Table of Contents
Plan Benefits
Prescription Program
PPO Network
Covered Preventive Services
General Limitations & Exclusions
Rx Exclusions and Limitations
Frequently Asked Questions
Table of Contents
1
2
3
5
7
9
10
Member Services
icamemberservices@premierhsllc.com | (214) 436-8883
Member Portal
icamembers.com
1
Basic Plan Benefits
Wellness Plan Benefits
Physician Office Visits
Preventative/Wellness Physician Office Visits
Physician’s Office or Clinic Visit for Preventive Care, Screening &
Immunization
100%
Preventive/Wellness Diagnostic Tests (x-ray, blood work)
100%
Physician Office Visit (injury or illness)
Copay Amount per Visit
$25
Maximum Visits per Membership Year
4
Maximum Amount per Visit after copay
$150
This guide is a summary document. If there are any discrepancies between this guide and the Plan Document, the Plan Document terms govern.
Prescription Program
SimpleScripts Rx is a MEC (Minimal Essential Coverage) Medication
Program that includes 95 ACA (Affordable Care Act) drugs at no-cost,
plus great discounts on all other medications. Their Customer Care
team operates as a pharmacy savings advocate, helping members find
the lowest price on medications available.
Rx Program Covers:
Drugs such as:
• Aspirin
• Bowel Preparation • Breast Cancer Prevention • Contraceptives • Fluoride Supplements • Folic Acid • Statins • Tobacco Cessation • Vitamin Supplements • and More! • Atorvastatin • Bupropion • Cholecalciferol • Junel • Lovastatin • Nonoxynol • Tamoxifen • Viorele • and Much More!
How the Program Works:
1. You can search for medications by entering the drug name in the search bar. If a medication is not on the No-cost Medication Program, a price will be displayed.
2. Present your ID Card to the pharmacy of your choice. There are over 67,000 retail pharmacies in the network. 3. If you need other medications, you can easily search our website for deeply discounted prices.
Home Delivery
In addition to retail pharmacies, SimpleScripts Rx offers members a Home Delivery Option, with free standard shipping and affordable express delivery. Members have access to discounts up to 80% and savings on all orders of quality and certified pharmaceutical brands. Orders are placed through a registered and licensed pharmacy using a secured payment encryption method. With a fast and responsive customer support team, members can get assistance quickly if needed.
Diabetic Supply Program
SimpleScripts Rx also offers a way to save on Diabetic Supplies. Members can choose from quarterly testing programs or purchase supplies as needed. All of the products are shipped to their home. No prescription is needed for OTC testing supplies.
Members Receive:
· Free talking blood glucose meter with first order · 100% satisfaction guaranteed or their money back · Tracking info on all orders via email and/or text
· Quarterly auto-shipping programs with option to choose how many times a day they test · Programs start as little as $24.99 per quarter ($8.33 per month)
SimpleScripts Rx
Member Access
Activate your SimpleScripts Rx Member Portal
1. You will receive an email and mailed RX Member ID card from SimpleScripts Rx on or before your effective date with your Member ID and Rx Group number. 2. Go to https://www.simplescriptsrx.com/login.php
3. Enter the Member ID and Rx Group number from your RX Member ID Card. 4. Create a new password and update your profile.
Questions about your Rx benefits? Please call us at (855) 798-2538
3
Members who need more help can select “Contact Us” on the lower left side of the web page to submit an online request. First Health’s Customer Service team will get back to them within 48 hours. Or, they may call (800) 226-5116 Monday through Friday from 8 a.m. to 8 p.m. (Eastern Time). The member needs to identify him/herself as a health plan participant accessing the First Health Limited Benefit Plan Network.Members should always check with the provider’s office before scheduling an appointment or getting services and confirm that they are still a participating provider in the First Health Limited Benefit Plan network. Participating physicians and other health care providers are independent contractors. They are neither agents nor employees of First Health. The availability of any particular provider cannot be guaranteed. Provider networks are subject to change.
Just a Few Easy Steps to Find In-Network Providers
First Health has made finding a health care provider fast and easy. With the improved Provider Online Search tool, members can quickly locate network providers and make educated health care choices. All they have to do is go to www.firsthealthlbp.com and follow the steps below to search for a provider and create a provider directory.
Essential Care includes the First Health® Limited Benefit Network. Members
have access to a premier national network that includes more than 5,100
hospitals, 110,000 ancillary facilities and 695,000 professional providers at
over 1 million health care service locations.*
The Value of the First Health Network
Broad Access - This extensive network offers a wide range of providers for preventive services, emergent/urgent care and other types of treatment that members or their covered dependents might need. Ninety-six percent of the U.S. population has access to a First Health provider within 20 miles*, including within urban, suburban and rural areas.
Great Discounts - With average savings of 32% to 52%** for the most commonly used medical providers/services, members benefit from lower out-of-pocket costs through the First Health Network.
Specialty Type
Number of Providers
Average Savings
Family Practice 60,000+ 37% Internal Medicine 65,000+ 40% Pediatrics 36,000+ 32%
Consistent Quality - As a network accredited by the National Committee for Quality Assurance (NCQA), First Health is known for network stability. In fact, 99% of their hospitals and 94% of their physicians are retained year after year.*
* Network statistics as of December 2017 First Health Data Warehouse
** Savings shown represent average savings achieved from actual claims data set representative of 12 months of claims history. Discounts do not account for any savings based on benefit plan design or member responsibility. Actual discounts vary by provider and specific geographic locations.
First Health is a brand name of First Health Group Corp. First Health Group Corp. is an indirect, wholly owned subsidiary of Aetna, Inc.
1. Find Providers
Search for providers
and refine criteria to
customize results
2. Get the Details
Check out
location, hours
and more
3. Keep It Handy
Send provider details
to yourself or others
via text or email
4. Create Directory
Save selected
providers for
quick reference
PPO Network
First Health Limited Benefit Plan Network
Preventive Services
5
Covered Preventive Services
Covered Preventive Services for Adults (Ages 18 and Older)
Service
Limitations
Abdominal Aortic Aneurysm Screening One-time screening for age 65-75 (Men only)
Annual Preventive Care Visit History, Physical exam, Measurements (Height, Weight & Body Mass Index) Aspirin use for men Ages 65-79 to prevent CVD when prescribed by a physician
Aspirin use for women Ages 55-79 to prevent CVD when prescribed by a physician Colorectal Cancer Screening Starting at age 50, limited to 1 every 5 years
General Health Screenings Blood pressure, Cholesterol screening based on age and individual risk factors, Depression screening, Diabetes screening for adults with high blood pressure, HIV screening, Obesity screening, Sexually transmitted infection (STI) screenings (Chlamydia, Gonorrhea, Syphilis) Health Counseling Alcohol misuse, Healthy diet, Obesity, Prevention of sexually transmitted infections (STIs), Tobacco use, Use of folic acid Hepatitis B Screening For adults at high risk, and one time for anyone born prior to 1966
Hepatitis C Screening For adults at high risk, and one time for anyone born prior to 1966
Immunizations Diphtheria-Tetanus-Pertussis, Hepatitis A&B, Human Papillomavirus (HPV), Influenza (flu shot), Measles-Mumps-Rubella, Meningococcal, Pneumococcal (Pneumonia), Tetanus, Diphtheria, Pertussis, Varicella (Chickenpox), Herpes Zoster
Lung Cancer Screening Low dose computed tomography (LDCT) for adults age 55-80 who have a 30-pack year smoking history and currently smoke or have quit within the past 15 years
Covered Preventive Services for Women, Including Pregnant Women
Service
Limitations
Alcohol Misuse Screening and Counseling Pregnant women
Anemia Screening Routine basis for pregnant women
Annual Well Woman Visit History, Physical exam, Measurements (Height, Weight & Body Mass Index) Bacteriuria Urinary Tract or Other Infection
Screening Pregnant women Blood Test Screening for Rh Incompatibility Pregnant women BRCA Counseling and Genetic Testing Women at higher risk
Breast Cancer Mammography Screenings Every year for women age 40 and over Breastfeeding Comprehensive Support and
Counseling from Trained Providers, as well as
access to Breastfeeding Supplies Pregnant and nursing women Cervical cancer screening including pap smear
Chemoprevention of Breast cancer
Contraception FDA approved contraceptive methods, sterilization procedures and patient education and counseling. Does not include abortifacient drugs Domestic Violence Counseling
Female Sterilization Tubal ligation
Folic Acid Supplements When prescribed by a Physician for women who may become pregnant Gestational Diabetes Screening Pregnant women
Covered Preventive Services
Covered Preventive Services for Women, Including Pregnant Women (Continued)
Service
Limitations
Hepatitis B Screening Pregnant women
Human Papillomavirus (HPV) DNA test Every 3 years for women with normal cytology who are 30 or older Osteoporosis Screening Over age 60
Screening for Sexually Transmitted Infections (STIs),
including Chlamydia, Gonorrhea and Syphilis Pregnant women
Tobacco Use Screening and Interventions Expanded counseling for pregnant tobacco users
Covered Preventive Services for Children
Service
Limitations
Autism screening Limited to 2 screenings up to age 26 months Behavioral Assessments Limited to 5 assessments up to age 17 Congenital Hypothyroidism Screening For Newborns
Depression Screening Adolescents age 12 and older
Immunizations Diphtheria-Tetanus-Pertussis, Hemophilus influenza type B, Hepatitis A&B, Human Papillomavirus (HPV), Influenza (flu shot), Measles-Mumps-Rubella, Meningococcal, Pneumococcal (Pneumonia), Inactivated Poliovirus, Rotavirus, Varicella (Chickenpox) Phenylketonuria (PKU) Screening Newborns
Preventive Treatments Gonorrhea preventive medication for eyes of all newborns
Screenings Hearing loss, sickle cell disease, Hematocrit or hemoglobin screening, Obesity screening, Lead screening, Dyslipidemia screening for children at higher risk of lipid disorder, Tuberculin testing, HIV screening, Cervical dysplasia screening
Sexually Transmitted Infection (STI) Prevention
Counseling & Screening Adolescents Vision Screening Under Age 5
Well Child Exams History, Physical exam, Measurements (Height, Weight & Body Mass Index), Vision acuity test, Oral health assessment, Anticipatory guidance
Medical (Preventive Care Only) Exclusions:
1. Injury or self-inflicted bodily harm 2. Sickness or disease
3. Preventive health services not included under ACA
4. Preventive health services rendered outside of the United States
5. Preventive health services that are performed by a person who is related to the Participant as a spouse, parent, child, brother or sister, whether the relationship exists by virtue of “blood” or “in law.”
7
General Limitations & Exclusions
General Limitations & Exclusions
Administrative Costs. That are solely for and/or applicable to administrative
costs of completing claim forms or reports or for providing records wherever allowed by applicable law and/or regulation.
After the Termination Date. That are Incurred by the Participant on or after
the date coverage terminates, even if payments have been predetermined for a course of treatment submitted before the termination date, unless otherwise deemed to be covered in accordance with the terms of the Plan or applicable law and/or regulation.
Alcohol. Involving a Participant who has taken part in any activity made
illegal due to the use of alcohol or a state of intoxication. Expenses will be covered for Injured Participants other than the person partaking in an activity made illegal due to the use of alcohol or a state of intoxication, and expenses may be covered for Substance Abuse treatment as specified in this Plan, if applicable. This Exclusion does not apply if the Injury (a) resulted from being the victim of an act of domestic violence, or (b) resulted from a documented medical condition (including both physical and mental health conditions).
Broken Appointments. That are charged solely due to the Participant’s
having failed to honor an appointment.
Complications of Non-Covered Services. That are required as a result of
complications from a service not covered under the Plan, unless expressly stated otherwise.
Confined Persons. That are for services, supplies, and/or treatment of
any Participant that were Incurred while confined and/or arising from confinement in a prison, jail, or other penal institution with said confinement exceeding 24 consecutive hours.
Cosmetic Surgery. That are Incurred in connection with the care and/
or treatment of Surgical Procedures which are performed for plastic, reconstructive or cosmetic purposes or any other service or supply which are primarily used to improve, alter or enhance appearance, whether or not for psychological or emotional reasons, except to the extent where it is needed for: (a) repair or alleviation of damage resulting from an Accident; (b) because of infection or Illness; (c) because of congenital Disease, developmental condition or anomaly of a covered Dependent Child which has resulted in a functional defect. A treatment will be considered cosmetic for either of the following reasons: (a) its primary purpose is to beautify or (b) there is no documentation of a clinically significant impairment, meaning decrease in function or change in physiology due to Injury, Illness or congenital abnormality. The term “cosmetic services” includes those services which are described in IRS Code Section 213(d)(9).
Custodial Care. That do not restore health, unless specifically mentioned
otherwise.
Deductible. That are amounts applied toward satisfaction of Deductibles and
expenses that are defined as the Participant’s responsibility in accordance with the terms of the Plan.
Excess. That exceed Plan limits, set forth herein and including (but not
limited to) the Maximum Allowable Charge in Salvasen Health’s discretion and as determined by Salvasen Health, in accordance with the Plan terms as set forth by and within this document.
Experimental. That are Experimental or Investigational.
Family Member. That are performed by a person who is related to the
Participant as a spouse/domestic partner, parent, Child, brother, or sister, whether the relationship exists by virtue of “blood” or “in law”.
Foreign Travel. That are received outside of the United States if travel is for
the purpose of obtaining medical services, unless otherwise approved by Salvasen Health.
Government. That the Participant obtains, but which is paid, may be paid,
is provided or could be provided for at no cost to the Participant through any program or agency, in accordance with the laws or regulations of any government, or where care is provided at government expense, unless there is a legal obligation for the Participant to pay for such treatment or service in the absence of coverage. This Exclusion does not apply when otherwise prohibited by law, including laws applicable to Medicaid and Medicare.
Government-Operated Facilities. That meet the following requirements:
1. That are furnished to the Participant in any veteran’s Hospital, military Hospital, Institution or facility operated by the United States government or by any State government or any agency or instrumentality of such governments.
2. That can be paid for by any government agency, even if the patient waives his rights to those services or supplies.
Note: This Exclusion does not apply to treatment of non-service-related disabilities or for Inpatient care provided in a military or other Federal government Hospital to Dependents of active duty armed service personnel or armed service retirees and their Dependents. This Exclusion does not apply where otherwise prohibited by law.
Illegal Acts. That are for any Injury or Sickness which is Incurred while
taking part or attempting to take part in an illegal activity, including but not limited to misdemeanors and felonies. It is not necessary that an arrest occur, criminal charges be filed, or, if filed, that a conviction result. Proof beyond a reasonable doubt is not required to be deemed an illegal act. This Exclusion does not apply if the Injury (a) resulted from being the victim of an act of domestic violence, or (b) resulted from a documented medical condition (including both physical and mental health conditions).
Illegal Drugs or Medications. That are services, supplies, care or treatment
to a Participant for Injury or Sickness Incurred while the Participant was voluntarily taking or was under the influence of any controlled substance, drug, hallucinogen or narcotic not administered on the advice of a Physician. This Exclusion will apply even if the Participant has a prescription for the drug and the drug is legal in the state where the Participant lives. Expenses will be covered for Injured Participants other than the person using controlled substances and expenses will be covered for Substance Abuse treatment as specified in this Plan. This Exclusion does not apply if the Injury (a) resulted from being the victim of an act of domestic violence, or (b) resulted from a documented medical condition (including both physical and mental health conditions).
Incurred by Other Persons. That are expenses Incurred by other persons. Long Term Care. That are related to long term care.
Medical Necessity. That are not Medically Necessary and/or arise from
services and/or supplies that are not Medically Necessary.
Some health care services are not covered by the Plan. Coverage is not available from the Plan for charges arising from care, supplies, treatment, and/or services:
Medical Exclusions
Military Service. That are related to conditions determined by the Veteran’s
Administration to be connected to active service in the military of the United States, except to the extent prohibited or modified by law.
Negligence. That are for Injuries resulting from negligence, misfeasance,
malfeasance, nonfeasance or malpractice on the part of any caregiver, Institution, or Provider, as determined by Salvasen Health, in its discretion, considering applicable laws and evidence available to Salvasen Health.
No Coverage. That are Incurred at a time when no coverage is in force for
the applicable Participant and/or Dependent.
No Legal Obligation. That are for services provided to a Participant for
which the Provider of a service does not and/or would not customarily render a direct charge, or charges Incurred for which the Participant or Plan has no legal obligation to pay, or for which no charges would be made in the absence of this coverage, including but not limited to charges for services not actually rendered, fees, care, supplies, or services for which a person, company or any other entity except the Participant or the Plan, may be liable for necessitating the fees, care, supplies, or services.
Non-Prescription Drugs. That are for drugs for use outside of a Hospital or
other Inpatient facility that can be purchased over the counter and without a Physician’s written prescription. Drugs for which there is a non-prescription equivalent available. This does not apply to the extent the non- prescription drug must be covered under Preventive Care, subject to the Affordable Care Act.
Not Acceptable. That are not accepted as standard practice by the
American Medical Association (AMA), American Dental Association (ADA), or the Food and Drug Administration (FDA).
Not Covered Provider. That are performed by Providers that do not satisfy
all the requirements per the Provider definition as defined within this Plan.
Not Specified as Covered. That are not specified as covered under any
provision of this Plan.
Other than Attending Physician. That are other than those certified by a
Physician who is attending the Participant as being required for the treatment of Injury or Disease and performed by an appropriate Provider.
Personal Injury Insurance. That are in connection with an automobile
accident for which benefits payable hereunder are, or would be otherwise covered by, mandatory no-fault automobile insurance or any other similar type of personal injury insurance required by state or federal law, without regard to whether the Participant had such mandatory coverage. This Exclusion does not apply if the Injured person is a passenger in a non-family owned vehicle or a pedestrian.
Postage, Shipping, Handling Charges, Etc. That are for any postage,
shipping or handling charges which may occur in the transmittal of information to the Third-Party Administrator; including interest or financing charges.
Prior to Coverage. That are rendered or received prior to or after any period
of coverage hereunder, except as specifically provided herein.
Professional (and Semi-Professional) Athletics (Injury/Illness). That
are in connection with any Injury or Illness arising out of or in the course of any employment for wage or profit; or related to professional or semi-professional athletics, including practice.
Prohibited by Law. That are to the extent that payment under this Plan is
prohibited by law.
Provider Error. That are required as a result of unreasonable Provider error. Self-Inflicted. That are Incurred due to an intentionally self-inflicted Injury or
Illness not definitively (a) resulting from being the victim of an act of domestic violence, or (b) resulting from a documented medical condition (including both physical and mental health conditions).
Subrogation, Reimbursement, and/or Third-Party Responsibility.
That are for an Illness, Injury or Sickness not payable by virtue of the Plan’s subrogation, reimbursement, and/or third-party responsibility provisions.
Unreasonable. That are not reasonable in nature or in charge (see definition
of Maximum Allowable Charge) or are required to treat Illness or Injuries arising from and due to a Provider’s error, wherein such Illness, Injury, infection or complication is not reasonably expected to occur. This Exclusion will apply to expenses directly or indirectly resulting from circumstances that, in the opinion of Salvasen Health in its sole discretion, gave rise to the expense and are not generally foreseeable or expected amongst professionals practicing the same or similar type(s) of medicine as the treating Provider whose error caused the loss(es).
Vehicle Accident. That are for treatment of any Injury where it is determined
that a Participant was involved in a motorcycle Accident while not wearing a helmet or in an automobile Accident while not wearing a seatbelt (or car seat), even if the cause of the Illness or Injury is not related to the failure of the Participant to wear a helmet or seatbelt (or car seat). This Exclusion does not apply: (a) to Participants who were passengers on public transportation, ride for hire or livery services or (b) when a seatbelt or helmet is not required by law.
War/Riot. That Incurred as a result of war or any act of war, whether
declared or undeclared, or any act of aggression by any country, including rebellion or riot, when the Participant is a member of the armed forces of any country, or during service by a Participant in the armed forces of any country, or voluntary participation in a riot. This Exclusion does not apply to any Participant who is not a member of the armed forces and does not apply to victims of any act of war or aggression.
With respect to any Injury which is otherwise covered by the Plan, the Plan will not deny benefits otherwise provided for treatment of the Injury if the Injury results from being the victim of an act of domestic violence or a documented medical condition. To the extent consistent with applicable law, this exception will not require this Plan to provide benefits other than those provided under the terms of the Plan.
CLAIMS ASSISTANCE
Premier Access, Inc. Attn: Claims Department P.O. Box 1468
Arlington, TX 76004 EDI Payor ID: #43152
9
Rx Limitations & Exclusions
(1) Read the Drug Formulary to see which drugs are covered.
(2) Retail Pharmacies are limited to a 30-day supply. Mail Order drugs are limited to a 90-day supply in most cases. Some medications qualify for a 30 day fill via mail order.
(3) In certain cases, if a drug is available from alternative sources, SimpleScripts Rx will make all options available to the covered person. If a drug is not on the formulary, (Non-Formulary with Exceptions) SimpleScripts Rx will provide advocacy to the Covered Person for such medications.
This is a Pharmacy Subscription Service. THIS IS NOT INSURANCE. We provide you direct access to medications at negotiated PBM pricing, and Home Delivery Pharmacy pricing on a pre-paid basis. Your Rx Card offers solutions for high-priced specialty medications via an International Pharmacy or PAP service. In addition, a discount pharmacy solution is available, where you search discount options and are directed to a specific pharmacy for super-low pricing. Sometimes, this can be your lowest price option.
SimpleScripts Rx is NOT Insurance. Discount Only - Discounts are available exclusively through participating pharmacies. The range of the discounts will vary depending on the type of prescription and the pharmacy chosen. This part of the program does not make payments directly to pharmacies. Members are required to pay for all prescription purchases. Cannot be used in conjunction with insurance. You may contact customer care anytime with questions or concerns, to cancel your registration, or to obtain further information. This program is administered by Medical Security Card Company, LLC, Tucson, AZ.
Your Rx Card is not available in the following states: MD, WA, ME. Pricing is subject to change without notice. Most pharmacies will accept Your Rx Card, but it is not guaranteed. The final price is determined by your local pharmacy. Formulary and pricing are subject to change. Please see website for current pricing.
Covered Prescription Drugs
Disclosures
Expenses Not Covered
This benefit will not cover a charge for any of the following:
(1) Generic Drugs. Expense incurred for brand name prescription drugs which exceed the cost of the generic brand, when the Generic drug is available, and the name brand is dispensed.
(2) Outside the United States. Prescriptions filled outside the United States for non-Emergency medical conditions
(3) Refills. Refills greater than the number of times specified by a Physician. Refills after one year from the date of order by a Physician.
(4) Administration. Any charge for administering the Prescription Drug. (5) Consumed on premises. Any drug or medicine that is consumed or
administered at the place where it is dispensed.
(6) Devices. Devices of any type, even though such devices may require a prescription. These include (but are not limited to) therapeutic devices, artificial appliances, braces, support garments, or any similar device. (7) Drugs used for cosmetic purposes. Charges for drugs used for
cosmetic purposes, such as anabolic steroids, Retin A or medications for hair growth or removal.
(8) Experimental. Experimental drugs and medicines, even though a charge is made to the Covered Person.
(9) FDA. Any drug not approved by the Food and Drug Administration. Also, any dosage that exceeds the dosage recommended by the United States Food and Drug Administration (FDA) to treat the condition unless outlined in the plan document
(10) Growth hormones. Charges for drugs to enhance physical growth or athletic performance or appearance.
(11) Immunization. Immunization agents or biological sera. (12) Impotence. A charge for impotence medication. (13) Infertility. A charge for infertility medication.
(14) Inpatient medication. A drug or medicine that is to be taken by the Covered Person, in whole or in part, while Hospital confined. This includes being confined in any institution that has a facility for the dispensing of drugs and medicines on its premises.
(15) Investigational. A drug or medicine labeled: “Caution - limited by federal law to investigational use”.
(16) Medical exclusions. A charge excluded under Medical Plan Exclusions. (17) No charge. A charge for Prescription Drugs which may be properly
received without charge under local, state or federal programs.
(18) Non-legend drugs. A charge for FDA-approved drugs that are prescribed for non-FDA-approved uses.
(19) No prescription. A drug or medicine that can legally be bought without a written prescription.
(20) Therapeutics. Therapeutic devices or appliances, including hypodermic needles and syringes other than when used for insulin; support garments; other non-medical items, regardless of their intended use.
