Individual & Family Products Comparison Chart

Transcription

1 Individual & Family Products 2014 Comparison Chart

2 Plan Description All Plan Features: Our 6 unique plans are designed for Arizonans in every stage of life. Choose a plan that works best for you or your family. Each plan has the choice of our large and broad statewide network of doctors. All of the plans cover in-network preventive care services and kids dental check-ups at no out-of-pocket cost to you. plan offers fixed copays and fees for many of the healthcare services you and your family use most when you use an in-network provider. This includes doctor visits, urgent care, prescriptions, vision checks, and more. Choose from four plan options to match your budget. CopayComplete When you need healthcare, it helps to know how much it will cost. With CopayComplete, you simply pay a set copayment for each covered service received from an innetwork provider. This simple-to-use plan with $0 in-network covers doctor visits, eye checks, prescriptions, diagnostic tests, and urgent, emergency and maternity care. FitRewards With FitRewards, you get a plan that pays you back. Earn $20 each month you exercise regularly at your favorite gym. Just submit a form showing you went to a gym or fitness facility at least 8 times in a month and we ll send you a check.* Your in-network primary care visits, eye exams and most prescriptions are covered at low copays too. Essential Many of your basic care needs are covered at a lower cost by having an Essential plan. This means you pay fixed copays for the first three in-network primary and specialist care office visits each year. You also have a set cost for in-network urgent care, eye checks, and most prescriptions. Choose one of four options that fit your budget. Portfolio Take charge of your own healthcare dollars like you do your budget. These high-, low-premium Portfolio plans are designed to work with a Health Savings Account (HSA) from a qualified financial institution. Each of the four plans covers many in-network preventive care services at no charge. Select the level that fits your budget. SimpleHealth You re never too young for health insurance. A SimpleHealth plan is great for members under age 30.** It provides coverage when you re sick and helps you stay well, covering most in-network preventive care services at no out-of-pocket cost to you. This plan gives you three visits to your primary care doctor for a low copay. Many services are covered at no cost after you meet your. This chart shows your in-network cost share amount. It s what you pay for care from a provider who is part of the BCBSAZ network. Your cost share and will be higher if you get care from an out-of-network provider. Also, when you go out-of-network, you usually have to pay the difference between what the provider charges and the allowed amount (called the balance bill ). For example: if an out-of-network hospital charges $1,500 for a service and the allowed amount is $1,000, you may have to pay the $500 difference, plus your out-of-network cost share. All of our plans are available with our extensive BCBSAZ statewide provider network. A few plans are also available at a lower cost with one of our two High Performance Networks, called Alliance and Select. If you choose the Alliance or Select network, most Arizona in-network doctors and hospitals are located in Maricopa County. Doctors and hospitals in the Alliance and Select networks can deliver more integrated care because they are part of a smaller, more localized and more integrated network. This is how BCBSAZ lowers the cost of services, passing the savings on to you with lower premiums for plans with these High Performance Networks. If your doctors are in Maricopa County, there s a good chance they re in one of these two networks. Alliance Network: The Alliance Network includes hospitals and doctors that are part of Banner Health and Scottsdale Healthcare. Select Network: The Select Network includes hospitals and doctors that are part of Phoenix Children s Hospital, Dignity Health, IASIS Healthcare, and Abrazo Health. This is only a brief summary of the benefit plans, and is designed to help you compare features of different plans. All plans are subject to the limitations and exclusions listed on page 10 of this summary. More detailed information about benefits, cost share, exclusions and limitations is in the benefit plan booklets and plan Summary of Benefits and Coverage (SBC), and is available prior to enrollment, on request. If the terms of this summary differ from the terms of the benefit plan booklets, the terms of the booklets control and apply. *FitReward s Exercise Rewards program is administered by American Specialty Health Fitness. American Specialty Health Fitness (ASHN) is an independent company that is contracted with BCBSAZ to administer the FitRewards ExerciseRewards program. For more information about the ASHN program, visit **SimpleHealth is available only to people under age 30, or to people who receive an exemption from the individual mandate through the Health Insurance Marketplace 2

3 Set costs for the most common health care needs such as doctor visits and prescriptions when you use in-network providers. Calendar Year Deductible The amount you pay for covered services before the plan begins to pay. After you meet the, you pay coinsurance. Copays are separate from the and do not count towards the $1,000/member and $2,000/family $4,000/member and $8,000/family 6000 $6,000/member and $12,000/family Metal Level Gold ($$$) Silver ($$) Silver ($$) Bronze ($) Provider Networks Available Coinsurance Percentage paid for certain covered services after meeting the, unless a copay or different coinsurance applies. Out-of-Pocket Limit The most you will pay in a calendar year for all covered services. This does not include premiums, precertification charges, or balance-bills. Primary Care Physician/ Pediatrician Includes internal medicine, family practice, general practice, and pediatricians. All other physicians are specialists. Specialist A physician or other health care professional who practices in a specific area other than those practiced by primary care providers. Urgent Care Visit Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Preventive Services Performed for screening purposes before any signs or symptoms of a condition or disease appear. The physician determines whether a service is considered preventive. Prescription Drugs Statewide PPO, Select, Alliance Statewide PPO, Select, Alliance Statewide PPO, Select, Alliance Statewide PPO, Select, Alliance 20% after 20% after 20% after 20% after $4,500/member and $9,000/family $4,500/member and $9,000/family $20 copay $30 copay $30 copay $40 copay $40 copay $60 copay $60 copay $80 copay $60 copay $60 copay $60 copay $80 copay No charge No charge No charge No charge Tier 2: $40 copay Tier 3: $80 copay Tier 1: $25 copay Tier 2: $50 copay Tier 3: $100 copay Tier 2: $50 copay Tier 3: $100 copay Tier 1: $25 copay Tier 2: $80 copay Tier 3: $160 copay Surgery (Inpatient/Outpatient) 20% after 20% after 20% after 20% after Emergency Room Visit Emergency services obtained in an emergency room. $250 copay $500 copay $350 copay $500 copay Ambulance 20% 20% 20% 20% Maternity $40 copay for all services included in the physician s global delivery charge, and 20% after for all other services $60 copay for all services included in the physician s global delivery charge, and 20% after for all other services $60 copay for all services included in the physician s global delivery charge, and 20% after for all other services $80 copay for all services included in the physician s global delivery charge, and 20% after for all other services Routine Vision 1 exam per year $20 copay $30 copay $30 copay $40 copay Pediatric Dental 2 check-ups and cleanings per year. Services covered for members under age 19. Dental Check-up: No charge Basic/Major Dental Care and Orthodontia: 50% after or no charge after 50% after 50% after 50% after 3

4 CopayComplete A $0 plan with convenient and predictable costs for most health care services obtained from in-network providers. Calendar Year Deductible The amount you pay for covered services before the plan begins to pay. After you meet the, you pay coinsurance. Copays are separate from the and do not count towards the. CopayComplete 20 CopayComplete 40 $0/member and $0/family $0/member and $0/family Metal Level Gold ($$$) Silver ($$) Provider Networks Available Statewide PPO, Select, Alliance Statewide PPO, Select, Alliance Out-of-Pocket Limit The most you will pay in a calendar year for all covered services. This does not include premiums, precertification charges, or balance-bills. Primary Care Physician/Pediatrician Includes internal medicine, family practice, general practice, and pediatricians. All other physicians are specialists. Specialist A physician or other health care professional who practices in a specific area other than those practiced by primary care providers. Urgent Care Visit Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Preventive Services Performed for screening purposes before any signs or symptoms of a condition or disease appear. The physician determines whether a service is considered preventive. Prescription Drugs Inpatient Stay $20 copay $40 copay $50 copay $80 copay $60 copay $80 copay No charge Tier 2: $45 copay Tier 3: $90 copay $500 each day for the first 4 days then no charge No charge Tier 1: $25 copay Tier 2: $70 copay Tier 3: $160 copay $1,000 each day for the first 4 days then no charge Outpatient Surgery $500 copay $500 copay Emergency Room Visit Emergency services obtained in an emergency room. $300 copay $500 copay Ambulance $150 copay $250 copay Maternity $50 copay for all services included in the physician s global delivery charge, and applicable copays for all other services. $80 copay for all services included in the physician s global delivery charge, and applicable copays for all other services. Routine Vision 1 exam per year $20 copay $40 copay Pediatric Dental 2 check-ups and cleanings per year. Services covered for members under age % after 50% after 4

5 FitRewards This plan has fixed costs for in-network primary care visits and most prescriptions, plus members can receive a $20 check for going to the gym 8 times a month. Calendar Year Deductible The amount you pay for covered services before the plan begins to pay. After you meet the, you pay coinsurance. Copays are separate from the and do not count towards the. FitRewards 1500 FitRewards 3000 FitRewards 4000 FitRewards 6000 $1,500/member and $3,000/family $4,000/member and $8,000/family $6,000/member and $12,000/family Metal Level Gold ($$$) Silver ($$) Silver ($$) Bronze ($) Provider Networks Available Statewide PPO Statewide PPO Statewide PPO Statewide PPO Coinsurance Percentage paid for certain covered services after meeting the, unless a copay or different coinsurance applies. Out-of-Pocket Limit The most you will pay in a calendar year for all covered services. This does not include premiums, precertification charges, or balance-bills. Primary Care Physician/ Pediatrician Includes internal medicine, family practice, general practice, and pediatricians. All other physicians are specialists. Specialist A physician or other health care professional who practices in a specific area other than those practiced by primary care providers. Urgent Care Visit Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Preventive Services Performed for screening purposes before any signs or symptoms of a condition or disease appear. The physician determines whether a service is considered preventive. Prescription Drugs 30% after 20% after 20% after 30% after $10 copay $15 copay $10 copay $15 copay 30% after 20% after 20% after 30% after $60 copay $60 copay $60 copay $75 copay No charge No charge No charge No charge Tier 1: $10 copay Tier 2: $55 copay Tier 3: $95 copay Tier 2: $55 copay Tier 3: $110 copay Tier 1: $10 copay Tier 2: $45 copay Tier 3: $90 copay Tier 2: $90 copay Tier 3: $180 copay Surgery (Inpatient/Outpatient) 30% after 20% after 20% after 30% after Emergency Room Visit Emergency services obtained in an emergency room. 30% after 20% after 20% after 30% after Ambulance 30% 20% 20% 30% Maternity 30% after 20% after 20% after 30% after Routine Vision 1 exam per year $10 copay $15 copay $10 copay $15 copay Pediatric Dental 2 check-ups and cleanings per year. Services covered for members under age % after 50% after 50% after 50% after 5

6 Essential The first three in-network doctor office visits and most in-network generic prescription medications are covered with minimal cost. Calendar Year Deductible The amount you pay for covered services before the plan begins to pay. After you meet the, you pay coinsurance. Copays are separate from the and do not count towards the. Essential 1500 Essential 3000 Essential 4000 Essential 6000 $1,500/member and $3,000/family $4,000/member and $8,000/family $6,000/member and $12,000/family Metal Level Gold ($$$) Silver ($$) Silver ($$) Bronze ($) Provider Networks Available Statewide PPO Statewide PPO Statewide PPO Statewide PPO Coinsurance Percentage paid for certain covered services after meeting the, unless a copay or different coinsurance applies. Out-of-Pocket Limit The most you will pay in a calendar year for all covered services. This does not include premiums, precertification charges, or balance-bills. Primary Care Physician/Pediatrician/ Specialist Includes internal medicine, family practice, general practice, and pediatricians. All other physicians are specialists. Urgent Care Visit Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Preventive Services Performed for screening purposes before any signs or symptoms of a condition or disease appear. The physician determines whether a service is considered preventive. Prescription Drugs 20% after 20% after 20% after 30% after $25 for first three office visits then 20% after $30 for first three office visits then 20% after $25 for first three office visits then 20% after $35 for first three office visits then 30% after $60 copay $60 copay $60 copay $75 copay No charge No charge No charge No charge Tier 2: $40 copay Tier 3: $90 copay Tier 2: $40 copay Tier 3: $90 copay Tier 1: $10 copay Tier 2: $25 copay Tier 3: $50 copay Tier 1: $25 copay Tier 2: $60 copay Tier 3: $120 copay Surgery (Inpatient/Outpatient) 20% after 20% after 20% after 30% after Emergency Room Visit Emergency services obtained in an emergency room. 20% after 20% after 20% after 30% after Ambulance 20% 20% 20% 30% Maternity 20% after 20% after 20% after 30% after Routine Vision 1 exam per year $25 copay $30 copay $25 copay $30 copay Pediatric Dental 2 check-ups and cleanings per year. Services covered for members under age % after 50% after 50% after 50% after 6

7 Portfolio Calendar Year Deductible The amount you pay for covered services before the plan begins to pay. After you meet the, you pay coinsurance. Copays are separate from the and do not count towards the. Portfolio 1500 Portfolio 2500 Portfolio 3500 Portfolio 5500 $1,500/member and $3,000/family $2,500/member and $5,000/family $3,500/member and $7,000/family $5,500/member and $11,000/family Metal Level Gold ($$$) Silver ($$) Silver ($$) Bronze ($) Provider Networks Available Statewide PPO Statewide PPO Statewide PPO Statewide PPO Coinsurance Percentage paid for certain covered services after meeting the, unless a copay or different coinsurance applies. Out-of-Pocket Limit The most you will pay in a calendar year for all covered services. This does not include premiums, precertification charges, or balance-bills. Primary Care Physician/ Pediatrician Includes internal medicine, family practice, general practice, and pediatricians. All other physicians are specialists. Specialist A physician or other health care professional who practices in a specific area other than those practiced by primary care providers. Urgent Care Visit Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Preventive Services Performed for screening purposes before any signs or symptoms of a condition or disease appear. The physician determines whether a service is considered preventive. 10% after 20% after No charge after No charge after $4,500/member and $9,000/family $3,500/member and $7,000/family $5,500/member and $11,000/family 10% after 20% after No charge after No charge after 10% after 20% after No charge after No charge after 10% after 20% after No charge after No charge after No charge No charge No charge No charge Prescription Drugs 10% after 20% after No charge after No charge after Surgery (Inpatient/Outpatient) 10% after 20% after No charge after No charge after Emergency Room Visit Emergency services obtained in an emergency room. 10% after 20% after No charge after No charge after Ambulance 10% after 20% after No charge after No charge after Maternity 10% after 20% after No charge after No charge after Routine Vision 1 exam per year 10% after 20% after No charge after No charge after Pediatric Dental 2 check-ups and cleanings per year. Services covered for members under age 19. A low premium plan eligible for use with a Health Savings Account (HSA) from a qualified financial institution. This plan provides flexibility on how your healthcare dollars are spent while offering potential tax savings when paired with an HSA. Many in-network preventive services are covered at no out-of-pocket cost to you. No charge after 50% after No charge after 50% after Dental Check-up: No charge Basic/Major Dental Care and Orthodontia: No charge after Dental Check-up: No charge Basic/Major Dental Care and Orthodontia: No charge after 7

8 SimpleHealth Available only to people under age 30 or who receive an exemption from the individual mandate through the Health Insurance Marketplace. The first 3 office visits to your in-network primary care doctor are covered at copay. Calendar Year Deductible The amount you pay for covered services before the plan begins to pay. After you meet the, you pay coinsurance. Copays are separate from the and do not count towards the. SimpleHealth Metal Level Catastrophic ($) Provider Networks Available Out-of-Pocket Limit The most you will pay in a calendar year for all covered services. This does not include premiums, precertification charges, or balance-bills. Primary Care Physician/Pediatrician Includes internal medicine, family practice, general practice, and pediatricians. All other physicians are specialists. Specialist A physician or other health care professional who practices in a specific area other than those practiced by primary care providers. Urgent Care Visit Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Preventive Services Performed for screening purposes before any signs or symptoms of a condition or disease appear. The physician determines whether a service is considered preventive. Prescription Drugs Surgery (Inpatient/Outpatient) Emergency Room Visit Emergency services obtained in an emergency room. Ambulance Maternity Routine Vision 1 exam per year Pediatric Dental 2 check-ups and cleanings per year. Services covered for members under age 19. Statewide PPO/Select/Alliance $20 for first three office visits then no charge after No charge after No charge after No charge No charge after No charge after No charge after No charge after No charge after No charge after No charge 8

9 IMPORTANT INFORMATION Allowed Amount All claims are processed using the BCBSAZ Allowed Amount. BCBSAZ reimbursement, member cost share payments, and accumulations toward s and out-of-pocket limits are calculated on the BCBSAZ Allowed Amount. The allowed amount is the total amount of reimbursement allocated to a covered service and includes both the BCBSAZ payment and the member cost share payment. It does not include any balance bill. The allowed amount is based on BCBSAZ or other fee schedules. It is not tied to and does not necessarily reflect a provider s regular billed charges. Balance Bill This is the difference between the BCBSAZ allowed amount and a noncontracted provider s billed charge. Any time you see a noncontracted provider, you are responsible for the balance bill. Any amounts paid for balance bills do not count toward any, coinsurance, or out-of-pocket limit. Providers, claims, and out-of-pocket costs: Each plan allows members to go to in and out-of-network providers. Network providers are independent contractors exercising independent medical judgment and are not employees, agents or representatives of BCBSAZ. BCBSAZ has no control over any diagnosis, treatment or service rendered by any provider. In-network providers will file members claims and generally cannot charge more than the allowed amount for covered services. Members have lower out-of-pocket costs for covered services when they use in-network providers. Noncontracted providers can charge members full billed charges, which will include the difference between the BCBSAZ allowed amount and the provider s regular billed charges ( the balance bill ). Members are responsible for paying up to a noncontracted provider s billed charges for covered services, even though BCBSAZ will reimburse members claims based on the allowed amount, less any deduction for the member s cost share portion. Emergency Services For emergency services, you will pay your in-network cost share, even if services received are from out-of-network providers. Except for Aliance and Select network plans, if you receive emergency services from a noncontracted provider, you will also be responsible for the balance bill, which may be substantial. Precertification Some services and medications require precertification. Except for emergencies, urgent care, and maternity admissions, precertification is always required for inpatient admissions (acute care, behavioral health, long term acute care, extended active rehabilitation, and skilled nursing facilities) home health services, and most specialty medications. Precertification may be required for other covered services and medications. The member is responsible for making sure his or her physician obtains precertification approval if it is required. If precertification is not obtained, the member s benefits may be denied or the member may be subject to a precertification charge. Information on precertification requirements, including a list of medications that require precertification, and the process for obtaining precertification is available on the BCBSAZ website at azblue.com. You may also call BCBSAZ at (602) or (800) , ext for precertification of medications, or at (602) (Maricopa County, (520) (Pima County), or (800) (Statewide) for precertification of all other medical services. Medications and Prescriptions BCBSAZ applies limitations to certain prescription medications obtained through the pharmacy benefit. A list of these medications and limitations is available online at azblue.com or by calling BCBSAZ. These limitations include, but are not limited to, quantity, age, gender, dosage, and refill limitations. BCBSAZ prescription medication limitations are subject to change at any time without prior notice. *IMPORTANT WARNING* THIS IS ONLY A BRIEF SUMMARY OF THE BENEFIT PLANS, AND IS DESIGNED TO HELP YOU COMPARE FEATURES OF DIFFERENT PLANS. MORE DETAILED INFORMATION ABOUT BENEFITS, COST SHARE, EXCLUSIONS AND LIMITATIONS IS IN THE BENEFIT PLAN BOOKLETS AND PLAN SBCs, AND IS AVAILABLE PRIOR TO ENROLLMENT, ON REQUEST. IF THE TERMS OF THIS SUMMARY DIFFER FROM THE TERMS OF THE BENEFIT PLAN BOOKLETS, THE TERMS OF THE BOOKLETS CONTROL AND APPLY. 9

10 Exclusions and Limitations Examples of services and supplies not covered The following is a partial list of conditions and services that are excluded or limited. Expenses for services that exceed the benefit limits are not covered. Detailed information about benefits, exclusions and limitations is in the benefit plan booklets and is available prior to enrollment upon request. Acupuncture Care that is not medically necessary Cosmetic surgery and related complications, cosmetics and beauty aids Custodial care Dental care (Adult) except as stated in plan DME rental/repair charges that exceed DME purchase price Experimental and investigational treatments Eye wear except as stated in plan Home health care and infusion therapy exceeding 42 visits (of up to 4 hours) per calendar year Infertility medication and treatment and reproductive services Inpatient EAR & SNF treatment exceeding 90 days per calendar year Long-term care, except long-term acute care Maintenance services Massage therapy other than allowed under medical coverage guidelines Out-of-network Mail order, Specialty, and 90 day supplies of drugs Out-of-network preventive care except mammography and foreign travel immunizations Personal comfort services and items Private-duty nursing PT, OT, ST, C&PR exceeding 60 visits per calendar year Respite care Routine vision exam except 1 visit/calendar year Services from naturopathic and homeopathic physicians Sexual dysfunction Weight loss programs 10

11 D /