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Palmetto Health Reimbursement Account Medical Plan

Administered by BlueCross BlueShield of South Carolina

The Palmetto Health Reimbursement Account medical plan is a consumer-driven health plan that maximizes your benefits when using Palmetto Health facilities and Palmetto Health Quality Collaborative physicians. The plan’s provider network consists of two tiers: a primary tier and a secondary tier. The primary tier consists mostly of Palmetto Health facilities and Quality Collaborative physicians. The secondary network tier consists of all providers in BCBS’ national network that aren’t already included in the primary tier. Please click here for a list of primary tier (Palmetto Health Quality Collaborative) providers. Please click here for a list of secondary tier (BCBS) providers.

The Palmetto Health Reimbursement medical plan is intended for individuals and families who anticipate needing more than just routine preventive and minor sick care in 2014. The plan is designed to reduce financial barriers to care for individuals and families who may need to regularly see primary and specialty care providers, perhaps to help manage a chronic condition like Diabetes or Congestive Heart Failure. When using a Palmetto Health Quality Collaborative physician, there is no deductible and no coinsurance charges for most services. To assist you with the Palmetto Health owned and operated facility charges for which you are responsible, you can payroll deduct amounts more than $50.

By enrolling in the Palmetto Health Reimbursement Account medial plan, you will be eligible for an employer-funded Health Reimbursement Account (HRA). HRAs will be administered by BlueCross BlueShield of South Carolina. The HRA is 100 percent funded by Palmetto Health and can be used to automatically pay for qualified medical expenses until funds are exhausted or insurance coverage kicks in. Palmetto Health’s 2014 contribution amount for employee-only coverage is $300/annually and $600/annually for all other coverage types. Funds will be available January 1, 2014. Any unused balances will be rolled over from year to year. If you leave Palmetto Health, your HRA balance will be forfeited; you will be unable to withdraw or transfer any unused HRA funds.

Palmetto Health is providing an HRA in your name to help pay for your eligible out-of-pocket medical expenses. You may not contribute to the funding of your HRA. However, you may contribute to a self-funded Flexible Spending Account (FSA) instead. If you use all of your HRA funds and incur additional medical expenses that are your responsibility, you’ll be required to pay for these additional expenses out of your own pocket or from an FSA.

Click here for a five-minute online tutorial about BCBS Health Reimbursement Accounts.

Palmetto Health Reimbursement Account Medical Plan Biweekly Contributions

2014 Palmetto Health Reimbursement Medical Plan FULL TIME-Class Code 5 PART TIME-Class Code 3, 4
With myHealth Rewards Discount Without myHealth Rewards Discount With myHealth Rewards Discount Without myHealth Rewards Discount
Less than $15.23 Per Hour
Employee Only $54 $118 $90 $163
Employee + Spouse $120 $198 $173 $258
Employee +
Child(ren)
$111 $186 $163 $247
Family $183 $270 $236 $327
$15.23 to $30.45 Per Hour
Employee Only $60 $124 $97 $171
Employee + Spouse $130 $209 $183 $270
Employee +
Child(ren)
$122 $200 $175 $261
Family $198 $288 $251 $348
$30.46 to $50.55 Per Hour
Employee Only $66 $136 $106 $178
Employee + Spouse $144 $222 $197 $286
Employee +
Child(ren)
$134 $213 $186 $274
Family $219 $311 $272 $371
Over $50.55 Per Hour
Employee Only $86 $159 $120 $198
Employee + Spouse $182 $269 $221 $314
Employee +
Child(ren)
$168 $255 $207 $298
Family $269 $370 $330 $439

Working Spouse Coverage Fee is an additional $100 per pay period if you choose Employee + Spouse or Family coverage. This fee applies if your spouse has access to other coverage with his or her employer but chooses to participate as your dependent in a Palmetto Health medical plan. This does not apply if you and your spouse are employees of Palmetto Health, or if your working spouse purchases coverage independently of their employer, perhaps through the new Health Insurance Marketplace. In addition, only one of you can cover your dependent children. The contributions above do not include the working spouse coverage fee.

Prescription Drug Benefits: Prescription drug benefits are a part of Palmetto Health’s group medical plans. Plan participants are eligible for 30-day or extended-day (90-day) supplies. There is no deductible for preventive drugs. Preventive drugs include those taken for a disease that has not yet manifested or to prevent recurrence of a disease. Examples include cholesterol-controlling medication and blood pressure medication.

All maintenance and specialty medications must be filled at the Palmetto Health Pharmacy in order to be covered under the plan. In addition, Step Therapy is required for medications prescribed to treat ongoing medical conditions.

The following chart is only an overview. You should refer to your Summary Plan Description for information on any exclusions or limitations that may apply to the specific benefits.

Pharmacy
Preventive Non-Preventive
30 Day 90 Day 30 Day 90 Day
PH Pharmacy Caremark Network PH Pharmacy PH Pharmacy Caremark Network PH Pharmacy
Deductible none none none In-Network Plan Deductible
Generic $10 copay no deductible $15 copay no deductible $20 copay no deductible $10 copay, after deductible $15 copay, after deductible $20 copay, after deductible
Preferred $20 copay no deductible $35 copay no deductible $40 copay no deductible $20 copay, after deductible $35 copay, after deductible $40 copay, after deductible
Non-preferred $40 copay no deductible $65 copay no deductible $80 copay no deductible $40 copay, after deductible $65 copay, after deductible $80 copay, after deductible
Specialty n/a 80% ($100 max), after deductible – Specialty Network Only n/a
Infertility n/a 80% ($100 max), after deductible ($5,000 life max) n/a

Click here for a list of preventive medications.

1. Plan participants are eligible for a 30-day or an extended-day (90-day) supply.
2. All maintenance medications must be filled at the Palmetto Health Pharmacy in order to be covered under the plan.
3. Specialty drugs are only available through the PH Pharmacy and require prior authorization.
4. Step Therapy is required for medications prescribed to treat ongoing medical conditions.
5. 
The Palmetto Health Pharmacy doesn’t compound medications or mail controlled substances. 

Caremark Pharmacy Network Directory: click here or call 800-760-9290.

Schedule of Benefits

The following chart is only an overview. You should refer to your Summary Plan Description for information on any exclusions or limitations that may apply to the specific benefits.

Deductibles and Out-of-Pockets Maximums
Primary (PH/PHQC) Tier Secondary (BCBS) Tier Out-of-Network
Individual Deductible $1,250 $3,125 $4,000
Family Deductible $2,500 $6,250 $8,000
Individual Out-of-Pocket Max $2,500 $6,250 none
Family Out-of-Pocket Max $5,000 $12,500 none
Palmetto Health’s HRA Contributions
Individual $300 per year deposited January 1, 2014
Family $600 per year deposited January 1, 2014
Physician Office Visits
Primary (PH/PHQC) Tier Secondary (BCBS) Tier Out-of-Network
Primary Care Preventive 100%, no deductible 100%, no deductible 50%, after deductible
Primary Care Sick 100%, no deductible 70%, after deductible 50%, after deductible
Specialists 100%, no deductible 70%, after deductible 50%, after deductible
Physician Office Services
Primary (PH/PHQC) Tier Secondary (BCBS) Tier Out-of-Network
Lab Tests and X-rays 100%, no deductible 70%, after deductible 50%, after deductible
Reading of Labs Preventive 100%, no deductible 100%, no deductible 50%, after deductible
Reading of Labs Sick and X-rays 90%, after deductible 70%, after deductible 50%, after deductible
Other Physician Office Services 90%, after deductible 70%, after deductible 50%, after deductible
Outpatient Hospital Charges
Primary (PH/PHQC) Tier Secondary (BCBS) Tier Out-of-Network
Surgery – Facility Charge 90% after deductible 70% after deductible 50% after deductible
Surgery – Physician/Anesthesiologist 90% after deductible 70% after deductible 50% after deductible
Labs – Test 90% after deductible 70% after deductible 50% after deductible
Labs – Reading of Labs 90% after deductible 70% after deductible 50% after deductible
X-rays – Facility 90% after deductible 70% after deductible 50% after deductible
X-rays – Physician 90% after deductible 70% after deductible 50% after deductible
MRI/CAT/PET/Nuc Scans – Facility 90% after deductible 70% after deductible 50% after deductible
MRI/CAT/PET/Nuc Scans – Physician 90% after deductible 70% after deductible 50% after deductible
Occupational, Physical and Speech Therapy and Cardiac Rehab 90% after deductible 70% after deductible 50% after deductible
Inpatient Hospital Charges
Primary (PH/PHQC) Tier Secondary (BCBS) Tier Out-of-Network
Facility 90% after deductible 70% after deductible 50% after deductible
Physician/Anesthesiologist 90% after deductible 70% after deductible 50% after deductible
Emergency Dept
Primary (PH/PHQC) Tier Secondary (BCBS) Tier Out-of-Network
Visit 90% after deductible 90% after deductible 90% after deductible
Urgent Care
Primary (PH/PHQC) Tier Secondary (BCBS) Tier Out-of-Network
Visit 100% no deductible 70% after deductible 50% after deductible
Mental Health
Primary (PH/PHQC) Tier Secondary (BCBS) Tier Out-of-Network
Office Visit 100% no deductible 70% after deductible 50% after deductible
ED Visit 90% after deductible 90% after deductible 90% after deductible
Other Ancillary Services
Primary (PH/PHQC) Tier Secondary (BCBS) Tier Out-of-Network
Home Health 100% after deductible 70% after deductible 50% after deductible
DME 90% after deductible 70% after deductible 50% after deductible
Hospice 100% no deductible 70% after deductible 50% after deductible

*For Employee + Spouse, Employee + Child(ren) and Family coverage, the family deductible is satisfied once your total family expenses reach the family deductible. One member alone might meet the family deductible, or a combination of individuals might meet the family deductible. Individual deductible only applies to Employee coverage. There is no individual deductible with Employee + Spouse, Employee + Child(ren) or Family coverage.
1. Palmetto Health Facilities include: Baptist (Columbia), Baptist Easley Hospital, Richland, Greenville Hospital System and Parkridge Surgery Center.
2. Pap Smear, PSA, Mammogram, Colonoscopy (screening), Bone Density, Physical, Immunizations (includes flu shots), Well-Baby, Well-Child Exam. Covered preventive services are subject to change.
3. Click here for a list of Primary Tier (PHQC) providers. Click here to search the BCBS network. 

 

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