Benefit Summary - Arkansas State Retirees (Without Medicare) - Members

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Arkansas State Retirees

If Medicare is your primary insurance, click here for benefit information.

For Retirees and Their Dependents Without Medicare

Deductible (Annual)
In-Network		Out-of-Network
Individual:	$0	Individual:	$1,000
Family:	$0	Family:	$2,000

Annual Out-of-Pocket Limits*
In-Network		Out-of-Network
Individual:	$1,000	Individual:	$5,000
Family:	$2,000	Family:	$10,000
Lifetime Maximum:	None	Lifetime Maximum:	$1 million

	Your Copayment* In-Network	Your Coinsurance** In-Network	Your Coinsurance** Out-of-Network
Preventive Care Services
Physical Exams, Adults (visit only)	$0 copayment	0% coinsurance	not covered
Well Baby/Child Care	$0 copayment	0% coinsurance	not covered
Children's Immunizations	$0 copayment	0% coinsurance	not covered
Annual Gynecological Visit (No referral required to in-network providers)	$0 copayment	0% coinsurance	not covered
Routine Mammogram (no referral required to in-network providers)	$0 copayment	0% coinsurance	not covered
Physician Services
PCP Visits	$25 copayment	0% coinsurance	40% coinsurance
Specialist Visits	$35 copayment	0% coinsurance	40% coinsurance
Inpatient Medical Care	$0 copayment	10% coinsurance	40% coinsurance
Outpatient Surgical Care	$0 copayment	10% coinsurance	40% coinsurance
Allergy Services
Specialist Visits	$35 copayment	10% coinsurance	40% coinsurance
Injections with no office visit	$0 copayment	10% coinsurance	40% coinsurance
Outpatient Services
Diagnostic Testing (lab and X-ray) High-tech Radiology Services - $250 copayment and 10% coinsurance member responsibility per case	$0 copayment	10% coinsurance	40% coinsurance
Surgical Services (facility charge)	$100 copayment	10% coinsurance	40% coinsurance
Emergency Room Visit	$100 copayment (Waived if admitted to same hospital or transferred directly to another facility from the emergency admission.)	0% coinsurance	$100 copayment 0% coinsurance
Urgent Care Center/ER After-hours Clinic Visit	$100 copayment (Waived if admitted to same hospital or transferred directly to another facility from the emergency admission.)	0% coinsurance	$100 copayment 0% coinsurance
Ambulance (Land or Air)
$1000 max per year (Limitation applies to transport charges only)	$0 copayment	0% coinsurance	40% coinsurance
Home Nurse Visits
	$0 copayment	10% coinsurance	40% coinsurance
Home Infusion IV Drugs/Solutions
	$0 copayment	10% coinsurance	40% coinsurance
Physical, Occupational and Speech Therapy
(15 visits per member per therapy per year)	$0 copayment	10% coinsurance	40% coinsurance
Chiropractic Services
(15 visits per member per therapy per year)	$35 copayment	10% coinsurance	40% coinsurance
Inpatient Hospital
Unlimited days at semiprivate room rate	$250 copayment per admission (maximum: 3 copays per year, per person)	10% coinsurance	40% coinsurance
Inpatient Rehab (limited to 60 days per year)	$250 copayment per admission (maximum: 3 copays per year, per person)	10% coinsurance	40% coinsurance
Maternity Services
Initial Physician Visit	$25 copayment	10% coinsurance	40% coinsurance
OB Services	$0 copayment	10% coinsurance	40% coinsurance
Hospital Services (facility fee)	$250 copayment per admission	10% coinsurance	40% coinsurance
Inpatient Physician Services	$0 copayment	10% coinsurance	40% coinsurance
Outpatient Diagnostic Testing (lab and X-ray)	$0 copayment	10% coinsurance	40% coinsurance
Transplants
(Specific transplants covered subject to contract-year limits when authorized in advance by Health Advantage)	$250 inpatient hospital copayment per admission	10% coinsurance	not covered
Durable Medical Equipment
($10,000 maximum per year)	$0 copayment	20% coinsurance	40% coinsurance
Prosthetics
($15,000 maximum per year)	0% copayment	20% coinsurance	40% coinsurance
TMJ
	Applicable office copayment	10% coinsurance	40% coinsurance
Mental Health/Substance Abuse
	Not covered by Health Advantage. Benefits administered and claims paid by CORPHEALTH. Call 1-866-378-1645 for coverage information.
Prescription Benefit
Prescription – Generic – Tier I	$10	0%	0%
Prescription – Generic – Tier II	$30	0%	0%
Prescription – Non-Preferred – Tier I	$60	0%	0%
Prilosec OTC	$5	0%	0%

This is only a summary of your benefits. A complete description of benefits are outlined in the Summary Plan Description (SPD) and can be viewed online at www.arbenefits.org under the Benefits Library section, or you may contact Employee Benefits Division for a paper copy.

*Treatment for infertility is not a covered benefit – benefits cover testing and counseling only.

ARHealth Benefit (for Medicare Primary members)

Medicare Does Not Pay	ARHealth Benefit

Part A Hospital Services

Inpatient Hospital Deductible/Benefit Period Copayment — 61-90 in Hospital Copayment — 91-150 in Hospital (Lifetime Reserve) Percent of Medicare Allowable Expenses (Additional 365 days after hospital benefits stop)	ARHealth will pick up the Part A deductible and copayment and 100% of Medicare-allowable expenses for an additional 365 days after Medicare hospital benefits stop.
Blood Deductible – First 3 pints (if deductible is not met by blood replacement)	ARHealth will pick up the Blood Deductible.
Copayment – days 21-100 in Skilled Nursing Facility	ARHealth will pay the copayment for skilled nursing for days 21-100
Part B – Physician and Medical Services

Part B Deductible Medicare Approved amounts applied to Part B coinsurance (20% medical/50% mental health) Part B Excess Charges	ARHealth will pick up the Medicare Part B deductible and 20% Part B coinsurance. ARHealth will pay 100% of Part B excess charges

NOTE: Out-of-Network Deductible, Copayment and Coinsurance amounts do not apply to the In-Network Annual Coinsurance Limit. Annual Coinsurance Limits are calculated on a fulfillment basis, not aggregate. Expenses incurred for services that exceed benefit limits are not applied to the Annual Coinsurance Limit.