NEW CASTLE COUNTY COMPARISON OF PRE-65 RETIREES/PENSIONERS BENEFITS PLAN YEAR 2019

Transcription

1 Deductible Per Calendar Year (Individual/Family) $200 Individual $400 Family (DME, Prosthetics and Hearing Aids only) $200 per Individual $400 per Family $200 per Individual $400 per Family $200 per Individual $400 per Family Plan Pays 80% after for DME, Prosthetics and Hearing Aids Co-Insurance Maximum: $2,000 per Individual/ $4,000 family for DME, Prosthetics and Hearing Aids Total Maximum Out of Pocket: Includes In-network medical, coinsurance and copays. Once met, the plan pays of covered services for the remainder of the calendar year. 1, 3 PREVENTIVE MEDICAL SERVICES 2 $7,900 Individual $15,800 Family 80% after 80% 80% $2,000 per Individual $4,000 per Family $7,900 Individual $15,800 Family $7,350 Individual $14,700 Family $7,900 Individual $15,800 Family Periodic Physical Exams Covered Not Covered Covered Covered Covered Covered Routine Gynecological Care, Pap Smears Covered Not Covered (except ) Covered Covered Covered Covered Routine Mammogram Covered Covered Covered Covered Covered Covered Routine Well Child Care Covered Not Covered Covered Covered Covered Covered Routine Immunizations Covered Not Covered Covered Covered Covered Covered Routine Sigmoidoscopy & Colonoscopy Covered Not Covered Covered Covered Covered Covered Routine Blood Antigen Test (PSA) Covered Not Covered Covered Covered Covered Covered New Castle County Pre-65 Retirees/Pensioners Benefit Comparison 2019 Page 1 of 6

2 TREATMENT OF ILLNESS OR INJURY Diagnosis and Treatment in the Primary Care Physician office $15 Co-pay; then 80% after $10 Co-pay then 80% after 80% after $10 Co-pay then Specialist Care $25 Co-pay then 80% after. $20 Co-pay then 80% after 80% after $20 Co-pay then Outpatient Surgery Covered 80% after Covered 80% Covered 80% Covered Covered Allergy Testing & Treatment PCP Specialist $15 Co-pay then $25 Co-pay then 80% after 80% after $10 Co-pay then 80% after ; treatment only 80% after ; treatment only $10 Co-pay then Lab Services covered 80% after Covered Covered Covered Covered X-Ray $10 Co-pay then 80% after $10 Co-pay then Covered Covered $10 Co-pay then Machine Tests Covered 80% after Covered Covered Covered Covered Physical Therapy Covered 80% after 80% Covered Covered Covered 80% Covered Speech and Occupational Therapy Covered 80% after 80% Covered Covered Covered 80% Covered Radiation Therapy & Chemotherapy Covered 80% after Covered Covered Covered Covered Nursing Home Visits Covered 80% after $25 Co-pay then 80% covered after 80% covered after $25 Co-pay then Covered Chiropractic- 80% Covered 80% after 80% Covered 80% Covered 80% Covered 80% Covered 30 visit calendar year maximum IN THE HOSPITAL New Castle County Pre-65 Retirees/Pensioners Benefit Comparison 2019 Page 2 of 6

3 Room and Board (Semi-private; includes intensive care, if medically appropriate and maternity) Covered 80% after Covered Covered $10 Co-pay first 7 days; Covered after first 7 days Covered IN THE HOSPITAL (CONTINUED) Physician s and Surgeon s Services Covered 80% after Covered except $25 Co-pay per procedure for Family Planning Services 80% Covered 80% Covered Covered except $25 Co-pay per procedure for Family Planning Services Other Medically Necessary Services Covered 80% after Covered Covered Covered Covered MATERNITY (PHYSICIAN S SERVICES) Prenatal/Postnatal Care Covered 80% after Covered 80% Covered 80% Covered Covered Delivery Covered 80% after Covered 80% Covered 80% Covered Covered EMERGENCY SERVICES Emergency Facility $50 Co-pay per visit (waived if admitted) then $50 Co-pay per visit (waived if admitted) then $50 Co-pay then (waived if admitted) $50 Co-pay then (waived if admitted) Medical Emergency Care in facility Covered Covered 100 % Covered 100 % Covered 100 % Covered Covered EMERGENCY SERVICES (Cont d) Medical Emergency Care in PCP Office $15 Co-pay; then 80% after $10 Co-pay then Covered after Covered after $10 Co-pay then AMBULANCE Covered Covered $25 Co-pay then Covered Covered Covered New Castle County Pre-65 Retirees/Pensioners Benefit Comparison 2019 Page 3 of 6

4 MENTAL HEALTH AND SUBSTANCE ABUSE Inpatient &/or Partial Hospital Care Covered. 80% after. Covered. Covered. Covered Covered. Office Visit (Out Patient) Covered 80% after. Covered 80% Covered after OTHER SERVICES Private Duty Nursing Covered; up to 240 hours per 12-month period (inpatient) 80% after ; up to 240 hours per 12- month period (inpatient) Covered for 240 hours in a 12- month period (inpatient) Hospice Covered Covered Covered up to 240 days Home Health Care Covered up to 240 Covered up to 240 Covered for up visits per calendar year. visits per calendar year to 100 visits per calendar year Prosthetic Devices 80% after. 80% after 80% Covered for the initial fitting and purchase only Covered 80% Covered for 240 hours in a 12-month period (inpatient) Covered up to 240 days 100 % Covered up to 240 visits 80% Covered after Covered 80% Covered for 240 hours in a 12-month period (inpatient) Covered up to 240 days 100 % Covered up to 240 visits Covered Outpatient coverage only. covered Covered Covered for up to 100 visits per calendar year 80% after 80% after 80% Covered for the initial fitting and purchase only Durable Medical Equipment, Hearing 80% after 80% after 80% Covered 80% Covered 80% Covered 80% Covered Aids 4 Skilled Nursing Facility Covered; up to 120 days per calendar year Covered; up to 120 days per calendar year Covered for 120 days (in lieu of hospitalization) Vision Exam Covered Not Covered. Covered One every 24 months Hearing Screening Covered Not Covered $10 Co-pay then With the PCP Covered for 120 days Covered for 120 days Covered for 120 days (in lieu of hospitalization) Covered Covered Covered One every 24 months Covered Covered $10 Co-pay then New Castle County Pre-65 Retirees/Pensioners Benefit Comparison 2019 Page 4 of 6

5 Health Education Programs Not Covered Not Covered $10 Co-pay then PRESCRIPTION DRUGS Express Scripts Not Covered Express Scripts Generic $5 copay Generic $5 copay Preferred $15 copay Preferred $15 copay Non-Preferred $30 copay Non-Preferred $30 90 day supply at retail or mail copay order for two copays 90 day supply at retail or mail order for two copays DEPENDENT CHILDREN Covered until the end of the month in which they turn 26. COBRA option available. Covered until the end of the month in which they turn 26. COBRA option available. Covered until the end of the month in which they turn 26. COBRA option available. Not Covered Not Covered $10 Co-pay then 80% Covered after Covered until the end of the month in which they turn 26. COBRA option available. 80% Covered after Covered until the end of the month in which they turn 26. COBRA option available. Generic $5 copay (1-30 day supply) $10 (31-90 day supply) Preferred Brand $15 copay (1-30 day supply) $30 (31-90 day supply Non-Preferred $30 (1-30 day supply) $60 (31-90 day supply) Covered until the end of the month in which they turn 26. COBRA option available. NOTES: 1. When calculating, coinsurance, copays and out of pocket maximums, only the allowable charges are considered. 2. Preventive Care services are limited to those listed on the Highmark Delaware Preventive Schedule. Gender, age, and frequency limits may apply. 3. Member cost share is based on the type of service performed and the place where it is rendered. 4. Hearing Aids are limited to one per impaired ear every 36 months. New Castle County Pre-65 Retirees/Pensioners Benefit Comparison 2019 Page 5 of 6

6 This is not a contract. This benefit comparison is intended to provide you with a general overview of Highmark Blue Cross Blue Shield Delaware s Comprehensive 80, Blue Choice PPO and EPO programs. The services, benefits, terms and conditions under which they are provided are contained in the group contract between the Corporations and New Castle County. New Castle County Pre-65 Retirees/Pensioners Benefit Comparison 2019 Page 6 of 6