Dental Benefit Summary - Kalispell

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Dental Benefit Summary - Kalispell
Medical Benefits
Revised Major Medical
(RM) Plan
Kalispell Plan Option Number
High Deductible Health Plan
(HDHP) Embedded Deductible
Option 1
Option 2
Deductible – individual
$1,000
$3,000
$6,050
Deductible – family
$2,000
$6,000
$12,100
Out-of-pocket maximum – individual
$3,000
$5,000
$6,050
Out-of-pocket maximum – family
$6,000
$10,000
$12,100
Benefit percentages available
70/30%
Option 3
100/0%
Office Visits (physician/chemical dependency/mental illness)
Deductible
Benefit percentage
First-dollar benefit (chemical dependency/mental illness only)
Waived
In network: $35 co-pay
Out of network: 70/30%
First three visits paid at 100%
Applies
100%
N/A
Accident
Deductible, benefit percentage
Waived, 100%
Maximum benefit per accident
$500 within 90 days of accident
Deductible, 100%
N/A
Autism Spectrum Disorders
Deductible, benefit percentage
First three visits paid 100%
Thereafter - In network: $35 co-pay
Deductible, 100%
Chemical Dependency (inpatient)
Deductible, benefit percentage
Applies, 70/30%
Deductible, 100%
Deductible, benefit percentage
Waived, 100%
Deductible, 100%
Maximum payment per visit
$25
$25
Maximum visits per benefit period (combined)
25
25
Chiropractic X-Rays (Limit of $100)
Waived, 100%
Deductible, 100%
Applies, 70/30%
Deductible, 100%
Deductible, benefit percentage
Applies, 70/30%
Deductible, 100%
Maximum visits per benefit period (combined)
180
Chiropractic/Acupuncture Visits & Chiropractic X-rays
Diagnostic X-Ray
Deductible, benefit percentage
Home Health/Hospice Care
180
Hospital Services
Deductible, benefit percentage
Applies, 70/30%
Deductible, 100%
Applies, 70/30%
Deductible, 100%
Applies, 70/30%
Deductible, 100%
Lab work
Deductible, benefit percentage
Mental Illness (inpatient)
Deductible, benefit percentage
Preventive Services
Preventive Office Visit
Covered in full
Covered in full
Immunizations
Covered in full
Covered in full
Rehabilitation Services
Deductible, benefit percentage
Applies, 70/30%
Deductible, 100%
Maximum benefit period (outpatient/inpatient)
50 visits/60 days
50 visits/60 days
Deductible, benefit percentage
Applies, 70/30%
Deductible, 100%
Maximum days per benefit period
60
Skilled Nursing Facility
60
Transplants
Deductible, benefit percentage
Applies, 70/30%
Lifetime maximum
N/A
Deductible, 100%
N/A
Pharmacy Benefits – Administered by MedImpact
RM Plans (Option 1 and 2 Only – does not apply to HDHP 6050 plan): $100 Deductible applies (Preventive drugs covered at 100%)
Retail Pharmacy
Mail Order
Generic (30 days supply) - $10 Copay
Generic (90 days supply) - $20 Copay
Preferred (30 days supply) - $20 Copay
Preferred (90 days supply) - $40 Copay
Non-Preferred (30 days supply) - $40 Copay
Non-Preferred (90 days supply) - $80 Copay
HDHP 6050 Plan: Prescription drugs are subject to the deductible and coinsurance of the plan
If you have questions about your pharmacy benefits, please contact MedImpact directly at 1-800-788-2949.
Dental Benefits
Deductible (per benefit period beginning 07/01/17)
Individual
$50
Family
$150
Benefit Maximum (per benefit period beginning 07/01/17)
Per Person
$1,000
Covered Services
Preventive Services (Cleanings, Exams, X-rays, and Fluoride Treatments)
$10 Copay, 100%
Basic Services (Example – Fillings)
Deductible, 80%
Major Services (Example – Root Canals)
Deductible, 50%
Vision Benefits – VSP Administered by Ameritas
Exam (once every 12 months based on date of service)
$10 Copay
Frames (once every 24 month based on date of service)
$10 Copay plus $130 allowance in-network, $10 Copay plus $70 allowance out-of-network
Lenses (once every 12 months based on date of service)
Covered in full in-network, $30-$100 allowance out-of-network
Contacts (in lieu of frames/lenses)
Contact fitting exam
Member cost up to $60 in-network only. Member pays all charges out-of-network.
Contacts (elective)
$130 allowance in-network, $105 allowance out-of-network
First Choice Health Customer Service: First Choice Health Customer Care for Kalispell Public Schools is available
from 8:00 am to 6:00 pm Monday through Friday MST, toll-free at 1-800-783-7312. You can also obtain claims and
benefit information online at www.fchn.com.
Case Management and Maternity Management: This is FREE to you! First Choice Healh helps advocate for and
your family members to help guide you through challenging health issues. This service is designed to assist you and
your family with support to reduce the fragmentation of service delivery, improves outcomes and saves money.
Should you need assistance during the course of treating a condition, or illness please contact our Case
Management team at (800) 808-0450. Maternity Management offers one-on-one support from a Registered Nurse
who will help you achieve a healthy pregnancy. Enroll today by calling (800) 756-7751.
Preventive Services: Preventive/Wellness services cover your annual health exams, immunizations, preventive
drugs, mammograms, contraceptives, screenings, colonoscopies and others at 100%.
Network Providers: The health plans offered to you by Kalispell Public Schools uses the First Choice Health
network of providers. This includes many of the same provider network that you have been accessing for the past few
years. You will experience the lowest out-of-pocket cost when utilizing providers that participate in the First Choice
Health network. You can access information about First Choice Health providers at www.fchn.com.
Non-network Providers: Since non-network providers are not contracted with First Choice Health, payment will be
based on the allowable amounts for non-network providers. You will be responsible for payment of any balances
owed to your providers. These balance-billed amounts do not accrue towards your deductible or out-of-pocket
maximum. Non-network providers are also not obligated to submit claims forms for you.
Care Received Outside the Service Area: The First Health Network is the provider network for plan participants
and/or their dependents who live or work outside of the First Choice Health service area. The First Health Network is
also available to all participants for urgent or emergency care when traveling. You may contact the First Health Network
at www.firsthealth.com, or by phone at 1-800-226-5116.
This is a brief summary of benefits; it is not a certificate of coverage. For full coverage provisions, including a description
of waiting periods, limitations, and exclusions, refer to the plan document on file with your group.

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