complete a claim form and submit with receipt for reimbursement to Luminare) |
|
|
Home Health Care |
100% after Deductible | |
| Home Infusion Services | 100% after Deductible | |
| Covered Services | Plan Pays | ||
|---|---|---|---|
| Hospice Care | 100% after Deductible | ||
| Hospital Inpatient |
100% after Deductible | ||
| Hospital Outpatient Surgical | 100% after Deductible | ||
| Mental Health* Office Visit |
100% after Deductible | ||
| Mental Health* Inpatient Treatment |
100% after Deductible | ||
| Mental Health* Residential Treatment |
100% after Deductible | ||
| Mental Health* Partial Day Program/Intensive Outpatient Treatment |
100% after Deductible | ||
| Morbid Obesity – Bariatric Surgery Inpatient |
100% after Deductible |
||
| Occupational Therapy (Outpatient) Facility |
100% after Deductible | ||
| Occupational Therapy (Outpatient) Office |
100% after Deductible | ||
| Covered Services | Plan Pays | |
|---|---|---|
| Physician Office Visits (Non-Routine) | 100% after Deductible | |
| Physician Visits (Inpatient) |
100% after Deductible | |
| Radiation Therapy Outpatient Facility |
100% after Deductible | |
| Radiation Therapy Office |
100% after Deductible | |
| Routine Health Maintenance | 100% | |
| Skilled Nursing Facility 180 days per calendar year: (Medicare-100 + OUH-80) |
100% after Deductible | |
| Speech Therapy (Outpatient) Facility |
100% after Deductible |
|
| Speech Therapy (Outpatient) Office |
100% after Deductible | |
| Substance Use Disorder* Office Visit |
100 % after Deductible | |
| Substance Use Disorder* Inpatient Treatment |
100 % after Deductible | |
| Substance Use Disorder* Residential Treatment |
100 % after Deductible | |
| Substance Use Disorder* Partial Day Program/Intensive Outpatient Treatment |
100% after Deductible | |
| Surgery - Physician | 100 % after Deductible | |
| Transplant Outpatient Physician |
100 % after Deductible | |
| Transplant Inpatient Facility |
100 % after Deductible | |
| Transplant Inpatient Physician |
100 % after Deductible | |
| Travel-International: (For Emergency Care ONLY) |
100 % after Deductible | |
| Urgent Care | 100 % after Deductible | |
| Weight Watchers-WW (6-month membership) Contact OUH plan office to obtain access code after $25 copay to OUH. |
100 % after Deductible after $25 copay | |
| Wigs Up to $800, once every 3 years, covered for hair loss due to chemotherapy, radiation, scalp burns, or alopecia. |
100 % after Deductible | |
Prescription Schedule of Benefits
Navitus MedicareRx - Part D
Customer Service - 866-270-3877
Medicare primary member Part D coverage administered by Navitus MedicareRx (Medicare Part D with OUH wrap)
| Tier 1 (Generics and Certain Lower Cost Brands) | Tier 2 (Preferred Brand) | Tier 3 (Non-Preferred Brand) | |
|---|---|---|---|
| Retail Pharmacy 30-Day Supply |
$5 Copay | $35 Copay | $60 Copay |
| Retail Pharmacy 90-Day Supply |
$5 Copay | $70 Copay | $120 Copay |
| Mail Order Pharmacy 84-90-Day Supply |
$0 Copay | $60 Copay | $110 Copay |
| Specialty Medication 30-Day Supply |
$5 Copay | $35 Copay | $60 Copay |
Copays at Navitus Preferred Pharmacies
| Tier 1 (Generics and Certain Lower Cost Brands) | Tier 2 (Preferred Brand) | Tier 3 (Non-Preferred Brand) | |
|---|---|---|---|
| Retail Pharmacy 30-Day Supply |
$0 Copay | $30 Copay | $55 Copay |
| Retail Pharmacy 90-Day Supply |
$0 Copay | $60 Copay | $110 Copay |
(Note - Pharmacies listed without a “P” designation are in-network but not “preferred”)
**For a list of preferred pharmacies in other states, please contact Navitus customer care at 866-270-3877
Note: If you request a brand-name drug when a generic equivalent is available, you will pay the generic copay PLUS the difference in cost between the brand-name drug and the generic drug.
Insulin prescriptions will not exceed $35 per 30 day supply.