ORDER NO. 30858
MEDICAL INSURANCE LAB CLAIMS AGAINST OUR INSURANCE
POLICY
Came to be heard this the 27th day of May, 2008, with a motion made by
Commissioner Williams, seconded by Commissioner Baldwin. The Court
unanimously approved by vote of 4-0-0 to:
Permit reimbursement by employees who were charged a deductible for laboratory
services as a result of office visits through May 31, 2008, and commencing June 1,
2008 that our schedule of benefits be changed to provide the waiver of deductible
only apply to laboratory services as a result of the office visit when it is done using
a preferred provider, that being Clinical Pathology Labs, being the only local one.
~~
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COMMISSIONERS' COURT AGENDA REQUEST
PLEASE FURNISH ONE ORIGINAL AND TEN (10) COPIES OF THIS
REQUEST AND DOCUMENTS TO BE REVIEWED BY THE COURT

MADE BY: Eva Hyde
MEETING DATE: May 27, 2008
OFFICE: Human Resources
TIME PREFERRED:
SUBJECT: Consider, discuss, and take appropriate action on Medical Insurance Lab
Claims against our policy.
EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON) Yes
NAME OF PERSON ADDRESSING THE COURT: Eva Hyde
ESTIMATED LENGTH OF PRESENTATION:
IF PERSONNEL MATTER -NAME OF EMPLOYEE:
Time for submitting this request for Court to assure that the matter is posted in
accordance with Title 5, Chapter 551 and 552, Government Code, is as follows:
Meeting scheduled for Mondays:
THIS REQUEST RECEIVED BY:
THIS RQUEST RECEIVED ON:
5:00 PM previous Tuesday
@ .M.
All Agenda Requests will be screened by the County Judge's Office to determine if adequate
information has been prepared for the Court's formal consideration and action at time of Court
Meetings. Your cooperation will be appreciated and contribute towards your request being
addressed at the earliest opportunity. See Agenda Request Rules Adopted by Commissioners'
Court.


* * *Kerr County Employee Benefits Notice*
The following benefit enhancement is effective immediately. Please be aware, to
get the maximum benefit you must utilize the preferred lab provider:
Clinical Patholo~_y Lab
PHYSICIAN SERVICES
Inpatient Visits	90%, after Deductible	70%, after Deductible
Office Visits	$30 Co-payment, then 90%	70%, after Deductible
Laboratory Services as a result of	100% when using preferred
Provider (i.e. Clinical	70%, after Deductible
the office visit, excluding High End	Pathology Lab's), Deductible	
Radiology	Waived	
Clinical Pathology Lab locations:
212 Wesley Drive
Kerrville, TX
830-257-1525
1331 Bandera Hwy #5
Kerrville, TX
830-895-2803
1201. S Main Street
Boerne, TX
830-249-8200
For a full listing of locations go to kerr.farabenefits.com and click on "Member"
or go direct to www.cpllabs.com.
* * * CPL is able to take lab requests, even if written on another lab's form.
~e~vcx~~
KERR COUNTY
SUMMARY PLAN DESCRIPTION
SCHEDULE OF MEDICAL BENEFITS
for Employees and Dependents-
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~~~ ~T~
~°' ~ ~-®~
This Summary Plan Description is a brief description of health benefits coverage provided by Kerr
County.. For a full description of all coverage, eligibility, Plan inclusions and exclusions, refer to the Plan
Document on file with Kerr County. The benefits described below are subject to the terms and conditions
of the Plan Document.
The Plan uses the services of Texas True Choice (www.texastruechoice.com) for Preferred Provider
Hospitals and Physicians.
IMPORTANT -the Plan has Preferred Provider Organization (PPO) and FARA Healthcare Management
Features. Under certain conditions, there will be a REDUCTION in benefits payable IF YOU DO NOT:
1. Go to a PPO Hospital and/or PPO Doctor,
2. Get Authorization for:
a. Hospital Confinement, Skilled Nursing Facility confinement and inpatient Hospice
Care Facility
b. Hospital Confinement and partial hospitalization for Mental and Nervous
Disorders or Alcohol and Drug Abuse and/or Chemical Dependency;
c. Outpatient Mental and Nervous Disorders or Alcohol and Drug Abuse and/or
Chemical Dependency Therapy;
d. Specialty Drugs and Medicines;
e. Outpatient High End Radiology. which are performed
(1) in a Physician's office or clinic;
(2) on an outpatient basis in a Hospital (excluding those performed in a Hospital
Emergency Room); or
(3) in an Independent Radiology and Pathology Center.
f. Outpatient Surgical Procedures which are performed:
(1) in an ambulatory surgical facility;
(2) in a Physician's office or clinic; or
(3) on an outpatient basis in a Hospital.
g. Specialty Drugs and Medicines which are given:
(1) in a Physician's office or clinic; or
(2) in a home health care setting.
h. Specialized Services and Supplies
The following penalties will apply if the Covered Person does not receive authorization for the services
shown above:
(a) Medically Necessary, benefits payable will be reduced by $500; or
(b) not Medically Necessary, no benefits are payable.
To obtain authorization, call FARA Healthcare Management at 1-800-215-3272.
Plan Administered By: FARA Benefit Services, Inc.
1625 West Causeway Approach
Mandeville, LA 70471
1-800-224-3272
htty://kerr.farabenefits.com Kerr County
May 7, 2008

COVEREQ SERVICES.: - _ .. ,,
HOSPITAL SERVICES
Room and Board	90%, after Deductible	70%, after Deductible
Semi-Private Room Rate		
Maximum ICU, CCU, Bum Unit and	90%, after Deductible	70%, after Deductible
Neonatal Care (Hospital's ICU		
Char e		
~ Miscellaneous Services and Su lies	90%, after Deductible	70%, after Deductible
Ancillaries	90%, after Deductible	70%, after Deductible
Skilled Nursing Facility (Semi-Private	90%, after Deductible	70%, after Deductible
Room Rate). 100 Days Maximum		$200 Maximum Allowable per
Per Calendar Year		da
PHYSICJAht SERVICES
In atient Visits	90%, after Deductible	70%, after Deductible
Office Visits.	$30 Co-payment, then 90%	70%, after Deductible
Laboratory Services as a result of	100% when using preferred	70%, after Deductible
the office visit, excluding High End	provider (ie: Clinical	
Radiology	Pathology Lab's), Deductible	
	Waived	
Sure In atient or Out atient	90%, after Deductible	70%, after Deductible
Pr nanc	90%, after Deductible	70%, after Deductible
Or an Trans lants	90%, after Deductible	70%, after Deductible
Well Newborn Nurse Care	90%, Deductible Waived	70%, Deductible Waived
PREVENTIVE-:CARE .
Routine Well Adult Care	100%, Deductible waived	70%, Deductible waived
	$200 Per Person Calendar	$200 Per Person Calendar
	Year Maximum.	Year Maximum
Childhood Immunizations through	100%, Deductible waived	70%, after Deductible
a e6		
Preventive Care for Dependent	100%, Deductible waived.	70%, Deductible waived.
Children through age 17 (includes	$200 Per Person Calendar	$200 Per Person Calendar
immunizations fora es 7 throu h 17	Year Maximum	Year Maximum.
		
L'~~'T'U'`~ U"V /U'v~ httD://kerr.farabenefits.com Kerr County
_ May 7, 2008

SCHEDULE OF BENEFITS

._.-,_
Home Health Care- Maximum of	
90%, after Deductible	
70%, after Deductible
100 Visits		
Hospice	90%, after Deductible	70%, after Deductible
Bereavement Counseling-	100%, Deductible Waived	100%, Deductible Waived
Maximum of $250 for all family		
members combined		
Chemothera /Radiation Thera	90%, after Deductible	70%, after Deductible
Ambulance Service	80%, Deductible Waived	80%, Deductible Waived
Independent Freestanding	90%, Deductible Waived	70%, after Deductible
Diagnostic X-Ray and. Laboratory		
Facili Services		
Routine Mammo rah	100%, Deductible Waived	70%, after Deductible
Emer enc Room	$50 Copa ,then 90%	$50 Copay, then 70%
Occupational Therapy, Speech	90%, after Deductible	70%, after Deductible
Thera , Ph ical Thera		
Durable Medical E ui ment	90%, after Deductible	70%, after Deductible
Prosthetics	90%, after Deductible	70%, after Deductible
Aller In'ections	90%, after Deductible	70%, after Deductible
Spinal Treatment -Maximum 30	90%, after Deductible	70%, after Deductible
Visits Per Calendar Year		
Routine Vision Care	100%, Deductible Waived	100%, Deductible Waived
1 exam limited to $60 per Calendar		
Year		
Any other eligible expenses not	90%, after Deductible	70%, after Deductible
mentioned above		
MENTAL 8 NERVOUS DISORDERS,.	CHEMICAL: DEPENDENCY ~ SU	BSTANCE: ABUSE.
Inpatient -Maximum of 30 Days Per	90%, after Deductible	70%, after Deductible
Calendar Year		
Outpatient -Maximum Allowable per	50%, after Deductible	50%, after Deductible
Visits: $70		
WELLNESS PROGRAM
The Plan will provide for the following under its Wellness Program with no co-pays or deductibles:
(a) On Site Health Fair, when offered
(b) Flu Shots
(c) Smoking Cessation
SCRIPT CARE, INC. PRESCRIPTION DRUG CARD PROGRAM
Co-payments
For Diabetic Supplies
$5 for each Diabetic Supply which is included on the Drug Formulary
$35 for each Diabetic Supply which is not included on the Drug Formulary
httn://kerr.farabenefits.com Kerr County
May 7, 2008
3

' For Covered Drugs (other than Diabetic Supplies)
$10 for each prescription or refill-for a Generic Drug -
$20 for each prescription or refill for a Brand Name Drug which is included on the
Drug Formulary
$35 for each prescription or refill for a Brand Name Drug which is not included on the
Drug Formulary
If aNon-Participating Retail Pharmacy is used
For Covered Drugs
50% of the F~cpense incurred for each prescription or refill or each Diabetic Supply
If a Participating Prescription-by-Mail (Mail Order) Pharmacy is used
For Diabetic Supplies
$10 for each Diabetic Supply which is included on the Drug Formulary
$70 for each Diabetic Supply which is not included on the Drug Formulary
For Covered Drugs (other than Diabetic Supplies)
$20 for each prescription or refill for a Generic Drug
$40 for each prescription or refill for a Brand Name Drug which is included on the
Drug Formulary
$70 for each prescription or refill for a Brand Name Drug which is not included on the
Drug Formulary
Over The Counter (OTC) Medication Coverage
The following Over The Counter (OTC) medications are covered at a $0 co-pay with a
written prescription from a physician:
Gastrointestinal medications: Allergy medications:
Prilosec OTC (20mg) Claritin OTC (10mg)
Pepcid AC OTC (10mg and 20mg) Zyrtec D OTC
Pepcid Complete OTC (10mg) Zyrtec OTC
Zantac OTC (75mg and 150mg)
Tagamet HB (200mg)
Axid AR (75 mg)
Smoking Cessation medications
http://ken .farabenefits.com Kerr County
May 7, 2008
4
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KERR'COUNTY -SCHEDULE OF BENEFITS ~ ~v~~ ~,~
January 1, 2008.. ~.tl.! ~~~~~
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	•. . -.
-• ~ -•
LIFETIME MAXIMUM (Lifetime Maximums are combined for PPO and Non-PPO Providers)
	52.000.000 52.000.000
	DEDUCTIBLE (Deductibles are combined for PP0 and Non-PPO Providers).
	Individual Calendar Year Deductible	$1,000	$2,000
	Maximum Family Deductible Per
Calendar Year.	$3,000	$6,000
	BENEFIT PERIOD:	CALENDAR YEAR
	OUT-OF-POCKET MAXIMUM (Excludes Deductibles, Copayments, Utilization Management Penalties,
charges incurred for Inpatient and Outpatient Mental & Nervous Disorders Chemical Dependency and
Substance Abuse. The Out-of=Pocke# Limits are combined for PP.O and Non-PPO Providers,
	Per Individual	$2,000	$ 5,000
	Per Famil	$6,000	$15,000
	OFFICE VISITS
	Office Visits	$30 Co-payment, then 90%	70%, after Deductible

~ -
~	Laboratory Services as a result of
the office visit, excluding High End
Radiolo	100%, Deductible- Waived	70%, after Deductible
	Alfergy~njections ""~`	$30 Co-payment, then 90%	70%, after Deductible
	Pre nanc	90%, after Deductible	70%, after Deductible
	Well Newborn Nurser Care	90%, Deductible Waived	70%. Deductible Waived
	HOSPITAL
	In atient Visits	90%, after Deductible	70%, after Deductible
	Sur er. In atient or Out atient	90%, after Deductible	70%, after Deductible
			
	PREVENTIVE CARE
	Routine Well Adult /Dependent
(children through age 17; includes
immunizations for ages 7 through 17)	100%, Deductible waived
$500 Per Person Calendar
Year Maximum.	70%, Deductible waived
$200 Per Person Calendar
Year Maximum
	Childhood Immunizations
throw h a e 6	100%, Deductible waived	70%, after Deductible
	Routine Mammo rah	100%, Deductible Waived	70%, after Deductible
	~ HOSPITAL SERVICES,
	Room and Board
(Semi-Private Room Rate	90%, after Deductible	70%, after Deductible
	Miscellaneous Services and Su lies	90%, after Deductible	70%, after Deductible
	Ancillaries	90%; after Deductible	70%, after Deductible
	Skilled Nursing Facility (Semi-Private
Room Rate). 100 Per Calendar Year	90%, after Deductible	70%, after Deductible
$200 Maximum Allowable per
da
	EMERGENCY ROOM		
		$50 Co a ,then 90%	$50 Co a ,then 70%

	

OTHER COVERED SERV1CESi	-~ • •~
-• ~ -• ~
	Home Health Care -Maximum of
100	90%, after Deductible	70%, after Deductible
	Hospice
Bereavement Counseling-
Maximum of $250 for all family
members combined	90%, after Deductible
100%, Deductible Waived	70%, after Deductible
100%, Deductible Waived
	Chemothera /Radiation Thera	90%, after Deductible	70%, after Deductible
	e	80%, Deductible Waived	80%, Deductible Waived
	Independent Freestanding
Diagnostic X-Ray and Laboratory
Facilit Services	90%, Deductible Waived	70%, after Deductible
	c erapy, peech
Thera , Ph sical Thera	90%, after Deductible	70%, after Deductible
	Durable Medical E ui ment	90%, after Deductible	70%; after Deductible
	Prosthetics	90%, after Deductible	70%, after Deductible
	Organ Transplants -Physician
Services	90%, after Deductible	70%, after Deductible
	Chiropractic Care -Maximum 30
Visits Per Calendar Year	90%, after Deductible	70%, after Deductible
	Any other eligible expenses not
mentioned above	90%, after Deductible	70%, after Deductible
	VISION -		
	Routine Vision Care
1 exam limited to $60 per Calendar
Year	100%, Deductible Waived	100%, Deductible Waived
	~-ME'NTAL'&~NERVOUS'DISORDERS,	CHEMICAL'D"EPENDENCY & SUBSTANCE ABUSE ~
	Inpatient -Maximum of 30 Days Per
Calendar Year	90%, after Deductible	70%, after Deductible
	Outpatient -Maximum Allowable per
Visit: $70	50%, after Deductible	50%, after Deductible
	PRESCRIPTION DRUG PROGRAM (Formulary) ,
	Generic	$10	50%
	Preferred	$20	50%
	Non-Preferred	$35	50%
	MAIL ORDER DRUG PROGRAM (90 day supply for 2 copays)
	Generic	$20	Not Covered
	Preferred	$40	Not Covered
	Non-Preferred	$70	Not Covered
	Diabetic Supplies	$10 Liberty Medical	
	OTC DRUG PROGRAM (ovER-THE-COUNTER) **
		ZERO COPAY **
(with a written prescription from a physician)
	DIABETIC SUPPLIES		
		$1 O (PER SUPPLI~	$70 non formulary
This is a Summary of Benefits and not a complete schedule of benefits. Refer to the Summary Plan Document for all crovered services,
limitations and exclusions. This does not replace or supersede the Summary Plan Document.
i
,~
KERR COUNTY
SUMMARY PLAN DESCRIPTION
SCHEDULE OF MEDICAL BENEFITS
For Employees and Dependents
This Summary Plan Description is a brief description of health benefits coverage provided by Kerr County.
For a full description of all coverage, eligibility, Plan inclusions and exclusions, refer to the Plan Document on
file with Kerr County. The benefits described below are subject to the terms and conditions of the Plan
Document.
The Plan uses the services of Texas True Choice for Preferred Provider Hospitals and Physicians.
IMPORTANT -the Plan has Preferred Provider Organization (PPO) and FARA Healthcare Management
Features. Under certain conditions, there will be a REDUCTION in benefits payable IF YOU DO NOT:
1. Go to a PPO Hospital and/or PPO Doctor;-
2. Get Authorization for:
a. Hospital Confinement, Skilled Nursing Facility confinement and inpatient Hospice
Care Facility
b. Hospital Confinement and partial hospitalization for Mental and Nervous Disorders
or Alcohol and Drug Abuse and/or Chemical Dependency;
c. Outpatient Mental and Nervous Disorders or Alcohol and Drug Abuse and/or
Chemical Dependency Therapy;
d. Specialty Drugs and Medicines;
e. Outpatient High End Radiology which are .performed
(1) in a Physician's office or clinic;
(2) on an outpatient basis in a Hospital (excluding those performed in a Hospital
Emergency Room); or
(3) in an Independent Radiology and Pathology Center.
f. Outpatient Surgical Procedures which are performed:
(1) in an ambulatory surgical facility;
(2) in a Physician's office or clinic; or
(3) on an outpatient basis in a Hospital.
g. Specialty Drugs and Medicines. which are given:
(1) in a Physician's office or clinic; or
(2) in a home health care setting.
h. Specialized Services and Supplies
The following penalties will apply if the Covered Person does not receive authorization for the services
shown above:
(a) Medically Necessary, benefits payable will be reduced by $500; or
(b) not Medically Necessary, no benefits are payable.
To obtain authorization, call FARA Healthcare Management at 1-800-215-3272.
Plan Administered By: FARA Benefit Services, Inc.
P.O. Box 8770
Metairie, LA 70011-8770
Customer Service 1-800-224-3272
This is a Summary of Benefits and not a complete schedule of benefits. Refer to the Summary Plan Document for all covered services,
limitations and exclusions. This does not replace or supersede the Summary Plan Document.
•~-~- r-r~~r~.


** Over The Counter (OTC) Medication Coverage -The following Over The Counter (OTC) medications
are covered at a $0 copay
Gastrointestinal medications:
Prilosec OTC (20mg)
Pepcid AC OTC (10mg and 20mg)
Pepcid Complete OTC (10mg)
Zantac OTC (75mg and 150mg)
Tagamet HB (200mg)
Axid AR (75mg)
Allergy medications:
Claritin OTC (10mg) _
Alavert OTC (10mg)
Loratidine OTC (10mg)
This is a Summary of Benefits and not a complete schedule of benefits. Refer to the Summary Plan Document for all rnvered services,
limitations and exclusions. This does not replace or supersede the Summary Plan Document.
•/

KERR`COUNTY -SCHEDULE OF BENEFITS
January 1, 2008.
i'.~t~i1C~l/v~L
~r yr ~~.~
~~~~ ~~ ~
•. . -•
-• . -• ~
LIFETIME"?MAXiMllM (Lifietirrie Maximums are combined for PPO and Non-PPO Providers}
S2,000,000 S2.000,000
DEDUCTIBLE (Deductibles are combined for PPO and Non-PPO Providers)
Individual Calendar Year Deductible	$1,000	$2,000
Maximum Family Deductible Per
Calendar Year.	$3,000	$6,000
BENEFIT PERIOD:	CALENDAR YEAR
OUT-OF-POCKET MAXIMUM (Excludes Deductibles, Copayments, Utilization Management Penalties,
charges incurred for Inpatient and Outpatient Mental & Nervous Disorders; Chemical Dependency and
Substance Abuse. The Out-o#=Pocke# Limits are combined for PPO and Non-PFO Providers;
Per Individual	$2,000	$ 5;000
Per Family	$6,000	$15,000
OFFIGE 1lISITS
Office Visits
Laboratory Services as a result of
the office visit, excluding High End
Radiolo	$30 Co-payment, then 90%
100%, Deductible Waived	70%, after Deductibie
70%, after Deductible
erg--y"~nle'"c~ions ""$	$30 Co-payment, then 90%	70%, after Deductible
Pre nanc	90%, after Deductible	70%, after Deductible
Well Newborn Nurser Care	90%, Deductible Waived	70%, Deductible Waived
HOSPITAL
In atient Visits	90%, after Deductible	70%, after Deductible
Sur er. In atient or Out atient	90%, after Deductible	70%, after Deductible
		
PREVENTIVE CARE
Routine Well Adult /Dependent
(children through age 17; includes
immunizations for ages 7 through 17)	100%, Deductible waived
$500 Per Person Calendar
Year Maximum.	70%, Deductible waived
$200 Per Person Calendar
Year Maximum
Childhood Immunizations
throw h a e 6	100%, Deductible waived	70%, after Deductible
Routine Mammo raph	100%, Deductible Waived	70%, after Deductible
HOSPITAL SERVICES
Room and Board
Semi-Private Room Rate	90%, after Deductible	70%, after Deductible
Miscellaneous Services and Su lies	90%, after Deductible	70%, after Deductible
Ancillaries	90%, after Deductible	70%, after Deductible
Skilled Nursing Facility (Semi-Private
Room Rate).100 Per Calendar Year	90%, after Deductible	70%, after Deductible
$200 Maximum Allowable per
da
EMERGENCY ROOM		
~~	$50 Co a ,then 90%	$50 Co a ,then 70%
.,


OTHEi3'COVEFi~D`SEAVICES: w	•~ ~ •~

-• ~ -• ~
Home Health Care -Maximum of
100	90%, after Deductible	70%, after ©eductible
Hospice
Bereavement Counseling-
Maximum of $250 for all family
members combined	90%, after Deductible
100%, Deductible Waived	70%, after Deductible
100%, Deductible Waived
Chemothera /Radiation Thera	90%, after Deductible	70%, after Deductible
' e	80%, Deductible Waived	80%, Deductible Waived
Independent Freestanding ~
Diagnostic X-Ray and Laboratory
Facilit Services	90%, Deductible Waived	70%, after Deductible
c erapy, peech
Thera , Ph sical Thera	90%, after Deductible	70%, after Deductible
Durable Medical E ui ment	90%, after Deductible	70%; after Deductible
Prosthetics	90%, after Deductible	70%, after Deductible
Organ Transplants -Physician
Services	90%, after Deductible	70%, after Deductible
Chiropractic Care -Maximum 30
Visits Per Calendar Year	90%, after Deductible	70%, after Deductible
Any other eligible expenses not
mentioned above	90%, after Deductible	70%, after Deductible
VISION I		
Routine Vision Care
1 exam limited to $60 per Calendar
Year	100%, Deductible Waived	100%, Deductible Waived
Mf'NTAL & NERVOUS'DISORDERS,	CHEMICAL DEPENDENCY & SUBSTANCE ABUSE
Inpatient -Maximum of 30 Days Per
Calendar Year	90%, after Deductible	70%, after Deductible
Outpatient -Maximum Allowable per
Visit: $70	50%, after Deductible	50%, after Deductible
PRESCRIPTION DRUG PROGRAM (Formulary) "
Generic	$10	50%
Preferred	$20	50%
Non-Preferred	$35	50%
MAIL ORDER DRUG PROGRAM (90 day supply for 2 copays)
Generic	$20	Not Covered
Preferred	$40	Not Covered
Non-Preferred	$70	Not Covered
Diabetic Supplies	$10 Liberty Medical	
OTC DRUG PROGRAM (ovER-TrtE-COUNTER) ••
	ZERO COPAY *'
(with a written prescription from a physician)
DIABETIC SUPPLIES		
	$1 O (PER SUPPLI()	$70 non formulary
This is a Summary of Benefits and not a complete schedule of benefits. Refer to the Summary Plan Document for all covered services,
limitations and exclusions. This does not replace or supersede the Summary Plan Document.
KERR COUNTY
SUMMARY PLAN DESCRIPTION
SCHEDULE OF MEDICAL BENEFITS
For Employees and Dependents
This Summary Plan Description is a brief description of health benefits coverage provided by Kerr County.
For a full description of all coverage, eligibility, Plan inclusions and exclusions, refer to the Plan Document on
file with Kerr County. The benefits described below are subject to the terms and conditions of the Plan
Document.
The Plan uses the services of Texas True Choice for Preferred Provider Hospitals and Physicians.
IMPORTANT -the Plan has Preferred Provider Organization (PPO) and FARA Healthcare-Management
Features. Under certain conditions, there will be a REDUCTION in benefits payable IF YOU DO NOT:
1. Go to a PPO Hospital and/or PPO Doctor;
2. Get Authorization for:
a. Hospital Confinement, Skilled Nursing Facility confinement and inpatient Hospice

b.	Care Facility
Hospital Confinement and partial hospitalization for Mental and Nervous Disorders
	or Alcohol and Drug Abuse and/or Chemical Dependency;
c.	Outpatient Mental and Nervous Disorders or Alcohol and Drug Abuse and/or
	Chemical Dependency Therapy;
d.	Specialty Drugs and Medicines;
e.	Outpatient High End Radiology which are .performed
	(1) in a Physician's office or clinic;
	(2) on an outpatient basis in a Hospital (excluding those performed in a Hospital
	Emergency Room); or
	(3) in an Independent Radiology and Pathology Center.
f.	Outpatient Surgical Procedures which are performed:
	(1) in an ambulatory surgical facility;
	(2) in a Physician's office or clinic; or
	(3) on an outpatient basis in a Hospital.
g.	Specialty Drugs and Medicines. which are given:
	(1) in a Physician's office or clinic; or
	(2) in a home health care setting.
h.	Specialized Services and Supplies
The following penalties will apply if the Covered Person does not receive authorization for the services
shown above:
(a) Medically Necessary, benefits payable will be reduced by $500; or
(b) not Medically Necessary, no benefits are payable.
To obtain authorization, call FARA Healthcare Management at 1-800-215-3272.
Plan Administered By: FARA Benefit Services, Inc.
P.O. Box 8770
Metairie, LA 70011-8770
Customer Service 1-800-224-3272
This is a Summary of Benefits and not a complete schedule of benefits. Refer to the Summary Plan Document for all covered services,
limitations and exclusions. This does not replace or supersede the Summary Plan Document.
•c~- r- ~~t~,


*' Over The Counter (OTC) Medication Coverage -The following Over The Counter (OTC) medications
are covered at a $0 copay
Gastrointestinal medications:
Prilosec OTC (20mg)
Pepcid AC OTC (10mg and 20mg)
Pepcid Complete OTC (10mg)
Zantac OTC (75mg and 150mg)
Tagamet HB (200mg)
Axid AR (75mg)
Allergy medications:
Claritin OTC (10mg) .
Alavert OTC (10mg)
Loratidine OTC (10mg)
This is a Summary of Benefits and not a complete schedule of benefits. Refer to the Summary Plan Document for all covered services,
limitations and exclusions. This does not replace or supersede the Summary Plan Document.