SUMMARY OF MATERIAL MODIFICATION TO THE SUMMARY PLAN DESCRIPTION OF THE MEDICAL BENEFITS UNDER THE UTICA COLLEGE HEALTH BENEFITS PLAN

Transcription

1 SUMMARY OF MATERIAL MODIFICATION TO THE SUMMARY PLAN DESCRIPTION OF THE MEDICAL BENEFITS UNDER THE UTICA COLLEGE HEALTH BENEFITS PLAN This Summary of Material Modification describes changes, to the Summary Plan Description of the Medical Benefits under the Utica College Health Benefits Plan (the Plan ). After reading it, you should attach it to your copy of the Summary Plan Description. 1. Effective as of January 1, 2017, the Excellus BluePPO Plan, Excellus BluePPO Plan Signature Deduct 3 No Deductible Preventative Rx, and Excellus BluePPO Plan Signature Deduct 3 plans are offered. See the attached Benefit Summaries. 2. Effective as of January 1, 2017, the Answer to Question 4 in the Summary Plan Description What are the special enrollment periods? is changed as follows: Generally, the special enrollment periods allow employees who satisfy the eligibility requirements explained in the Answer to Question 1 to enroll in Plan coverage in the following situations: The employee initially declined Plan coverage because he had other health care coverage, but he later loses that other coverage through no fault of his own. The employee can enroll himself, his spouse (or eligible domestic partner) and eligible children. He must complete the enrollment form within thirty (30) days after losing the other health care coverage. Note, in order for this special enrollment rule to apply, at the time the employee initially declines Plan coverage he must provide, in writing, his reason for declining it. The employee initially declined Plan coverage because he had other health care coverage from another employer, but that employer stops contributing toward the cost of that other coverage. The employee can enroll himself, his spouse (or eligible domestic partner) and eligible children. The employee must complete the enrollment form within thirty (30) days after that employer stops contributing toward the cost of the other coverage. Note, in order for this special enrollment rule to apply, at the time he initially declines Plan coverage he must provide, in writing, his reason for declining it. 1 Copyright 2017 Lifetime Benefit Solutions, Inc.

2 The employee declined Plan coverage and he later acquires a new spouse (or eligible domestic partner) or a new eligible child (through birth or adoption of a child). The employee can enroll himself, his spouse (or eligible domestic partner) and eligible children. The employee must complete the enrollment form within thirty (30) days after the marriage, birth, adoption or placement for adoption. The employee, his spouse (or eligible domestic partner) or eligible children lose eligibility for Medicaid coverage or coverage under a State Children s Health Insurance Program. The employee must complete the enrollment form within sixty (60) days after the loss of that coverage. The employee, his spouse (or eligible domestic partner) or eligible children become eligible to participate in a premium assistance program under Medicaid or a State Children s Health Insurance Program. The employee must complete the enrollment form within sixty (60) days after that eligibility determination. 3. Effective as of January 1, 2017, the answer to Question and Answer 5 in the Summary Plan Description How much must participants pay for Plan coverage? is changed as follows. If there are ordinary increases or decreases in the premium, your payroll deductions will automatically be adjusted to reflect any change in your cost. Following is the current cost for this coverage. The Employer will provide participants with advance written notice of any changes to their cost. Medical Option Monthly Rate Employee Cost Employer Share Excellus PPO Single $1, $ $ Employee + 1 $2, $ $1, Family $2, $ $2, HealthyBlue Single $ $ $ Employee + 1 $1, $ $ Family $1, $ $1, Copyright 2017 Lifetime Benefit Solutions, Inc.

3 Medical Option Monthly Rate Employee Cost Employer Share Single $ $ $ Employee + 1 $1, $ $1, Family $1, $ $1, The explanation of COBRA Continuation Coverage beginning on page 22 of the Summary Plan Description in the Answer to Question 17 What additional rights does a participant have? is changed as follows: COBRA Continuation Coverage This section has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. It explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-ofpocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse s plan), even if that plan generally doesn t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a qualifying event. Specific qualifying events are listed below. After a qualifying event, COBRA continuation coverage must be offered to each person who is a qualified beneficiary. You, your spouse, and your dependent children could become 3 Copyright 2017 Lifetime Benefit Solutions, Inc.

4 qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you re an employee, you ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: (1) Your hours of employment are reduced; or (2) Your employment ends for any reason other than your gross misconduct. If you re the spouse of an employee, you ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: (1) Your spouse dies; (2) Your spouse's hours of employment are reduced; (3) Your spouse's employment ends for any reason other than his or her gross misconduct; (4) Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or (5) You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: (1) The parent-employee dies; (2) The parent-employee's hours of employment are reduced; (3) The parent-employee's employment ends for any reason other than his or her gross misconduct; (4) The parent-employee becomes enrolled in Medicare (Part A, Part B, or both); (5) The parents become divorced or legally separated; or (6) The child stops being eligible for coverage under the Plan as a dependent child. Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to the Employer and that bankruptcy results in the loss of any retired employee s coverage under the Plan, the retired employee is a qualified beneficiary. The retired employee's spouse, surviving spouse, and dependent children will also be qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. 4 Copyright 2017 Lifetime Benefit Solutions, Inc.

5 When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The Employer must notify the Plan Administrator of the following qualifying events. The end of employment or reduction of hours of employment; Death of the employee; Commencement of a proceeding in bankruptcy with respect to the employer; or The employee s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a child's losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Benefits Coordinator, Utica College, 1600 Burrstone Road, Utica, New York, The notice must be in writing, and must contain your name and address, the name and address of any affected persons, a description of the qualifying event, and the date of the qualifying event. You may be asked to provide additional documentation or information after you have submitted the notice. How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each qualified beneficiary. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. 5 Copyright 2017 Lifetime Benefit Solutions, Inc.

6 There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration ( SSA ) to be disabled and you provide proper and timely notice of the SSA determination, you and your entire family may be entitled to get up to an additional 11 months of COBRA coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. You must provide this notice to the Benefits Coordinator, Utica College, 1600 Burrstone Road, Utica, New York, within 60 days of the date of the SSA determination and before the end of the 18-month period of COBRA continuation coverage. The notice must be in writing, and must contain your name and address, the name and address of the disabled qualified beneficiary, and the date the disability was determined to have begun. You must also attach a copy of the SSA determination. You may be asked to provide additional documentation or information after you have submitted the notice. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified of the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. You must provide this notice to the Benefits Coordinator, Utica College, 1600 Burrstone Road, Utica, New York, within 60 days after the second qualifying event. The notice must be in writing, and must contain your name and address, the name and address of any affected persons, a description of the second qualifying event, and the date of the second qualifying event. You may be asked to provide additional documentation or information after you have submitted the notice. 6 Copyright 2017 Lifetime Benefit Solutions, Inc.

7 Are there other coverage options besides COBRA continuation coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website.) For more information about the Marketplace, visit Keep your Plan informed of address changes To protect your family's rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information Information about the Plan and COBRA continuation coverage can be obtained from: Utica College Health Benefits Plan Benefits Coordinator Utica College 1600 Burrstone Road Utica, New York (315) Copyright 2017 Lifetime Benefit Solutions, Inc.

8 Refer to the attached 2017 Excellus BlueCross BlueShield 3-Tier Formulary Guide and Preventative Drug List. To access current Participating Provider information (free of charge), go to the following website: Excellus BlueCross BlueShield Upon request, copies of the provider lists will be furnished to you, without charge, as a separate document. 8 Copyright 2017 Lifetime Benefit Solutions, Inc.

9 Excellus BluePPO $5/$15/$30 Benefit Time Period: 01/01/ /31/2017 UTICA COLLEGE General Information Cost Sharing Expenses Deductible - Single $0 $750 Deductible - Family $0 $2,250 Each individual does not exceed the single deductible. 0% 30% Annual Out of Pocket Maximum - Single $4,200 $4,200 Annual Out of Pocket Maximum - Family $12,600 $12,600 Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-ofpocket maximums exclude balances over allowable expense and non-covered services. Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-ofpocket maximums exclude balances over allowable expense and non-covered services. Office Visit Cost Shares Cost Share - Primary Care Cost Share - Specialist $20 Copayment $20 Copayment Plan Limits Plan/Calendar Year Diabetic Preauthorization and Step Therapy Calendar Year Benefits Yes Who is Covered Domestic Partner Coverage Covered 1 of /29/ :12:38

10 Inpatient Services Inpatient Facility Inpatient Hospital Services Mental Health Care Substance Use Detoxification Skilled Nursing Facility Covered in Covered in Covered in Covered in Physical Rehabilitation Covered in Covered in Maternity Care Covered in 45 Days Per Year Limits are combined INN and OON. 60 Days per year Limits are combined INN and OON. Inpatient Professional Services Inpatient Hospital Surgery Anesthesia Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. Outpatient Facility Services Outpatient Facility Services SurgiCenters and Freestanding Ambulatory Centers Surgical Care Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy $20 Copayment $20 Copayment Covered in Covered in Covered in Infusion Therapy Inclusive of Primary Service Inclusive of Primary Service Dialysis Mental Health Care Substance Use Care Covered in $20 Copayment $20 Copayment Advanced Imaging Services includes PET scans, MRI, nuclear medicine, and CAT scans. Is inclusive in the Home Care benefit and not covered as a separate benefit. Includes Partial Hospitalization Includes Partial Hospitalization Home and Hospice Care Home Care Home Care Covered in 25% Subject to $50 Deductible Limits are combined INN and OON. 2 of /29/ :12:38

11 Hospice Care Hospice Care Inpatient Covered in Outpatient and Office Professional Services Professional Services Office Surgery Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Dialysis Mental Health Care Maternity Care TeleMedicine Program Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine PCP/Specialist - $20 Copayment PCP/Specialist - $20 Copayment PCP/Specialist - Inclusive of Primary Service PCP/Specialist - $20 Copayment PCP/Specialist - $10 Copayment PCP/Specialist - $20 Copayment PCP/Specialist - $20 Copayment Inclusive of Primary Service Not Covered PCP/Specialist - Not Covered Not Covered Is inclusive in the Home Care benefit and not covered as a separate benefit. Covers online internet consultations between the member and the providers who participate in our telemedicine program for medical conditions that are not an emergency condition. Allergy Testing includes injections and scratch and prick tests. Includes desensitization treatments (injections & serums). Not Covered Limits are combined INN and OON. Rehab and Habilitation Outpatient Facility Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation $20 Copayment $20 Copayment $20 Copayment 45 Visits per year Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 45 Visits per year 45 Visits per year 3 of /29/ :12:38

12 Outpatient Professional Services Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation PCP/Specialist - $20 Copayment PCP/Specialist - $20 Copayment PCP/Specialist - $20 Copayment 45 Visits per year Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 45 Visits per year 45 Visits per year Preventive Services Preventive Professional Services Meeting Federal Guidelines* Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Pre/Post-Natal Care Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional Not Covered Covered in 1 Exam per year Preventive Facility Services Meeting Federal Guidelines* Cervical Cytology Preventative Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility Covered in Covered in Covered in Covered in Preventive services in addition to those required under Federal Guidelines - Professional Prostate Cancer Screening Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional PCP/Specialist - $20 Copayment PCP/Specialist - $20 Copayment 4 of /29/ :12:38

13 Preventive services in addition to those required under Federal Guidelines - Facility Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility Covered in $20 Copayment $20 Copayment Other Benefits Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Equipment Durable Medical Equipment (DME) Medical Supplies Acupuncture PCP/Specialist - $20 Copayment PCP/Specialist - $20 Copayment PCP/Specialist - 20% PCP/Specialist - 20% PCP/Specialist - Not Covered Not Covered Private Duty Nursing PCP/Specialist - Not Covered Not Covered Not Covered Limited to a 30 day supply for retail pharmacy or a 90 day supply for mail order pharmacy. Not Covered Limits combined INN and OON. Emergency Services ER Facility Facility Emergency Room Visit $50 Copayment $50 Copayment Prior Authorization may not apply to any emergency care services. Emergency services are covered worldwide if provided by a hospital facility. Transportation Prehospital Emergency and Transportation - Ground or Water $20 Copayment $20 Copayment Urgent Care Urgent Care Center Facility Visit $25 Copayment 5 of /29/ :12:38

14 Ancillary Benefits Vision Adult Eye Exams - Routine $20 Copayment Adult Eyewear - Routine Not Covered Not Covered Pediatric Eye Exams - Routine $20 Copayment Pediatric Eyewear - Routine Not Covered Not Covered 1 Exam per calendar year Limits are combined INN and OON. Not Covered Includes Frames/Lenses or Contact Lenses 1 Exam per calendar year Limits are combined INN and OON. Not Covered Includes Frames/Lenses or Contact Lenses Rx Benefits Rx Plan Rx Plan $5/$15/$30 Rx Benefits Days Supply Per Retail Order 30 Days Supply Per Mail Order 90 Copays Per Mail Order Supply 2 This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined by the terms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of the contract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits are combined limits for both in and out of network benefits. * For non-grandfathered groups, Preventive Services coverage required by the Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive Services Task Force list of items and services rated "A" or "B" that are covered pursuant to the Patient Protection and Affordable Care Act requirements. 6 of /29/ :12:38

15 Excellus BluePPO Signature Deduct 3 $5/$35/$70, $0 gen for kids Integrated Rx, No Ded Prev Rx Benefit Time Period: 01/01/ /31/2017 UTICA COLLEGE General Information Cost Sharing Expenses Deductible - Single $1,800 $3,600 Deductible - Family $3,600 $7,200 10% 20% Annual Out of Pocket Maximum - Single $3,600 $7,200 Annual Out of Pocket Maximum - Family $7,200 $14,400 Annual Out of Pocket Maximum - Per Person Cap $6,550 $14,400 Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-ofpocket maximums exclude balances over allowable expense and non-covered services. Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-ofpocket maximums exclude balances over allowable expense and non-covered services. The Out-of-Pocket Maximum Per Person Cap includes deductible, coinsurance, copays and prescription drugs. If a member under a family contract meets the Out-Of-Pocket Maximum Per Person Cap amount, the individual will no longer pay for covered services and claims will be paid at 100% of the allowable amount by the Health Plan for the remainder of the plan year. The remaining annual out-of-pocket maximum still needs to be met by any combination of family members on the contract before claims are paid at 100% for the whole family. Office Visit Cost Shares Cost Share - Primary Care Cost Share - Specialist Plan Limits Plan/Calendar Year Diabetic Preauthorization and Step Therapy Calendar Year Benefits Yes Who is Covered Domestic Partner Coverage Covered 1 of /02/ :46:36

16 Inpatient Services Inpatient Facility Inpatient Hospital Services Mental Health Care Substance Use Detoxification Skilled Nursing Facility Physical Rehabilitation Maternity Care 45 Days per contract year Limits are combined INN and OON. 60 Days per year Limits are combined INN and OON. Inpatient Professional Services Inpatient Hospital Surgery Anesthesia Subject to $1,800 Deductible Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. Outpatient Facility Services Outpatient Facility Services SurgiCenters and Freestanding Ambulatory Centers Surgical Care Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Inclusive of Primary Service Inclusive of Primary Service Dialysis Mental Health Care Substance Use Care Is inclusive in the Home Care benefit and not covered as a separate benefit. Includes Partial Hospitalization Includes Partial Hospitalization Home and Hospice Care Home Care Home Care Hospice Care 2 of /02/ :46:36

17 Hospice Care Inpatient Outpatient and Office Professional Services Professional Services Office Surgery Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Dialysis Mental Health Care Maternity Care TeleMedicine Program Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine PCP/Specialist - Inclusive of Primary Service Inclusive of Primary Service Not Covered Is inclusive in the Home Care benefit and not covered as a separate benefit. Covers online internet consultations between the member and the providers who participate in our telemedicine program for medical conditions that are not an emergency condition. Allergy Testing includes injections and scratch and prick tests. Includes desensitization treatments (injections & serums). 1 Exam per contract year Limits are combined INN and OON. 3 of /02/ :46:36

18 Rehab and Habilitation Outpatient Facility Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 45 Visits per contract year Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 45 Visits per contract year 45 Visits per contract year Outpatient Professional Services Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 45 Visits per contract year Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 45 Visits per contract year 45 Visits per contract year Preventive Services Preventive Professional Services Meeting Federal Guidelines* Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Pre/Post-Natal Care Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional Covered in 1 Exam per year Preventive Facility Services Meeting Federal Guidelines* Cervical Cytology Preventative Mammography Screening Facility Colonoscopy Screening Facility Covered in Covered in Covered in 4 of /02/ :46:36

19 Bone Density Screening Facility Covered in Preventive services in addition to those required under Federal Guidelines - Professional Prostate Cancer Screening Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional Preventive services in addition to those required under Federal Guidelines - Facility Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility Covered in Covered in Other Benefits Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Equipment Durable Medical Equipment (DME) Medical Supplies Acupuncture PCP/Specialist - Not Covered Not Covered Not Covered Private Duty Nursing PCP/Specialist - Not Covered Not Covered Not Covered Limited to a 90 day supply for retail pharmacy or a 90 day supply for mail order pharmacy. Emergency Services ER Facility Facility Emergency Room Visit Subject to $1,800 Deductible Prior Authorization may not apply to any Emergency services are covered worldwide if provided by a hospital facility. 5 of /02/ :46:36

20 Transportation Prehospital Emergency and Transportation - Ground or Water Subject to $1,800 Deductible Urgent Care Urgent Care Center Facility Visit Ancillary Benefits Vision Adult Eye Exams - Routine 1 exam per contract year Adult Eyewear - Routine Not Covered Not Covered Not Covered Pediatric Eye Exams - Routine 1 exam per contract year Pediatric Eyewear - Routine Not Covered Not Covered Not Covered Rx Benefits Rx Plan Rx Plan $5/$35/$70, $0 gen for kids Integrated Rx, No Ded Prev Rx Rx Benefits Days Supply Per Retail Order 30 Days Supply Per Mail Order 90 Copays Per Mail Order Supply 2 This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined by the terms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of the contract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits are combined limits for both in and out of network benefits. * For non-grandfathered groups, Preventive Services coverage required by the Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive Services Task Force list of items and services rated "A" or "B" that are covered pursuant to the Patient Protection and Affordable Care Act requirements. 6 of /02/ :46:36

21 Excellus BluePPO Signature Deduct 3 $5/$35/$70, $0 gen for kids Integrated Rx Benefit Time Period: 01/01/ /31/2017 Utica College General Information Cost Sharing Expenses Deductible - Single $1,800 $3,600 Deductible - Family $3,600 $7,200 10% 20% Annual Out of Pocket Maximum - Single $3,600 $7,200 Annual Out of Pocket Maximum - Family $7,200 $14,400 Annual Out of Pocket Maximum - Per Person Cap $6,550 $14,400 Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-ofpocket maximums exclude balances over allowable expense and non-covered services. Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-ofpocket maximums exclude balances over allowable expense and non-covered services. The Out-of-Pocket Maximum Per Person Cap includes deductible, coinsurance, copays and prescription drugs. If a member under a family contract meets the Out-Of-Pocket Maximum Per Person Cap amount, the individual will no longer pay for covered services and claims will be paid at 100% of the allowable amount by the Health Plan for the remainder of the plan year. The remaining annual out-of-pocket maximum still needs to be met by any combination of family members on the contract before claims are paid at 100% for the whole family. Office Visit Cost Shares Cost Share - Primary Care Cost Share - Specialist Plan Limits Plan/Calendar Year Diabetic Preauthorization and Step Therapy Calendar Year Benefits Yes Who is Covered Domestic Partner Coverage Covered 1 of /04/ :13:18

22 Inpatient Services Inpatient Facility Inpatient Hospital Services Mental Health Care Substance Use Detoxification Skilled Nursing Facility Physical Rehabilitation Maternity Care 45 Days per contract year Limits are combined INN and OON. 60 Days per year Limits are combined INN and OON. Inpatient Professional Services Inpatient Hospital Surgery Anesthesia Subject to $1,800 Deductible Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. Outpatient Facility Services Outpatient Facility Services SurgiCenters and Freestanding Ambulatory Centers Surgical Care Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Inclusive of Primary Service Inclusive of Primary Service Dialysis Mental Health Care Substance Use Care Is inclusive in the Home Care benefit and not covered as a separate benefit. Includes Partial Hospitalization Includes Partial Hospitalization Home and Hospice Care Home Care Home Care Hospice Care 2 of /04/ :13:18

23 Hospice Care Inpatient Outpatient and Office Professional Services Professional Services Office Surgery Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Dialysis Mental Health Care Maternity Care TeleMedicine Program Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine PCP/Specialist - Inclusive of Primary Service Inclusive of Primary Service Not Covered Is inclusive in the Home Care benefit and not covered as a separate benefit. Covers online internet consultations between the member and the providers who participate in our telemedicine program for medical conditions that are not an emergency condition. Allergy Testing includes injections and scratch and prick tests. Includes desensitization treatments (injections & serums). 1 Exam per contract year Limits are combined INN and OON. 3 of /04/ :13:18

24 Rehab and Habilitation Outpatient Facility Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 45 Visits per contract year Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 45 Visits per contract year 45 Visits per contract year Outpatient Professional Services Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 45 Visits per contract year Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 45 Visits per contract year 45 Visits per contract year Preventive Services Preventive Professional Services Meeting Federal Guidelines* Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Pre/Post-Natal Care Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional Covered in 1 Exam per year Preventive Facility Services Meeting Federal Guidelines* Cervical Cytology Preventative Mammography Screening Facility Colonoscopy Screening Facility Covered in Covered in Covered in 4 of /04/ :13:18

25 Bone Density Screening Facility Covered in Preventive services in addition to those required under Federal Guidelines - Professional Prostate Cancer Screening Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional Preventive services in addition to those required under Federal Guidelines - Facility Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility Covered in Covered in Other Benefits Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Equipment Durable Medical Equipment (DME) Medical Supplies Limited to a 90 day supply for retail pharmacy or a 90 day supply for mail order pharmacy. Acupuncture PCP/Specialist - Not Covered Not Covered Private Duty Nursing PCP/Specialist - Not Covered Not Covered Not Covered Emergency Services ER Facility Facility Emergency Room Visit Subject to $1,800 Deductible Prior Authorization may not apply to any Emergency services are covered worldwide if provided by a hospital facility. 5 of /04/ :13:18

26 Transportation Prehospital Emergency and Transportation - Ground or Water Subject to $1,800 Deductible Urgent Care Urgent Care Center Facility Visit Ancillary Benefits Vision Adult Eye Exams - Routine 1 exam per contract year Adult Eyewear - Routine Not Covered Not Covered Not Covered Pediatric Eye Exams - Routine 1 exam per contract year Pediatric Eyewear - Routine Not Covered Not Covered Not Covered Rx Benefits Rx Plan Rx Plan $5/$35/$70, $0 gen for kids Integrated Rx Rx Benefits Days Supply Per Retail Order 30 Days Supply Per Mail Order 90 Copays Per Mail Order Supply 2 This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined by the terms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of the contract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits are combined limits for both in and out of network benefits. * For non-grandfathered groups, Preventive Services coverage required by the Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive Services Task Force list of items and services rated "A" or "B" that are covered pursuant to the Patient Protection and Affordable Care Act requirements. 6 of /04/ :13:18

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