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Summary Plan Description of Covered Summary Plan Description Cook County Pension Fund Choice Plan Effective: January 1, 2019 Group Number: 902956 COOK COUNTY PENSION FUND MEDICAL CHOICE PLAN TABLE OF CONTENTS SECTION 1 - WELCOME ................................................................................................................. 1 SECTION 2 - INTRODUCTION ......................................................................................................... 3 Eligibility ....................................................................................................................................... 3 Cost of Coverage ......................................................................................................................... 3 How to Enroll .............................................................................................................................. 4 When Coverage Begins ............................................................................................................... 4 Changing Your Coverage ............................................................................................................ 5 SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 7 Accessing Benefits ....................................................................................................................... 7 Eligible Expenses ......................................................................................................................... 9 Copayment .................................................................................................................................. 10 Out-of-Pocket Maximum ......................................................................................................... 10 SECTION 4 - PERSONAL HEALTH SUPPORT ............................................................................ 11 Requirements for Notifying the Claims Administrator ........................................................ 12 Special Note Regarding Medicare ............................................................................................ 12 SECTION 5 - PLAN HIGHLIGHTS ................................................................................................. 13 Payment Terms and Features ................................................................................................... 13 Schedule of Benefits .................................................................................................................. 14 SECTION 6 - ADDITIONAL COVERAGE DETAILS ...................................................................... 20 Acupuncture Services ................................................................................................................ 20 Ambulance Services ................................................................................................................... 20 Cancer Resource Services (CRS) ............................................................................................. 21 Cellular and Gene Therapy ....................................................................................................... 22 Clinical Trials .............................................................................................................................. 22 Congenital Heart Disease (CHD) Surgeries ........................................................................... 24 Dental Services ........................................................................................................................... 25 Diabetes Services ....................................................................................................................... 27 Durable Medical Equipment (DME) ...................................................................................... 27 Emergency Health Services - Outpatient ............................................................................... 29 I TABLE OF CONTENTS COOK COUNTY PENSION FUND MEDICAL CHOICE PLAN Enteral and Parenteral Nutritional Therapy .......................................................................... 29 Hearing Aids ............................................................................................................................... 29 Home Health Care ..................................................................................................................... 30 Hospice Care .............................................................................................................................. 30 Hospital - Inpatient Stay ........................................................................................................... 31 Kidney Resource Services (KRS) ............................................................................................. 31 Lab, X-Ray and Diagnostics - Outpatient .............................................................................. 32 Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient................................................................................................................................. 32 Mental Health Services .............................................................................................................. 33 Neurobiological Disorders - Autism Spectrum Disorder Services ..................................... 33 Nutritional Counseling .............................................................................................................. 34 Ostomy Supplies ........................................................................................................................ 35 Pharmaceutical Products - Outpatient .................................................................................... 35 Physician Fees for Surgical and Medical Services ................................................................. 36 Physician's Office Services - Sickness and Injury .................................................................. 36 Pregnancy - Maternity Services ................................................................................................ 36 Preventive Care Services ........................................................................................................... 37 Private Duty Nursing - Outpatient .......................................................................................... 37 Prosthetic Devices ..................................................................................................................... 38 Reconstructive Procedures ....................................................................................................... 38 Rehabilitation Services - Outpatient Therapy and Manipulative Treatment ..................... 39 Scopic Procedures - Outpatient Diagnostic and Therapeutic ............................................. 41 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 41 Substance Use Disorder Services ............................................................................................ 42 Surgery - Outpatient .................................................................................................................. 43 Temporomandibular Joint (TMJ) Services ............................................................................. 44 Therapeutic Treatments - Outpatient ..................................................................................... 44 Transplantation Services ........................................................................................................... 45 Travel and Lodging .................................................................................................................... 45 Urgent Care Center Services .................................................................................................... 47 Wigs ............................................................................................................................................. 47 SECTION 7 - CLINICAL PROGRAMS AND RESOURCES ........................................................... 48 II TABLE OF CONTENTS COOK COUNTY PENSION FUND MEDICAL CHOICE PLAN Consumer Solutions and Self-Service Tools .......................................................................... 48 Disease and Condition Management Services ....................................................................... 52 Wellness Programs ..................................................................................................................... 54 SECTION 8 - EXCLUSIONS AND LIMITATIONS: WHAT THE MEDICAL PLAN WILL NOT COVER ........................................................................................................................................... 56 Alternative Treatments .............................................................................................................. 56 Dental .......................................................................................................................................... 56 Devices, Appliances and Prosthetics ...................................................................................... 57 Drugs ........................................................................................................................................... 58 Experimental or Investigational or Unproven Services ......................................................
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