Click on Link below to desired Fletcher Allen Preferred Medical Plan:

• Fletcher Allen Preferred and Preferred Plus
• Fletcher Allen Pre-65 Retiree Plan
• Fletcher Allen Post-65 Retiree Plan
  
  

*  All inpatient hospital admissions require Prior Authorization and Continued Stay Review. 

**Chiropractic Providers - There is not a defined network of Chiropractors. Fletcher Allen employees and their dependents can utilize the chiropractor of their choice!  

***Benefits  - This is a benefit plan outline of the Fletcher Allen Preferred and Fletcher Allen Preferred Plus Medical Plan benefits; it does not include every detail of the Plan.  Please refer to your "Summary Plan Document" 

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Explanation of out-of-network benefits

Calculations regarding out-of-network benefits will be based on the usual and customary (U&C) allowance. In many cases, the U&C allowance will be lower, therefore your out-of-pocket costs could be higher. You will be responsible for any differences between the U&C allowance and the provider's fee. This could be a significant cost to you and will not be credited toward your deductible nor your out-of-pocket maximum. Please consider this fact when making your decision to use an out-of-network provider.

Refer to numbered notions in Benefit Summary for Cross-reference to the following notes.

1. Annual deductible and out-of-pocket maximum refer to the period of January 1 - December 31. (Does not apply to co-pays, pharmacy or mental health services)
2. Once the out-of-pocket maximum is reached the plan pays 100% of allowable charges for the remainder of the plan year.
3. For the purposes of these plans, Primary care is defined as Family Practice, Internal Medicine and Pediatrics. OB/GYN services for routine well women care and maternity care will be assessed the PCP copayment rate.
4. Preventive care includes well child exams & immunizations, well woman exams and routine physical exams. Your PCP must provide these services. Well Woman exams can be provided by your OB/GYN provider.
5. For maternity care no copayments are required after the initial visit to confirm pregnancy. This includes prenatal visits, delivery and postnatal visits.
6. All inpatient hospital admissions require Prior Authorization and Continued Stay Review. If your admission/stay is not prior-authorized there may be a reduction or denial of coverage.
7. Out-of-network benefit are not available for outpatient surgery within Addison, Chittenden, Franklin, Lamoille, Orange, Orleans, Washington, and Windsor counties in Vermont; Coos and Grafton counties in New Hampshire.
8. Non-prescription drugs are not covered.

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Fletcher Allen Health Care Summary of Benefits for The Pre-65 Retiree Effective 1/1/2009
Benefits	Comprehensive
Annual Deductible      Individual      Family	None None
Annual Out-Of-Pocket Maximum      Individual      Family	None None
Pre-Existing Condition Limitation	Not Applicable
Lifetime Maximum	$1,000,000
Your Plan Pays
Office Visit      Illness/Injury	100% up to 20 visits per year
Preventive Care      Office Visit	100% up to $500 per year (including lab and x-ray)
Independent X-Ray and Lab	100% up to $5,000 per year
Prescription Drugs	Not Covered
Emergency:      Doctors Office      Emergency Room / Urgent Care Facility      Ambulance	100% 100% 100%
Hospital Inpatient:      Facility Services      Doctors Visits      Pre-Admission Certification / Continued Stay Review (1)	100% up to 120 days per admission 100% (Physician charges capped at $10,000 per year) Patient must get approval
Outpatient Surgical Facility	100%
Surgery      Surgeons Fees      Second Opinion Consultation	100% up to $10,000 per year 100%
Outpatient Rehabilitation      Includes Physical Therapy, Occupational &      Chiropractic Therapy (2)	100% up to 30 visits per calendar year
Special Services      Skilled Nursing Facility      Home Health Care      Hospice - Inpatient      Hospice - Outpatient	100% up to 120 days per admission 100% up to 120 days per admission 100% up to 120 days per admission 100%
Durable Medical Equipment	80% up to an annual maximum of $2,000 per year
External Prosthetic Appliances	100%
Mental Health      Inpatient      Outpatient	100% up to 120 days per admission 100% up to 30 visits per year
Alcohol & Drug Abuse Rehabilitation      Inpatient      Outpatient	100% up to 30 days per admission 100% up to 60 visits per year
Group Therapy	Subject to Mental Health, Alcohol or Drug Abuse outpatient maximums and limitations
Vision Care	Not Covered

1 - All inpatient hospital admissions require Pre-Admission Certification and Continued Stay Review.  If your admission/stay is not authorized there may be reduction or denial of coverage.
2 - Speech therapy, which is not restorative in nature, will not be covered.

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Summary of Benefits for The POST-65 Retiree Effective 1/1/2009
Benefits	Comprehensive
Annual Deductible      Individual      Family	None None
Annual Out-Of-Pocket Maximum      Individual      Family	None None
Pre-Existing Condition Limitation	Not Applicable
Lifetime Maximum	$1,000,000
Your Plan Pays
Office Visit      Illness/Injury	100%
Preventive Care	Not Covered
Independent X-Ray and Lab	100%
Prescription Drugs	Not Covered
Emergency:      Doctors Office      Emergency Room / Urgent Care Facility      Ambulance	100% 100% 100%
Hospital Inpatient      Doctors Office      Pre-Admission Testing	100% 100% 100%
Outpatient Surgical Facility	100%
Surgery      Surgeons Fees      Second Opinion Consultation	100%  100%
Outpatient Rehabilitation      Includes Physical Therapy, Occupational &      Chiropractic Therapy (1)	100% up to 30 visits per calendar year
Special Services      Skilled Nursing Facility      Home Health Care      Hospice - Inpatient      Hospice - Outpatient	100% up to 100 days per admission 100% unlimited Not Covered Not Covered
Durable Medical Equipment	100%
External Prosthetic Appliances	100%
Mental Health      Inpatient      Outpatient	100% up to 30 days per year  100% up to 30 visits per year
Alcohol & Drug Abuse Rehabilitation      Inpatient      Outpatient	100% up to 30 days per year 100% up to 60 visits per year
Group Therapy	Subject to Mental Health, Alcohol or Drug Abuse outpatient maximums and limitations
Vision Care	Not Covered

(1) Speech therapy that is not restorative in nature will not be covered.

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