Grievances 71 CONTACT INFORMATION QUESTIONS ABOUT: CONTACT: Eligibility Initial enrollment, adding Dependents, qualifying change of status events, proof documentation, and eligibility rules UNM Division of Human Resources Phone: 505-277-MyHR(6947) Website: Medical Plan TPA Plan coverage, Benefit Determination, Prior Authorization, provider networks, billing, Explanations of Benefits, medical Appeals and grievance procedures UNM Health Customer Care: 505-925-2432 Or Toll free 1-844-866-2224 Website: Prescription Drug PBM Express Scripts Customer Service: 1-800-232-6549 Website: UNM Health Network Accessing services and care in the UNM Health Network ABQ Health Partners Customer Care: 505-925-2432 Or Toll free 1-844-866-2224 Website: Customer Service: 505-262-7600 Or Toll free 1-888-354-4968 COBRA Administrator Continuation of coverage after participant and/or a Dependent are no longer eligible for coverage Chard-Snyder Customer Service: 1-888-993-4646 Website:
SCHEDULE OF BENEFITS UNM Medical Plan Benefits and Coverage UNM Health Network Extended Network (Benefit Determination Required) (1) Out-of-Network ANNUAL PLAN YEAR DEDUCTIBLE (Deductible must be met for services subject to the deductible before benefits are paid) Individual: $600(3) Family: $1,200(3) Individual: $1,800 Family: $3,600 ANNUAL PLAN YEAR OUT-OF-POCKET MAXIMUM (Includes: Medical Deductible, Coinsurance, AND Medical and Prescription Copayments) Individual: $3,000 Family: $6,000 (Includes: Medical Deductible, Medical and Prescription Coinsurance and Copayments) Individual: $7,500 Family: $15,000 (Includes Medical Coinsurance ONLY. Excludes Medical Deductible and Prescription Copayments and Coinsurance) ANNUAL and MAXIMUM LIFETIME BENEFIT Unlimited Pre-Existing Condition Exclusion None PROVIDER/PRACTITIONER SERVICES Including: Non-specialist office visits – (non-preventive) $25(2,3) Co-pay per visit $30(1,2,3) Co-pay per visit 40%(,5) Coinsurance Specialist office visits – (non-preventive) $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5) Coinsurance Outpatient surgery (In-Provider/Practitioner’s office) Included in office Co-pay Included in office 40%(5) Coinsurance Allergy services Testing and Extract Injections Only (no office visit billed) $55(2,3) Co-pay No Co-pay(2) $55(1,2,3) Co-pay No Co-pay(1,2) 40%(5) Coinsurance 40%(5) Coinsurance Injections such as insulin, heparin and antibiotics Included in office visit Co-pay Included in office visit Co-pay 40%(5) Coinsurance Infertility services – diagnosing only $25(2,3) Co-pay per visit $30,(1,2,3) Co-pay per visit 40%(5) Coinsurance pay
Non-specialist office visits Specialist office visit $35(2,3,6) Co-pay per visit $45(1,2,3,6) Co-pay per visit 40%(5,6) Coinsurance HOSPITAL SERVICES – Inpatient (6,7) Coverage includes: Room and board Newborn delivery and other hospital obstetrical services In-hospital Provider/Practitioner visits, Surgeons, Anesthesiologist and other Inpatient services Detoxification Administration of blood/blood components 10%(3,4,6,7) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance MEDICAL SERVICES – Outpatient Surgeries(1)(7) Hospital/ASC Facility Fees Professional Fees 10%(3,4,6) Coinsurance 10%(3,4,6) Coinsurance 30%(1,2,3) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance 40%(5,6) Coinsurance X-ray, laboratory, and diagnostic tests Preventive Non-preventive No Co-pay(2) No Co-pay(2) No Co-pay(1,2) No Co-pay(1,2) Not Covered 40%(5) Coinsurance Endoscopy (6) Colonoscopy(Non-preventive or Preventive) 10%(3,4,6) Coinsurance No Co-pay(2) 30%(1,3,4,6) Coinsurance No Co-pay(1,2) 40%(5,6) Coinsurance 40%(5) Coinsurance
URGENT CARE $75(2,3) Co-pay per visit $75(2,3) Co-pay per visit 40%(5,6) Coinsurance AMBULANCE SERVICES Includes: Emergency or high risk Ground and Air ambulance Inter-facility transfer services Ground and Air ambulance Applies to In-Network Benefit 30%(3,4) Coinsurance No Co-pay(2) Applies to In-Network Benefit CLINICAL PREVENTIVE SERVICES Includes: Well child care including vision and hearing screening Preventive physical exam Adult and child immunizations Office based health education Family Planning Services Colonoscopy No Co-pay(2,8) No Co-pay(1,2,8) Not Covered
WOMEN’S HEALTH CARE Preventive Care Services Well-woman visits to include adult and female-specific screenings Mammograms Cytological Screening (Pap tests) including screening for papillomavirus Screening for gestational diabetes Counseling for HIV and sexually transmitted diseases Screening and counseling for interpersonal and domestic violence FDA Approved Surgical sterilization procedures for women’s sterilization Contraceptive implant insertion/re- insertion fee Contraception counseling Breast feeding support, supplies and counseling(8) No Co-pay(2,8) No Co-pay(1,2,8) 40%(5) Coinsurance Non-preventive Non-specialist $25(2,3) Co-pay per visit $30(1,2,3) Co-pay per visit 40%(5) Coinsurance Specialist (includes Perinatologist) $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5) Coinsurance Obstetrical/Maternity/Prenatal and Postnatal care (excludes delivery) $25(2, 3) Co-pay for first visit. (Plan pays 100% thereafter) $30(1,2,3) Co-pay for first visit. (Plan pays 100% thereafter) 40%(5) Coinsurance DIABETES SERVICES Office visit and Diabetes Education Non-specialist $25(2,3) Co-pay per visit $30(1,2,3) Co-pay per visit 40%(5) Coinsurance
Specialist Diabetes supplies (6) (If purchased through a Durable Medical Equipment Provider). Other Diabetic Supplies are covered under the Express Scripts Prescription Drug Benefit. $35(2,3) Co-pay per visit 10%(3,4,6) Coinsurance $45(1,2,3) Co-pay per visit 30%(1,3,4,6) Coinsurance 40%(5) Coinsurance 40%(5) Coinsurance PRESCRIPTION DRUGS(2,3) Administered by Express Scripts. Call Express Scripts at 1-800-232-6549. MENTAL HEALTH SERVICES Outpatient $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5) Coinsurance Inpatient/Partial Hospitalization (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5) Coinsurance ALCOHOL AND SUBSTANCE ABUSE SERVICES Rehabilitation Outpatient $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5) Coinsurance Inpatient/Partial Hospitalization (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance Detoxification Outpatient $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5,6) Coinsurance Inpatient/Partial Hospitalization (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance
Exercise Equipment, videos, personal trainers, club membership and weight reduction programs are not Covered Services under this Plan. Experimental or Investigational, as determined by PHP, drugs, medicines, treatments, or procedures as listed in the Exclusions Section under “Experimental or Investigational” of the Participant Benefit Booklet. Extracorporeal shock wave therapy involving the musculoskeletal system. Eye Exercises and Refractions are not Covered Services under this Plan. Food and Lodging Expenses are not covered except for those that are eligible for per diem coverage under the “Transplant Services” provision in the Covered Services section. Foot care (routine), except as provided in the Participant Benefit Booklet. Genetic Inborn Errors of Metabolism as listed in the Participant Benefit Booklet. “Get acquainted” visits without physical assessment or diagnostic or therapeutic intervention provided. Gloves, unless part of a wound treatment kit. Hair loss (or baldness) treatments, medications, supplies and devices including wigs, and special brushes. Health Care that is associated with an injury that is obtained or associated in the commission of a crime. Hearing aids and the evaluation for the fitting of hearing aids except for school-aged children under 18 years old (or under 21 years of age if still attending high school). Home Health Care Services for care that: Is provided primarily for the convenience of the Participant or the Participant’s family; Consists mostly of bathing, feeding, exercising, preparing meals, homemaking, moving the patient, giving medications, or acting as a sitter Is provided by a nurse who ordinarily resides in the Participant’s home or is a member of the Participant’s immediate family. Hospice benefits are not available for the following services Food, housing, and delivered meals; or Volunteer services; or Comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered under Durable Medical Equipment benefits); or Homemaker and housekeeping services; or Private duty nursing; or Pastoral and spiritual counseling; or Bereavement counseling Human Chorionic Gonadotrophin (HCG) injections Hypnotherapy Implantation of artificial organs or mechanical devices except as specified in the Participant Benefit Booklet