Benefits at a Glance - Active Employees and Pre-65 Retirees
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Active Employees and Pre-65 Retirees
View/Download Benefits at a Glance for Active Employees and Pre-65 Retirees
Orange Ulster School Districts’ Health Plan Effective 1/1/25
The following information applies to Active Employees and Pre-65 Retirees
CLAIMS PROCESSOR:
Luminare Health Benefits 1-855-656-3261
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
NETWORK:
Anthem - Find a doctor at Anthem.com
PRECERTIFICATION REQUIREMENTS:
HealthCare Strategies - hcare.net
– Call (800) 582-1535 to precertify the following services:
- Inpatient Admissions
- Air Ambulance
- Durable Medical Equipment over $1,500 (exclusive of Hearing Aids, CPAP machines & Insulin Pumps)
- Gender Dysphoria/Sex Reassignment Surgeries
- Gene Therapy/CAR-T Therapy
- Genetic Testing
- Home Health Care
- Private Duty Nursing
- Transplants
- Infertility Treatment/Assisted Reproduction Procedures
- Weight Loss Meds (Zepbound & Wegovy)
- Any Surgeries Considered Cosmetic
Outpatient Surgery requiring precertification: Abdominoplasty, Bariatric Surgeries, Breast Surgeries, Lipectomy, Nasal Surgeries & Panniculetomy
Quantum Health Solutions
– Call (888) 214-4001 to precertify the following inpatient Mental Health and Substance Use Disorder services:
- Partial Hospitalization
- Intensive Outpatient Treatment
- Inpatient Admissions
- ABA Therapy
Quantum Health Solutions is able to assist with access to providers and treatment for Mental Health and Substance Use Disorder treatment. Please contact Quantum Health (888) 214-4001
MEDICAL SCHEDULE OF BENEFITS - Anthem
Payment for In-Network services is based on provider’s negotiated rate. Provider cannot balance bill charges in excess of negotiated rate.
Payment for Out-of-Network services is based on Usual, Customary and Reasonable (UCR). Provider can balance bill charges in excess of UCR.
| In-Network | Out-of-Network | |
|---|---|---|
| Deductible (Per Calendar Year) |
Individual $0 |
Individual $1,000 No member will have more than a $500 calendar year deductible for treatment from an out of network Mental Health/Substance Use Disorder provider. |
|
In-Network and Out-of-Network Deductibles are combined and cross apply Family Accumulation – The Individual Deductible for all family members will accumulate to the family Deductible. One family member cannot satisfy the entire family Deductible. |
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| Coinsurance |
Plan Pays 100% Member Pays 0% Unless otherwise indicated |
Plan Pays 75% |
|
Medical - Out-of-Pocket Maximum (OOPM) Includes Medical Deductible, |
Individual $4,650 Family $9,300 |
Individual $6.200 Family $12,400 |
|
Pharmacy (Rx) - Out-of- Pocket Maximum (OOPM) Includes Prescription Deductible and Copays |
Individual $2,500 Family $5,000 |
Individual $3,000 Family $6,000 |
| Combined (Medical+Rx) Out-of-Pocket Maximum Includes Deductible, Copays and Coinsurance (Medical and Pharmacy |
Individual $7,150 Family $14,300 |
Individual $9,200 Family $18,400 |
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In-Network and Out-of-Network OOPM are combined and cross apply. Once you have reached your OOPM, the Plan will pay 100% of eligible expenses for services for the remainder of the calendar year. Family Accumulation – The Individual OOPM for all family members will accumulate to the family OOPM. One family member cannot satisfy the entire family OOPM. Prior authorization penalties and ineligible expenses do not accumulate to the OOPM. |
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| Lifetime Maximum | Unlimited | Unlimited |
| Covered Services | In-Network Plan Pays | Out-of-Network Plan Pays |
|---|---|---|
| Acupuncture 50 visits per calendar year |
100% after $25 Copay per visit | 75% of U&C after Deductible and $25 copay |
| Allergy Services Office visit & Testing |
100% after $25 Copay per visit | 75% of U&C after Deductible and $25 copay |
|
Allergy Services |
100% | 75% of U&C after Deductible and $25 copay |
| Ambulance Services Air & Ground Services |
100% after $70 copay | 100% of U&C after Deductible and $70 copay |
| Ambulatory Surgical Facility | 100% after $50 copay | 75% of U&C after Deductible and $85 copay |
| Anesthesia | 100% after $25 copay per visit | 75% of U&C after Deductible and $25 copay |
| Autism Spectrum Disorder Applied Behavioral Analysis (ABA) conact Quantum @ accessqhs.com |
100% after $25 copay per visit - up to $45,000 annually | 75% of U&C after Deductible and $25 copay per service |
| Breast Pumps Covered up to $300 for electric and manual pumps and $100 for initial pump supplies |
100% of Plan Allowance (Purchase on your own from anywhere and complete a claim form and attach receipt for reimbursement to Luminare after the baby is born) |
100% of Plan Allowance (Purchase on your own from anywhere and complete a claim form and attach receipt for reimbursement to Luminare after the baby is born) |
| Cardiac Rehabilitation (Outpatient) Physician |
100% after $25 Copay per visit |
75% of U&C after Deductible and $25 copay |
| Cardiac Rehabilitation (Outpatient) Outpatient Facility |
100% after $50 Copay per visit | 75% of U&C after Deductible and $85 copay |
| Cardiac Scoring (Calcium testing) |
Not covered | Not covered |
| Chemotherapy | 100% | 75% of U&C after Deductible and $85 copay |
| Chiropractic | 100% after $25 Copay per visit | 75% of U&C after Deductible and $25 copay |
| Covered Services | In-Network Plan Pays |
Out-of-Network Plan Pays |
|---|---|---|
| Diagnostic, X-ray and Lab (Outpatient) Outpatient Hospital |
100% after $50 Copay per visit | 75% of U&C after Deductible and $85 copay |
| Diagnostic, X-ray and Lab (Outpatient) Inpatient Hospital |
100% | 75% of U&C after Deductible |
| Diagnostic, X-ray and Lab (Outpatient) Independent Lab/Imaging Center/Office |
100% after $25 Copay per visit | 75% of U&C after Deductible and $25 copay |
| Diagnostic, X-ray and Lab (Outpatient) Quest Diagnostics |
100% after $5 Copay per visit | Not available |
| Durable Medical Equipment Supplies (Includes orthotics) |
100% after $25 Copay per order | 75% of U&C after Deductible and $25 copay per order |
| Emergency Room Emergency Care |
100% after $100 copay per visit | In-Network benefit applies |
| Emergency Room Non-Emergency Care |
100% after $100 copay per visit | 75% of U&C after Deductible and $125 copay per service |
| Hearing Aid and Exam Hardware limited to one device up to $1,500 per ear every 3 calendar years |
100% of Plan Allowance (Can be purchased from an Anthem provider and submitted to insurance or member can purchase from any other provider such as Costco, Amazon etc., complete a claim form and attach receipt for reimbursement from Luminare.) |
100% of Plan Allowance (Can be purchased from an Anthem provider and submitted to insurance or member can purchase from any other provider such as Costco, Amazon etc., complete a claim form and attach receipt for reimbursement from Luminare.) |
| Home Health Care 180 visits per calendar year (does not cover custodial care for seniors with memory issues) |
100% |
75% of U&C after Deductible |
| Home Infusion Services | 100% | 75% of U&C after Deductible |
| Hospital Inpatient |
100% after $100 copay per admission | 75% of U&C after Deductible and $500 copay per admission |
| Hospital Outpatient Surgical |
100% after $50 copay | 75% of U&C after Deductible and $85 copay |
| Infertility Treatment/Assisted Reproduction Treatment includes office visits, testing, IVF, GIFT, ZIFT, AID and IUI Maximum Lifetime Benefit: 3 IVF cycles |
100% after $25 copay per service | 75% of U&C after Deductible and $25 copay per service |
| Infertility Treatment/Assisted Reproduction Infertility Specialty Meds |
Provider must contact HealthCare Strategies for infertility treatments at 800-582-1535 Plan pays 100% for covered Infertility Specialty Medications when obtained from Schrafts II Pharmacy at 855-724-7238 |
Provider must contact HealthCare Strategies for infertility treatments at 800-582-1535 Plan pays 100% for covered Infertility Specialty Medications when obtained from Schrafts II Pharmacy at 855-724-7238 |
| Covered Services | In-Network Plan Pays |
Out-of-Network Plan Pays |
|---|---|---|
| Maternity Prenatal/Postnatal |
100% | 75% of U&C after Deductible and $25 copay |
| Maternity Initial Office Visit |
$25 Copay | 75% of U&C after Deductible and $25 copay |
| Maternity Delivery |
$25 Copay | 75% of U&C after Deductible |
| Maternity Inpatient Facility |
100% after $100 Copay per admission | 75% of U&C after Deductible and $500 copay per admission |
| Mental Health Office Visit |
$25 Copay per visit | 75% of U&C after $500 Deductible and $25 copay |
| Mental Health Virtual visit |
100% | 75% of U&C after $500 Deductible and $25 copay |
| Mental Health ABA Therapy* |
$25 Copay per visit | 75% of U&C after $500 Deductible and $500 copay per admission |
| Mental Health Inpatient Treatment* |
100% after $100 copay per admission | 75% of U&C after $500 Deductible and $500 copay per admission |
| Mental Health Residential Treatment |
100% after $100 copay per admission | 75% of U&C after $500 Deductible and $500 copay per admission |
| Mental Health Partial Day Program* with Intensive Outpatient Treatment |
100% after $100 copay per course of treatment | 75% of U&C after $500 Deductible and $500 copay per admission |
| *Preauthorization is required. Contact Quantum Health at (888) 214-4001 for mental health, ABA Therapy (behavioral health) and substance use disorder services. | ||
| Nutritionist/ Nutritional Counseling |
100% after $25 copay | 75% of U&C after Deductible and $25 copay |
| Occupational Therapy (Outpatient) Facility |
100% after $50 copay | 75% of U&C after Deductible and $85 copay |
| Occupational Therapy (Outpatient) Office |
$10 Copay per visit | 75% of U&C after Deductible and $25 copay |
| Covered Services | In-Network Plan Pays |
Out-of-Network Plan Pays |
|---|---|---|
| Physical Therapy (Outpatient) Facility |
100% after $50 copay | 75% of U&C after Deductible and $85 copay |
| Physical Therapy (Outpatient) Office |
$10 Copay per visit | 75% of U&C after Deductible and $25 copay |
| Physician Office Visits (Non-routine) | $25 Copay per visit | 75% of U&C after Deductible and $25 copay |
| Physician Office Visits (Inpatient) | 100% | 75% of U&C after Deductible |
| Radiation Therapy Outpatient Facility |
100% | 75% of U&C after Deductible and $85 copay |
| Radiation Therapy Office |
100% | 75% of U&C after Deductible and $25 copay |
|
Routine Health Maintenance: Ob/Gyn (2x/yr) Routine Physical Mammogram Pap Smear Bone Density Colonoscopy(1x every 5 yrs) Prostate Screening |
100% | 75% of U&C after Deductible and $25 copay |
|
Skilled Nursing Facility 180 days per calendar year |
100% after $100 copay per admission | 75% of U&C after Deductible and $500 copay per admission |
| Speech Therapy (Outpatient) Facility |
100% after $50 copay | 75% of U&C after Deductible and $85 copay per admission |
| Speech Therapy (Outpatient) Office |
100% after $25 copay | 75% of U&C after Deductible and $25 copay |
| Substance Use Disorder Office Visit |
$25 copay per visit | 75% of U&C after Deductible and $25 copay |
| Substance Use Disorder Inpatient Treatment* |
100% after $100 copay per admission | 75% of U&C after $500 Deductible and $500 copay per admission |
| Substance Use Disorder Residential Treatment* |
100% after $100 copay per admission | 75% of U&C after $500 Deductible and $500 copay per admission |
| Substance Use Disorder Partial Day Program* with Intensive Outpatient Treatment* |
100% after $100 copay per course of treatment | 75% of U&C after $500 Deductible and $500 copay per treatment |
| *Preauthorization is required. Contact Quantum Health at (888) 214-4001 for mental health, behavioral health and substance abuse disorder services. | ||
| Covered Services | In-Network Plan Pays |
Out-of-Network Plan Pays |
|---|---|---|
| Surgery - Physician | 100% after $25 copay | 75% of U&C after Deductible and $25 copay |
| Telehealth Virtual visit with the PCP or Specialist in lieu of an in-person office visit. |
100% | 75% of U&C after Deductible and $25 copay |
| Telemedicine Virtual service provided by Anthem's Live Health Online (Telemedicine 24/7 by computer, tablet or smart phone |
100% | Not available |
| Transplant Outpatient Physician |
100% after $25 copay | 75% of U&C after Deductible and $25 copay |
| Transplant Inpatient Facility |
100% after $100 copay per admission | 75% of U&C after Deductible and $100 copay per admission |
| Transplant Inpatient Physician |
100% | 75% of U&C after Deductible |
|
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Centers of Excellence ONLY include $10,000 limit per transplant for Transportation/Lodging/Meals | No coverage for Transportation/Lodging Meals |
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Travel International: (For Emergency Care Only) |
Not available | 100% after Deductible and applicable OON Co-Pays |
| Urgent Care | 100% after $35 copay | 75% of U&C after Deductible and $45 copay |
| Weight Watchers-WW (6-month membership) Contact OUH plan office to obtain access code after $25 copay to OUH |
100% after $25 copay to OUH (Member can attend in-person or virtual meetings; or use the WW app to participate on their own) |
Not available |
| Wigs Covered for hair loss due to chemotherapy, radiation, scalp burns or alopecia. Limited to one wig per lifetime up to $800 |
100% after $25 copay per wig | 75% of U&C after Deductible and $25 copay per wig |
Prescription Schedule of Benefits
Navitus Rx
Navitus Customer Service - 855-673-6504
Mail Order – Costco – 800-607-6861
Specialty – Lumicera – 855-847-3553
| Generic | Preferred Brand | Non-Preferred Brand | |
|---|---|---|---|
| Retail Pharmacy 30-Day Supply |
$5 Copay | $35 Copay | $60 Copay |
| Retail Pharmacy 90-Day Supply |
$10 Copay | $70 Copay | $120 Copay |
| Mail Order Pharmacy 90-Day Supply |
$10 Copay | $70 Copay | $120 Copay |
| Specialty Medication 30-Day Supply |
N/A | $35 Copay | $60 Copay |
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Note: If you purchase 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. |
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