3-RFP Attachment 1 - Exhibits.docx
DOCX document 10 MB Posted
- Attached to
- Employee Healthcare Benefits Provider
- Solicitation number
- RFP-25-030-HR
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
The document is a comprehensive Employee Benefit Plan document for the Arizona Metropolitan Trust (AzMT), a self-funded governmental employee benefit pool covering multiple participating entities including cities and towns in Arizona such as Apache Junction, El Mirage, Litchfield Park, and Paradise Valley. The plan provides detailed health insurance coverage for active employees and their dependents, offering multiple plan options including PPO, PPO Buy-Up, and High Deductible Health Plan (HDHP) for the benefit year beginning July 1, 2025. The document outlines eligibility requirements, enrollment procedures, coverage details, medical and prescription drug benefits, cost-sharing arrangements, and administrative processes for claims and appeals.
The health insurance plans feature varying deductible levels ranging from $250 to $3,300 depending on the plan type, with corresponding out-of-pocket maximums between $3,000 and $7,000 for network coverage. Prescription drug benefits are administered by Navitus Health Solutions, with tiered co-payment structures for generic, brand name, and specialty medications. The plan is fully self-funded by the participating governmental entities and is exempt from federal Employee Retirement Income Security Act (ERISA) requirements. The document provides comprehensive coverage including preventive care, mental health services, transplant programs, and special provisions for certain public safety employees, with explicit protections for dependents and provisions for continuation of coverage under specific circumstances like family medical leave or military service.
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Other files
| File | Type | Posted |
|---|---|---|
| 2-RFP Exhibit C - Forms to Complete.docx | DOCX document | |
| 1-RFP-25-030-HR Employee Healthcare Benefits Provider.pdf |
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Text version
Underwriting Documents
| Document Title |
| Document |
| Notes |
Rate History
Please note that the 2026/27 renewal rates are not yet available
Medical
| Document Title |
| Document |
| Notes |
SBC/Plan Summary
Plan Document
Monthly / Large claims and enrollment by month
Report includes medical, dental and vision claims
Dental
| Document Title |
| Document |
| Notes |
Plan Summary
Vision
| Document Title |
| Document |
| Notes |
Plan Summary
Life/AD&D
| Document Title |
| Document |
| Notes |
Plan Summary
Plan Certificate
Short-Term Disability
| Document Title |
| Document |
| Notes |
Plan Certificate image4.emf
2025 Arizona Metro Trust HDHP SBC.pdf
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2025 – 06/30/2026 Arizona Metropolitan Trust (AzMT): Employee Benefit Plan Coverage for: Individual and Family | Plan Type: HDHP
(HHS - OMB control number: 0938-1146/Expiration date: 05/31/2026)
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.MyAmeriBen.com or call 1-855- 350-8699. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-855-350-8699 to request a copy.
Important Questions Answers Why This Matters:
What is the overall deductible?
Network Non-Network Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Per participant: $3,300 $5,000
Per family: $6,600 $10,000
Are there services covered before you meet your deductible?
Yes. Network preventive care services, wellness care services not defined by PPACA (limited).
This plan covers some items and services even if you haven’t yet met the deductible amount. But a co-payment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?
No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?
Network Non-Network The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
Per participant: $3,300 $10,000
Per family: $6,600 $20,000
What is not included in the out-of-pocket limit?
Premiums, balance-billed charges, health care this Plan doesn’t cover, pre-certification penalties, and medical food charges.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider?
Yes, for medical: BlueCross® BlueShield® of Arizona. For a list of network providers, call BCBSAZ at 1-800-232-2345 or visit www.azblue.com/CHSNetwork.
Yes, for prescription drugs: Navitus. For a list of retail and mail pharmacies, log on to
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
www.navitus.com.
Do you need a referral to see a specialist?
No. You can see the specialist you choose without a referral.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information Network Provider
(You will pay the least) Non-Network Provider (You will pay the most)
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
No charge after deductible
50% co-insurance after
–––––––––––––––––none––––––––––––––––
Specialist visit
Preventive care/screening/ immunization
No charge, deductible waived
Not Covered
AzMT L.I.V.E. on-site wellness screenings and programs will be covered at no charge.
Please refer to the Routine Preventive Care provision listed in the plan document for a further description and limitations to this benefit.
You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your Plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Pre-certification is required. Benefits will be reduced by $300 per paid claim for non-compliance.
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.navitus.com
Generic drugs deductible/30-day supply or 90-day supply
The amount payable in excess of the amounts shown to the left will be the difference between the non-network pharmacy and the network pharmacy.
The Plan works with the Copay Max Plus Program to obtain co-payment assistance on your behalf. This program applies to certain prescription drugs that have manufacturer-funded co-payment assistance programs available. For additional information on limitations to this benefit, refer to the Summary Plan Description.
Preventive prescription medications (including contraceptives) when purchased from a network pharmacy are paid at 100% and the co-payment/deductible (if applicable) is waived.
Members who elect a brand name drug when a generic is available will be subject to a penalty equivalent to the cost difference between the brand and generic.
Not all prescription drugs are covered. To determine if a specific drug is covered under your Plan, log into your account at
Note: Specialty drugs are only available through the Navitus SpecialtyRx Program Pharmacy.
Preferred brand drugs
Non-preferred brand drugs
Specialty drugs deductible/30 day supply
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center)
Providers who do not typically contract (e.g.
anesthesiologist, pathologists, and assistant surgeons) are to be paid based on the network status of the facility in which the services were rendered.
Physician/surgeon fees
If you need immediate medical attention
Emergency room care No charge after deductible –––––––––––––––––none––––––––––––––––
Emergency medical transportation
Urgent care
If you have a hospital stay
Facility fee (e.g., hospital room)
Limited to the semi-private room rate.
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
If you need mental health, behavioral health, or substance abuse services
Outpatient services
Pre-certification is required for partial hospitalization and intensive outpatient treatment in excess of twenty (20) visitsfor psychiatric day treatment, for partial hospitalization in excess of twenty (20) visits, and for intensive outpatient programs in excess of eighteen (18) visits. Benefits will be
Inpatient services
If you are pregnant
Office visits
Cost sharing does not apply for preventive services.
Childbirth/delivery professional services
Childbirth/delivery facility
If you need help recovering or have other special needs
Home health care
Benefit year maximum: Sixty (60) visits per plan participant.
Rehabilitation services
Services include speech, occupational, or physical therapy provided on an inpatient or outpatient basis.
Combined benefit year maximum: Twenty (20) visits per plan participant.
Pre-certification is required for services in
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
excess of the twenty (20) visit limit. Benefits will be reduced by $300 per paid claim for non-
Habilitation services
Coverage for Autism Spectrum Disorder – Behavior Therapy Services ONLY. Behavioral therapy services for the treatment of Autism spectrum disorder are available for plan participants who have been diagnosed with autism spectrum disorder.
Skilled nursing care
Benefit year maximum: Sixty (60) days per
Durable medical equipment
Pre-certification is required for durable medical equipment (DME) in excess of $31,000. Benefits will be reduced by $300 per paid claim for non-compliance.
Hospice services
Lifetime maximum: Six (6) months per plan participant.
Services include bereavement counseling;
limited to $300 per plan participant.
If your child needs Children’s eye exam No charge, Not Covered This describes benefits provided by your
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
dental or eye care deductible waived medical Plan. AzMT provides Dental and Vision coverage through stand-alone plans at a low monthly cost. If this is elected, please refer to your vision and/or dental administrator for additional benefits.
Children’s glasses Not Covered Not Covered
Children’s dental check-up Not Covered Not Covered
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Acupuncture
• Cosmetic surgery
• Dental care (adult and children covered under stand-alone dental plan)
• Glasses (adult and children)
• Infertility treatment
• Long-term care (except for a facility licensed to provide long term acute care)
• Non-emergency care when traveling outside the U.S.
• Private duty nursing
• Routine foot care (except when medically appropriate for diabetes, neurological involvement or peripheral vascular disease of the foot or lower leg)
• Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Bariatric surgery [limited to one (1) procedure per lifetime]
• Chiropractic care [limited to thirty (30) visits per benefit year]
• Hearing aids [limited to $1,000 per lifetime] • Routine eye care (children)
Your Rights to Continue Coverage: You may contact the Plan’s COBRA Administrator at AmeriBen, P.O. Box 7186, Boise ID 83707, 1-855-350-8699. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan.
You may contact the third party administrator (TPA) to assist the plan administrator with claims adjudication. The TPA’s name, address, and telephone number are:
AmeriBen Attention: Appeals Coordination P.O. Box 7186 Boise, ID 83707 1-855-350-8699
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-855-350-8699.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-350-8699.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-855-350-8699.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-350-8699.
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
https://www.healthcare.gov/sbc-glossary/#plan
The plan would be responsible for the other costs of these EXAMPLE covered services.
Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital delivery)
Mia’s Simple Fracture
(in-network emergency room visit and follow up care)
Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a well-controlled condition)
◼ The plan’s overall deductible $3,200300 ◼ Specialist cost sharing 0% ◼ Hospital (facility) cost sharing 0% ◼ Other cost sharing 0%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
Total Example Cost $12,700
In this example, Peg would pay:
Cost Sharing
Deductibles $3,300
Copayments $0
Coinsurance $0
What isn’t covered
Limits or exclusions $20
The total Peg would pay is $3,320
◼ Hospital (facility) cost sharing 0% ◼ Other cost sharing 0%
This EXAMPLE event includes services like:
Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
Total Example Cost $5,600
In this example, Joe would pay:
Deductibles $2,200
Limits or exclusions $0
The total Joe would pay is $2,200
◼ Hospital (facility) cost sharing 0% ◼ Other cost sharing 0%
This EXAMPLE event includes services like:
Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost $2,800
In this example, Mia would pay:
Deductibles $2,800
The total Mia would pay is $2,800
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#cost-sharing https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#excluded-services
We’re here for you – in many languages
The law requires us to include a message in all of these different languages. Curious what they say?
Here’s the English version: “You have the right to get help in your language for free. Just call the Member Services number on your ID card.” Visually impaired? You can also ask for other formats of this document.
Spanish Usted tiene derecho a obtener asistencia en su idioma sin cargo. Llame al número de Servicios para Miembros que figura en su tarjeta de identificación ¿Tiene alguna deficiencia visual? También puede solicitar este documento en otros formatos.
Chinese 您有權免費獲得使用您的語言提供的協助。只需撥
打印於您的 ID
卡上的會員服務部電話號碼即可。視力障礙？您也 可以索取本文件的其他格式。
Vietnamese Quý vị có quyền nhận trợ giúp bằng ngôn ngữ của mình, miễn phí. Quý vị chỉ cần gọi đến số điện thoại của Ban Dịch vụ Thành viên trên thẻ ID của quý vị. Quý vị bị khiếm thị? Quý vị cũng có thể yêu cầu các định dạng khác của tài liệu này.
Korean 귀하는 귀하의 언어로 된 도움을 무료로 받을
권리가 있습니다. 귀하의 ID 카드에 있는 가입자
서비스 번호로 전화하십시오. 시각 장애인이신가요? 다른 형식으로 된 이 문서를 요청하실 수 있습니다.
Tagalog May karapatan kang makakuha ng tulong na nasa iyong wika nang libre. Tawagan lang ang numero ng Member Services na nasa iyong ID card. May kapansanan sa paningin? Maaari ka ring humingi ng iba pang mga format ng dokumentong ito.
Russian У вас есть право на бесплатное получение помощи на вашем родном языке. Просто позвоните в отдел обслуживания участников по номеру, указанному на вашей идентификационной карте. У вас проблемы со зрением? Вы также можете запросить этот документ в других форматах.
French Creole Ou gen dwa jwenn èd nan lang ou gratis. Jis rele nimewo Sèvis Manm ki sou Kat ID ou a gratis Gen pwoblèm vizyèl? Ou ka mande tou pou lòt fòma nan dokiman sa a.
Arabic
لك الحق في الحصول على هذه المعلومات والحصول على المساعدة بلغتك مجانًا. فقط اتصل برقم خدمات الأعضاء الموجود على بطاقة
هويتك. هل تعاني من ضعف البصر؟ يمكنك أيضًا طلب تنسيقات أخرى لهذه الوثيقة.
French Vous avez le droit d’obtenir de l’aide dans votre langue gratuitement. Appelez simplement le numéro du Services membres figurant sur votre carte d’identité. Vous êtes une personne malvoyante ? Vous pouvez également demander à accéder à ce document dans d’autres formats.
Persian شما حق داريد به زبان خود به صورت رايگان کمک بگيريد. فقط با
شماره خدمات اعضا مندرج در کارت عضويت خود تماس بگيريد. آيا های ديگر اين سند توانيد فرمتدچار اختلال بينايی هستيد؟ همچنين می
را درخواست کنيد.
Armenian Դուք իրավունք ունեք անվճար օգնություն ստանալու ձեր լեզվով։ Պարզապես զանգահարեք ձեր ID քարտի վրա գտնվող Անդամների սպասարկման համարին: Տեսողության խանգարում ունեցո՞ղ եք։ Կարող եք նաև խնդրել այս փաստաթղթի այլ ձևաչափեր։
Japanese あなたにはあなたの言語で無料で支援を受ける
権利があります。IDカードに記載されている会
員サービス番号にお電話ください」視覚障害を
お持ちですか？他の形式でこの文書を要求する こともできます。
Italian Hai il diritto di ricevere assistenza gratuita nella tua lingua. Basta chiamare il numero del Servizio Membri presente sulla tua tessera identificativa.
Hai problemi di vista? È possibile richiedere anche altri formati di questo documento.
German Sie haben das Recht, kostenlose Hilfe in Ihrer Sprache zu erhalten. Rufen Sie einfach die Nummer des Mitgliederservices auf Ihrer ID-Karte an.
Sehbehindert?
Sie können dieses Dokument auch in anderen Formaten anfordern.
Polish Masz prawo do bezpłatnej pomocy w swoim języku. Wystarczy zadzwonić pod numer Biura Obsługi Klienta podany na karcie identyfikacyjnej.
Masz wadę wzroku? Możesz również poprosić o inne formaty tego dokumentu.
Pennsylvania Dutch Du hoscht’s Recht fer Hilf griege in dei Schprooch fer nix. Duh yuscht die Member Services Number uffrufe uff dei ID Card. Hoscht Druwwel fer sehne? Du kannscht des do Schreiwes in en differnter Weg griege so as du’s besser sehne kannscht.
It’s important we treat you fairly
We follow federal civil rights laws in our health programs and activities. Members can get reasonable modifications as well as free auxiliary aids and services if you have a disability. We don’t discriminate, on the basis of race, color, national origin, sex, age or disability. For people whose primary language isn’t English (or have limited proficiency), we offer free language assistance services like interpreters and other written languages. Interested in these services? Call the
Member Services number on your ID card for help (TTY/TDD: 711) or visit our website. If you think we failed in any areas or to learn more about grievance procedures, you can mail a complaint to:
Compliance Coordinator, P.O. Box 7186 Boise, ID 83707, or directly to the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW;
Room 509F, HHH Building; Washington, D.C.
20201. You can also call 1-800- 368-1019 (TDD: 1- 800-537-7697) or visit https://ocrportal.hhs.gov/ocr/portal/lobby.jsf image5.emf
2025 Arizona Metro Trust PPO SBC.pdf
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2025 – 06/30/2026 Arizona Metropolitan Trust (AzMT): Employee Benefit Plan Coverage for: Individual and Family | Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.MyAmeriBen.com or call 1-855- 350-8699. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-855-350-8699 to request a copy.
plan, each family member must meet their own individual deductible until the
Per participant: $750 $2,000
Per family: $1,500 $4,000 care services not defined by PPACA (limited), services which require a co-payment.
deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you
Per participant: $3,500 $5,000
Per family: $7,000 $10,000
For Prescription Drugs
Per participant: $3,600
Per family: $7,200
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
$25 co-payment/visit, deductible waived
$45 co-payment/visit, 20% co-insurance after
There is no charge when labs are received at a free-standing facility.
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
condition More information about prescription drug
$15 co-payment/ 30-day supply
$30 co-payment/ 90-day supply
You pay the network pharmacy co-payment plus the difference between the non-network and network pharmacy cost.
Prescription drug charges apply to the Prescription Drug out-of-pocket limit.
your behalf. This program applies to certain prescription drugs that have manufacturer-funded co-payment assistance programs available. For additional information on network pharmacy are paid at 100% and the
$35 co-payment/
$80 co-payment/
$55 co-payment/
$130 co-payment/
20% co-payment to a maximum of $300/30-day supply
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
surgeons) are to be paid based on the network
Emergency room care $300 co-payment/visit, plus 20% co-insurance after
Co-payment waived if admitted.
$50 co-pay/visit, $25 co-payment/visit treatment in excess of twenty (20) visits.
Benefits will be reduced by $300 per paid claim for non-compliance.
20% co-insurance after deductible
First visit to confirm pregnancy is subject to a $25 co-payment, deductible waived.
services. Depending on the type of services, a co-payment, co-insurance, or deductible may apply.
Childbirth/delivery professional 20% co-insurance 50% co-insurance after –––––––––––––––––none––––––––––––––––
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
services after deductible deductible
Covered as any other illness depending on provider type, service performed, and place of service.
therapy services for the treatment of Autism spectrum disorder are available for plan
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
medical equipment (DME) in excess of $3,000.
Hospice services
Lifetime maximum: Six (6) months per plan participant.
If your child needs dental or eye care
Children’s eye exam No charge, This describes benefits provided by your medical Plan. AzMT provides Dental and Vision coverage through stand-alone plans at a low monthly cost. If this is elected, please
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
Your Rights to Continue Coverage: You may contact the Plan’s COBRA Administrator at AmeriBen, P.O. Box 7186, Boise ID 83707, 1-855-350-8699. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
You may contact the third party administrator (TPA) to assist the plan administrator with claims adjudication. The TPA’s name, address, and telephone number are:
P.O. Box 7186
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
◼ The plan’s overall deductible $750 ◼ Specialist co-payment $45 ◼ Hospital (facility) cost sharing 20% ◼ Other cost sharing 20%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services
Deductibles $750
Copayments $10
Coinsurance $2,300
The total Peg would pay is $3,080
◼ Hospital (facility) cost sharing 20% ◼ Other cost sharing 20%
This EXAMPLE event includes services like:
Primary care physician office visits (including disease education) Diagnostic tests (blood work)
Deductibles $400
Copayments $600
The total Joe would pay is $1,000
◼ Hospital (facility) cost sharing 20% ◼ Other cost sharing 20%
This EXAMPLE event includes services like:
Emergency room care (including medical supplies) Diagnostic test (x-ray)
Deductibles $750
Copayments $400
Coinsurance $300
The total Mia would pay is $1,450
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
https://www.healthcare.gov/sbc-glossary/#cost-sharing https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#excluded-services
Here’s the English version: “You have the right to get help in your language for free. Just call the Member Services number on your ID card.” Visually idioma sin cargo. Llame al número de Servicios para Miembros que figura en su tarjeta de identificación mình, miễn phí. Quý vị chỉ cần gọi đến số điện thoại của Ban Dịch vụ Thành viên trên thẻ ID của quý vị. Quý vị bị khiếm thị? Quý vị cũng có thể yêu
권리가 있습니다. 귀하의 ID 카드에 있는 가입자
서비스 번호로 전화하십시오. 시각 iyong wika nang libre. Tawagan lang ang numero ng Member Services na nasa iyong ID card. May kapansanan sa paningin? Maaari ka ring humingi помощи на вашем родном языке. Просто позвоните в отдел обслуживания участников по номеру, указанному на вашей идентификационной карте. У вас проблемы nimewo Sèvis Manm ki sou Kat ID ou a gratis Gen langue gratuitement. Appelez simplement le numéro du Services membres figurant sur votre carte d’identité. Vous êtes une personne ստանալու ձեր լեզվով։ Պարզապես զանգահարեք ձեր ID քարտի վրա գտնվող Անդամների սպասարկման համարին: Տեսողության խանգարում ունեցո՞ղ lingua. Basta chiamare il numero del Servizio Membri presente sulla tua tessera identificativa.
Hai problemi di vista? È possibile richiedere anche altri formati
Sprache zu erhalten. Rufen Sie einfach die Nummer des Mitgliederservices auf Ihrer ID-Karte an.
Sehbehindert?
języku. Wystarczy zadzwonić pod numer Biura Obsługi Klienta podany na karcie identyfikacyjnej.
fer nix. Duh yuscht die Member Services Number uffrufe uff dei ID Card. Hoscht Druwwel fer sehne? Du kannscht des do Schreiwes in en differnter Weg griege so as reasonable modifications as well as free auxiliary aids and services if you have a disability. We don’t discriminate, on the basis of race, color, national origin, sex, age or disability. For people whose primary language isn’t English (or have limited proficiency), we offer free language assistance failed in any areas or to learn more about grievance procedures, you can mail a complaint to:
Compliance Coordinator, P.O. Box 7186 Boise, ID 83707, or directly to the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW;
Room 509F, HHH Building; Washington, D.C.
20201. You can also call 1-800- 368-1019 (TDD: 1-image6.emf
2025 Arizona Metro Trust PPO Buy-Up SBC.pdf
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2025 – 06/30/2026 Arizona Metropolitan Trust (AzMT): Employee Benefit Plan Coverage for: Individual and Family | Plan Type: PPO Buy-Up
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.MyAmeriBen.com or call 1-855- 350-8699. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-855-350-8699 to request a copy.
plan, each family member must meet their own individual deductible until the
Per participant: $250 $500
Per family: $500 $1,000 care services not defined by PPACA (limited), services which require a co-payment.
deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you
Per participant: $3,000 $5,000
Per family: $6,000 $10,000
For Prescription Drugs
Per participant: $4,100
Per family: $8,200
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
$25 co-payment/visit, $45 co-payment/visit, There is no charge when labs are received at a free-standing facility.
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
condition More information about prescription drug
$15 co-payment/
$30 co-payment/ 90-day supply You pay the network pharmacy co-payment plus the difference between the non-network and network pharmacy cost.
Prescription drug charges apply to the Prescription Drug out-of-pocket limit.
your behalf. This program applies to certain prescription drugs that have manufacturer-funded co-payment assistance programs available. For additional information on network pharmacy are paid at 100% and the
$35 co-payment/
$80 co-payment/
$55 co-payment/
$130 co-payment/
20% co-payment to a maximum of $300/30-day supply
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
surgeons) are to be paid based on the network
Emergency room care $300 co-payment/visit, plus 20% co-insurance after
Co-payment waived if admitted.
$50 co-pay/visit, $25 co-payment/visit treatment in excess of twenty (20) visits.
First visit to confirm pregnancy is subject to a $25 co-payment , deductible waived.
services. Depending on the type of services, a co-payment, co-insurance, or deductible may apply.
Childbirth/delivery professional
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
Covered as any other illness depending on provider type, service performed, and place of service.
therapy services for the treatment of Autism spectrum disorder are available for plan medical equipment (DME) in excess of $3,000.
Hospice services 20% co-insurance 50% co-insurance after Lifetime maximum: Six (6) months per plan
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
after deductible deductible participant.
If your child needs dental or eye care
Children’s eye exam No charge, This describes benefits provided by your medical Plan. AzMT provides Dental and Vision coverage through stand-alone plans at a low monthly cost. If this is elected, please
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Your Rights to Continue Coverage: You may contact the Plan’s COBRA Administrator at AmeriBen, P.O. Box 7186, Boise ID 83707, 1-855-350-8699. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
You may contact the third party administrator (TPA) to assist the plan administrator with claims adjudication. The TPA’s name, address, and telephone number are:
* For more information about limitations and exceptions, see the plan or policy document at www.MyAmeriBen.com.
P.O. Box 7186
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
◼ The plan’s overall deductible $250
◼ Hospital (facility) cost sharing 20% ◼ Other cost sharing 20%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services
Deductibles $250
Copayments $10
Coinsurance $2,400
The total Peg would pay is $2,680
◼ Hospital (facility) cost sharing 20% ◼ Other cost sharing 20%
This EXAMPLE event includes services like:
Primary care physician office visits (including disease education) Diagnostic tests (blood work)
Copayments $600
Coinsurance $40
The total Joe would pay is $890
◼ Hospital (facility) cost sharing 20% ◼ Other cost sharing 20%
This EXAMPLE event includes services like:
Emergency room care (including medical supplies) Diagnostic test (x-ray)
Copayments $400
Coinsurance $400
The total Mia would pay is $1,050
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
https://www.healthcare.gov/sbc-glossary/#cost-sharing https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#excluded-services
Here’s the English version: “You have the right to get help in your language for free. Just call the Member Services number on your ID card.” Visually idioma sin cargo. Llame al número de Servicios para Miembros que figura en su tarjeta de identificación mình, miễn phí. Quý vị chỉ cần gọi đến số điện thoại của Ban Dịch vụ Thành viên trên thẻ ID của quý vị. Quý vị bị khiếm thị? Quý vị cũng có thể yêu
권리가 있습니다. 귀하의 ID 카드에 있는 가입자
서비스 번호로 전화하십시오. 시각 iyong wika nang libre. Tawagan lang ang numero ng Member Services na nasa iyong ID card. May kapansanan sa paningin? Maaari ka ring humingi помощи на вашем родном языке. Просто позвоните в отдел обслуживания участников по номеру, указанному на вашей идентификационной карте. У вас проблемы nimewo Sèvis Manm ki sou Kat ID ou a gratis Gen langue gratuitement. Appelez simplement le numéro du Services membres figurant sur votre carte d’identité. Vous êtes une personne ստանալու ձեր լեզվով։ Պարզապես զանգահարեք ձեր ID քարտի վրա գտնվող Անդամների սպասարկման համարին: Տեսողության խանգարում ունեցո՞ղ lingua. Basta chiamare il numero del Servizio Membri presente sulla tua tessera identificativa.
Hai problemi di vista? È possibile richiedere anche altri formati
Sprache zu erhalten. Rufen Sie einfach die Nummer des Mitgliederservices auf Ihrer ID-Karte an.
Sehbehindert?
języku. Wystarczy zadzwonić pod numer Biura Obsługi Klienta podany na karcie identyfikacyjnej.
fer nix. Duh yuscht die Member Services Number uffrufe uff dei ID Card. Hoscht Druwwel fer sehne? Du kannscht des do Schreiwes in en differnter Weg griege so as reasonable modifications as well as free auxiliary aids and services if you have a disability. We don’t discriminate, on the basis of race, color, national origin, sex, age or disability. For people whose primary language isn’t English (or have limited proficiency), we offer free language assistance failed in any areas or to learn more about grievance procedures, you can mail a complaint to:
Compliance Coordinator, P.O. Box 7186 Boise, ID 83707, or directly to the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW;
Room 509F, HHH Building; Washington, D.C.
20201. You can also call 1-800- 368-1019 (TDD: 1-image7.emf
2025 AzMT PPO Plan Document.pdf
Arizona Metropolitan Trust (AzMT)
Employee Benefit Plan PPO Plan Document and Summary Plan Description
Amended and Restated Effective July 1, 2025
In addition to providing benefit information and descriptions this document includes notices of your rights and responsibilities under various United States laws including without limitation:
Consolidated Omnibus Budget Reconciliation Act (COBRA); Health Insurance Portability and Accountability Act (HIPAA); Consolidated Appropriations Act (CAA); Women’s Health and Cancer Rights Act; Newborns’ and Mothers’ Health Protection Act; Patient Protection and Affordable Care Act (PPACA); and Medicaid and Children’s Health Insurance Program (CHIP).
i
TABLE OF CONTENTS
SECTION I— INTRODUCTION
A. Quick Reference Chart
SECTION II— ELIGIBILITY, EFFECTIVE DATE, AND TERMINATION PROVISIONS
A. Eligibility B. Enrollment C. Timely Enrollment D. Special Enrollment Rights E. Special Enrollment Periods F. Qualifying Events Chart G. Effective Date H. Termination of Coverage I. Continuation during Family and Medical Leave J. Continuation during Periods of Employer-Certified Disability, Leave of Absence, or Layoff K. Continuation of Coverage for Certain Public Safety Employees L. Special Eligibility for Surviving Spouses and Surviving Unmarried Dependents of Certain Law Enforcement
Officers M. Rehiring a Terminated Employee N. Open Enrollment
SECTION III— CONSOLIDATED APPROPRIATIONS ACT OF 2021 AND TRANSPARENCY IN COVERAGE REGULATIONS A. Surprise Billing Claims B. No Surprises Billing Act Requirements C. How Cost-Shares Are Calculated D. Appeals E. Transparency Requirements F. Continuity of Care
SECTION IV— MEDICAL NETWORK INFORMATION
A. Network and Non-Network Services B. Choosing a Physician – Patient Protection Notice C. Special Reimbursement Provisions D. Network Information
SECTION V— SCHEDULES OF BENEFITS
A. Schedule of Medical Benefits B. Balance Bill C. Co-Insurance D. Co-Payments E. Deductible F. Benefit Payment G. Out-of-Pocket Limit H. Diagnosis-Related Grouping (DRG) I. Schedule of Medical Benefits – PPO Plan J. Schedule of Prescription Drug Benefits – PPO Plan
SECTION VI— MEDICAL BENEFITS
A. Covered Medical Charges B. Medical Plan Exclusions
SECTION VII— TRANSPLANT PROGRAM
A. Transplant Program B. Program Benefits C. Transplant Requirements D. Transplant Exclusions E. Transplant Travel and Lodging
SECTION VIII— HEALTH CARE MANAGEMENT PROGRAM
A. Utilization Review B. Concurrent Review and Discharge Planning C. Case Management D. Courtesy Reviews ii
SECTION IX— PRESCRIPTION DRUG BENEFITS
A. About Your Prescription Benefits B. Out-of-Pocket Limit C. Manufacturer Coupons D. Co-Payments E. Mail Order Drug Benefit Option F. Specialty Pharmacy Program G. Tablet Splitting H. Step Therapy Program I. Medicare Part D Prescription Drug Plans for Medicare Eligible Participants J. Covered Prescription Drug Charges K. Limits to This Benefit L. Dispense As Written (DAW) Program M. Prescription Drug Plan Exclusions
SECTION X— CLAIMS AND APPEALS
A. Timeframes for Claims and Appeal Processes B. Assignment of Benefits C. Types of Claims Managed by the Medical Management Administrator D. Urgent Care Claims E. Concurrent Care Claims F. Other Pre-Service Claims G. Second Level Appeals Process for Urgent Care, Concurrent Care, and Other Pre-Service Claims H. External Review of Pre-Service Claims I. Incomplete Claims J. Post-Service Claims K. Second Level Appeal Process of Post-Service Claims L. External Review Rights M. External Review of Claims N. Designation of Authorized Representative O. Physical Examinations P. Managed Care Recommendations Q. Autopsy R. Payment of Benefits S. Assignments T. Non-U.S. Providers U. Recovery of Payments
SECTION XI— COORDINATION OF BENEFITS
A. Coordination of the Benefit Plans B. Excess Insurance C. Allowable Charge D. General Limitations E. Application to Benefit Determinations F. Benefit Plan Payment Order G. Coordination with Government Programs H. Claims Determination Period I. Right to Receive or Release Necessary Information J. Facility of Payment K. Right of Recovery
SECTION XII— MEDICARE
A. Application to Active Employees and Their Spouses B. Applicable to All Other Participants Eligible for Medicare Benefits C. Applicable to Medicare Services Furnished to Covered Plan Participants on Dialysis
SECTION XIII— REIMBURSEMENT, SUBROGATION, AND RECOVERY PROVISIONS
A. Definitions B. Subrogation C. Reimbursement D. Secondary to Other Coverage E. Assignment F. Applicability to All Settlements and Judgments iii
G. Constructive Trust H. Lien Rights I. First-Priority Claim J. Cooperation K. Discretion
SECTION XIV— CONTINUATION COVERAGE RIGHTS UNDER COBRA
A. COBRA Continuation Coverage B. Qualified Beneficiary C. Qualifying Event D. Notice of Unavailability of Continuation Coverage E. Factors to Consider in Electing COBRA Continuation Coverage F. Procedure for Obtaining COBRA Continuation Coverage G. The Election Period H. Responsibility for Informing the Plan Administrator of the Occurrence of a Qualifying Event I. Waiver before the End of the Election Period J. If a Qualified Beneficiary has other group health plan coverage or Medicare K. When a Qualified Beneficiary’s COBRA Continuation Coverage May be Terminated L. Maximum Coverage Periods for COBRA Continuation Coverage M. Circumstances in Which the Maximum Coverage Period Can be Expanded N. How a Qualified Beneficiary Becomes Entitled to a Disability Extension O. Payment for COBRA Continuation Coverage P. Initial Payment for COBRA Continuation Coverage Q. Timely Payment for COBRA Continuation Coverage R. Non-Sufficient Funds Payments (NSF) S. COBRA Continuation Coverage Availability for Domestic Partners and Children of Domestic Partners T. If You Have Questions U. Keep Your Human Resources Department Informed of Address Changes V. If You Wish to Appeal
SECTION XV— RESPONSIBILITIES FOR PLAN ADMINISTRATION
A. Plan Administrator B. Duties of the Plan Administrator C. Amending and Terminating the Plan D. Plan Administrator Compensation E. Third Party Administrator is Not a Fiduciary
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .