Attachment 2_SFC SPD PHS PPO 2025

Description

Santa Fe County Summary Plan Description Preferred Provider Organization (PPO) Plan HWP20011 Administered by Presbyterian Health Plan MPC122460 01/01/2025 Welcome This Summary Plan Description describes your group medical benefits. Santa Fe County strongly believes in providing for employees’ protection and welfare and is pleased to offer this Plan. This booklet is intended to provide you with easy-to-understand general explanations of the more significant provisions of your Plan, effective January 1, 2025. Every effort has been made to make these explanations as accurate as possible. If any conflict should arise between this booklet and the claims administrative procedures of our Third-Party Claim Administrator, Presbyterian Health Plan, Inc., (PHP) or if any provision is not covered or only partially covered, the terms of this benefit booklet will govern in all cases. This booklet does not imply a contract of employment. Santa Fe County reserves the right to terminate, discontinue, alter, modify or change this Plan or any provision of this Plan at any time. It is your responsibility to read and understand the terms and conditions in this booklet. You are urged to read this booklet carefully and use it to make well-informed benefits decisions for you and your family. Very truly yours, Santa Fe County Presbyterian Customer Service Center: (505) 923-7324 or 1-855-593-7737 (TTY: 711) SANTA FE COUNTY-PPO 1/1/2025 2 Table of Contents Welcome ................................................................................................2 Section 1 - Introduction .....................................................................10 Section 2 - How the Plan Works .......................................................12 In-network Providers.........................................................................................12 Provider Directory.............................................................................................12 National Network Providers..............................................................................13 Out-of-network Providers/Practitioners............................................................13 Out-Of-Network Care And Bills.......................................................................14 What Is Prior Authorization? ............................................................................16 What Procedures Require Prior Authorization?................................................16 Prior