Keystone Health Plan East

Transcription

1 Keystone Health Plan East Keystone Select - OOPM 2015 PAISBOA HBT Keystone Health Plan East is a Health Maintenance Organization (HMO). This is a managed care program. Coverage is available when your care is provided by a Keystone Primary Care Physician. Your Keystone Primary Care Physician may also refer you to other Keystone providers for care, if needed. To get the most out of your benefits program, below are some key terms that you will need to understand. Referral-Documentation from your PCP authorizing care at a participating specialist for covered services. Preapproval/Precertification - Approval from Independence Blue Cross (IBC) for non-emergency or elective hospital admissions and procedures prior to the admission or procedure. Your participating provider will contact Independence Blue Cross for authorization. For more information on the services requiring precertification, please refer to the back page of this summary. Designated site - PCPs are required to choose one radiology, physical therapy, occupational therapy, and laboratory provider where they will send all their Keystone members. You can view the sites selected by your PCP at Your Member Handbook will provide additional details about your benefits program. It will include information about exclusions and benefit limitations. It is important to note that this program may not cover all your health care services. Services may not be covered because they are not included under your benefits contract, not medically necessary, or limited by a benefit maximum (e.g., visit limit). After reviewing this information, please contact our Customer Service department if you have additional questions. Benefit Benefits and Services Coverage Doctor Visits Preventive Health Services Office visits to your Primary Care Physician Home visits by your Primary Care Physician Non-routine after hours visits to your Primary Care Physician Office visits to referred specialists Preventive Care for Adults and Children $10 copayment $15 copayment $15 copayment $15 copayment Covered 100% Pediatric Immunizations (except for Covered 100% travel or employment) Routine gynecological care (no referral Covered 100% required) Mammography (no referral required) Covered 100% Nutrition Counseling For Weight Covered 100% Management 6 visits per calendar year The benefits may be changed by IBC to comply with applicable federal/state laws and regulations. Benefits are administered by Keystone Health Plan East, a subsidiary of Independence Blue Crossindependent licensees of the Blue Cross and Blue Shield Association. 07/15 - PA HMO Select - OOPM

2 Benefit Benefits and Services Coverage Maternity Obstetrical care (including pre- and postnatal care) Newborn care (both doctor and hospital) Covered with a $15 copayment for first visit. Subsequent visits to your OB/GYN covered 100%. Inpatient admission covered with a $240 copayment per admission 3 Covered 100% Hospital Services * Unlimited inpatient stay $240 copayment per admission 3 Surgery Covered 100% Anesthesia Covered 100% Drugs and medication Covered 100% Inpatient doctor care Covered 100% General nursing care Covered 100% Administration of blood Covered 100% Organ transplantation, Covered 100% non-experimental Outpatient Surgery * Facility $100 copayment Physician/Surgeon Covered 100% Emergency Care Treatment in hospital emergency room Covered with a $150 copayment (which is waived if you are admitted to the hospital) Ambulance service Covered 100% when medically necessary Urgent Care Center Treatment received in urgent care facility $105 copayment Ambulance Emergency Covered 100% Non-Emergency Covered 100% Specialized Services Allergy testing and treatment Covered 100% ** Diagnostic, Laboratory, and X-ray Covered 100% services *** Short-term Rehabilitation Therapy (including Speech *, Occupational, and Physical Therapy) Covered 100%. Up to 60 consecutive days per condition covered, subject to significant improvement Spinal Manipulation Services Covered 100%. Up to 60 consecutive days per condition covered, subject to significant improvement Orthoptic/Pleoptic Covered 100%. 8 sessions maximum per lifetime Respiratory Therapy Covered 100% Chemotherapy Covered 100% Radiation Therapy Covered 100% Vision Care, including screening, eye $15 copayment (once every two exams, and refractions calendar years) Hearing Screening Covered 100% ** * Preauthorization required. Preauthorization is not a determination of eligibility or a guarantee of payment. Coverage and payment are contingent upon, among other things, the patient being eligible, i.e., actively enrolled in the health benefits plan when the preauthorization is issued and when approved services occur. Coverage and payment are also subject to limitations, exclusions, and other specific terms of the health benefits plan that apply to the coverage request. ** Office visit subject to copayment. *** MRI/MRA, CT/CTA scan, PET scan and Nuclear Cardiac Studies require preauthorization. 3 Copayment waived if readmitted within 10 days of discharge for any condition. The benefits may be changed by IBC to comply with applicable federal/state laws and regulations.

3 Benefit Benefits and Services Coverage Specialized Services (Continued) Skilled nursing facility services, as specified* 1 Durable Medical Equipment * Prosthetics * Home Health Care * Covered 100% Dialysis Covered 100% Covered 100% up to 180 days per calendar year All purchases and rentals (including repairs and replacements) are covered 100% when authorized by your Primary Care Physician 2 All purchases (including repairs and replacements) are covered 100% when authorized by your Primary Care Physician 2 Mental Health Inpatient * $240 copayment per admission 3 Outpatient $15 copayment Serious Mental Illness (SMI) Inpatient * $240 copayment per admission 3 Outpatient $15 copayment Substance Abuse Inpatient * $240 copayment per admission 3 Outpatient $15 copayment Detoxification Inpatient * $240 copayment per admission 3 Outpatient $15 copayment Out-of-Pocket Maximum 4 Individual $6,350 Family $12,700 * Preauthorization required. Preauthorization is not a determination of eligibility or a guarantee of payment. Coverage and payment are contingent upon, among other things, the patient being eligible, i.e., actively enrolled in the health benefits plan when the preauthorization is issued and when approved services occur. Coverage and payment are also subject to limitations, exclusions, and other specific terms of the health benefits plan that apply to the coverage request. 1 Inpatient Hospital copay applies if admitted without prior hospital stay. 2 Purchases over $500 and all rentals require preauthorization. 3 Copayment waived if readmitted within 10 days of discharge for any condition. 4 Out-of-pocket maximum includes deductible, copays and coinsurance. The benefits may be changed by IBC to comply with applicable federal/state laws and regulations.

4 Benefits and Services Not Covered As with all health insurance plans, KHPE's coverage excludes certain services. Those not covered by KHPE include, but are not limited to, the following: Services not medically necessary Services not provided or referred by your Primary Care Physician, except in emergencies Service or supplies that are experimental or investigative except, when approved by Keystone Health Plan East, Routine Costs associated with Qualifying Clinical Trials Routine physical exams for non-preventive purposes such as insurance or employment applications, college, or premarital examinations Services or supplies payable under Workers' Compensation, Motor Vehicle Insurance, or other legislation of similar purpose The cost of services for which another party has primary responsibility Long-term rehabilitative therapy (e.g. maintenance of chronic conditions) Non-medical, rehabilitative services for the treatment of substance abuse in an acute-care hospital Hearing aids, hearing examinations/tests for the prescription/fitting of hearing aids, and cochlear electromagnetic hearing devices Radial keratotomy Custodial or domiciliary care Personal or comfort items not medically necessary, such as air conditioners, humidifiers, telephones, or similar items Assisted fertilization techniques such as in-vitro fertilization, GIFT, and ZIFT Reversal of voluntary sterilization Transsexual surgery Cosmetic services/supplies Immunization for travel or employment Prescription drugs and medications, except as required by law or by additional rider Treatment for temporomandibular joint syndrome (TMJ) Care of the feet, unless medically necessary Services required by a member who is an organ donor Dental care, including dental implants Alternative therapies/complementary medicine Self-injectable drugs This summary represents only a partial listing of benefits and exclusions of the Keystone Health Plan East program described in this summary. If your employer purchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. This managed care plan may not cover all your health care expenses. Read your contract/member handbook carefully to determine which health care services are covered. If you need more information, please call (if calling within Philadelphia) or (outside Philadelphia).

5 Select Drug Program $20/$75/$100 PAISBOA HBT The Select Drug Program is a comprehensive benefit that provides coverage for prescription drugs 1 when prescribed by a licensed, practicing physician. The Select Drug Program is based on an incentive formulary that includes all generic drugs and a defined list of brand drugs that have been evaluated for their medical effectiveness, positive results, and value. Generic drugs are just as effective as brand drugs and result in the lowest cost sharing for you. Ask your physician whether generic drugs are right for you. Benefit Retail Pharmacy - Member Cost Sharing (Participating Pharmacy) Coverage Generic Formulary $20 Copayment Brand Formulary $75 Copayment Non-Formulary Brand $100 Copayment Mail Order Pharmacy - Member Cost Sharing (Participating Pharmacy) Available for maintenance drugs Generic Formulary $20 Copayment (1-30 days supply); $40 Copayment (31-90 days supply) Brand Formulary $75 Copayment (1-30 days supply); $150 Copayment (31-90 days supply) Non-Formulary Brand Total Out-of-Pocket Maximum $100 Copayment (1-30 days supply); $200 Copayment (31-90 days supply) Please refer to your Medical Coverage Benefits at a Glance for information about out-of-pocket maximum values. Out-of-pocket maximum includes applicable copayments, coinsurance and deductibles. Your out-of-pocket maximum is a combined maximum of medical, prescription drug and any included pediatric vision and pediatric dental benefits as defined by your benefit plan Out-of-Network Reimbursement 30% of drugs retail cost for the total amount dispensed. For an emergency, you will only be responsible for the applicable copayments listed above. Member must submit for reimbursement. Network FutureScripts network * includes more than 60,000 retail pharmacies. You can locate a participating pharmacy near you on by selecting the Find a Participating Pharmacy feature. Benefits are underwritten or administered by Keystone Health Plan East, a subsidiary of Independence Blue Crossindependent licensees of the Blue Cross and Blue Shield Association. 08/15 - PA - HMO-POS Select RX Rider $20/$75/$100 w Orals

6 Benefit Dispensing Limits Coverage Retail Up to 30 days supply Formulary Mail order for maintenance drugs Up to 90 days supply IBC Select Drug Program Formulary. To check the formulary status of a drug or to view a copy of the most recent formulary, log onto Specialty Pharmacy Program Mandatory for Self-Administered Specialty Drugs All covered self-administered specialty medications except insulin will be provided through the convenient Specialty Pharmacy Program for the appropriate cost sharing indicated above. Benefits are available for up to a thirty (30) days supply. If your doctor wants you to start the drug immediately, an initial 30-day supply may be obtained at a retail pharmacy. However, all subsequent fills must be purchased through the Specialty Pharmacy Program. Covered Prescription Drugs 1 Compound medications of which at least one ingredient is a prescription drug Contraceptives Prescribed smoking cessation drugs Self-injectable drugs Retin-A through age 35 Insulin Insulin needles and syringes Lancets (no copayment required at participating pharmacies) Glucometers (no copayment required at participating pharmacies) Diabetic supplies (i.e., test strips) 1 This summary is intended to highlight the benefits available to you. For a complete program description, including all benefits, limitations, and exclusions, refer to your benefit booklet or group contract. What is Not Covered? Injectable fertility drugs Non Federal Legend Drugs Weight control drugs Devices or supplies except those specifically listed under covered drugs Drugs used for cosmetic purposes (e.g., anabolic steroids and minoxidil lotion, Retin-A for aging skin) Drugs labeled 'Caution-limited by Federal Law to investigational use', even though a charge is made to an individual Any prescription refilled in excess of the number of refills specified by the physician, or any refill dispensed after one year from the physician's original order Experimental drugs Immunization agents, biologicals, allergy serums, blood, or blood plasma Drugs and supplies that can be purchased over the counter except those covered per mandate (with a doctors prescription)

7 $100 Eyewear Benefit Biennial Benefit The Keystone Health Plan East $100 HMO/POS Vision Rider program, administered by Davis Vision, offers members corrective eyewear, including eyeglasses or contact lenses. The vision rider program is easy to use. Benefits are maximized by using Davis Vision providers that are conveniently located throughout the area. Paid-in-full benefits for eyeglasses with standard lenses are possible when you choose from a select grouping known as the Davis Collection of Frames. Benefit Eyeglasses, including spectacle lenses and frames, at participating providers Spectacle lenses Additional lens options Frames Two options are available for selecting frames: Eyeglasses including spectacle lenses and frames at non-participating providers Coverage Spectacle lenses covered at no extra cost include: all range of prescriptions, oversize lenses, glass or plastic lenses, single vision, bifocal, trifocal or lenticular lenses Additional spectacle lens options covered at no cost include: glass grey #3 prescription sunglass lenses, tinting, polycarbonate lenses for dependent children, monocular patients, and patients with prescriptions greater than or equal to +/ diopters Choose from participating provider's own frame collection and member receives allowance of $65 1 OR Choose from the Davis Collection of Frames that is available at most participating providers and frames are covered in full. Eyeglasses (spectacle lenses and frames) are available up to a $100 reimbursement to member 2 Contact lenses (in lieu of eyeglasses) including standard, specialty and disposable lenses and evaluation and fitting Participating providers Member receives allowance up to $100 1 Non-participating providers Up to $100 reimbursement to member 2 Benefit frequency Network Once every two calendar years Davis Vision Network To locate a participating provider, go to and click on the 'Find a Doctor' feature. 1 Member is responsible for balance 2 In lieu of participating provider benefit, member is responsible for balance This summary is intended to highlight the benefits available to you. For a complete description, including benefits and exclusions, refer to your benefit booklet. Administered by: Benefits are underwritten or administered by Keystone Health Plan East, a subsidiary of Independence Blue Crossindependent licensees of the Blue Cross and Blue Shield Association. 08/07 - PA - $100 Eyewear Benefit

8 Value-added Services* Spectacle lens options available at most participating providers, MEMBER PAYS fixed discounted prices: Spectacle Lens Option Fixed Discounted Price Blended invisible bifocals $10 Ultraviolet (UV) coating $12 Scratch-resistant coating - single vision $15 Scratch-resistant coating - multifocal $25 Intermediate vision lenses $30 Anti-reflective coating - standard $33 Anti-reflective coating - premium $48 Anti-reflective coating - ultra $60 Progressive additional multifocal lenses - standard $50 Progressive additional multifocal lenses - premium $90 Polarized lenses $60 Polycarbonate 3 $30 High index $55 Photochromic glass - single vision $15 Photochromic glass - multifocal $25 Photochromic plastic - single vision $60 Photochromic plastic - multifocal $70 Warranty - Unconditional one-year breakage warranty to repair or replace frames or lenses purchased at a participating provider for a period of one year. This warranty applies to all spectacle lenses, Davis Vision Collection of Frames and regional/national retailer frames, when the Collection is not available. Replacement Contact Lenses - Through Lens 123, a free mail order program, member may receive replacement contact lenses offered at guaranteed, discounted prices. Laser Vision Correction Services - Discount on Laser Vision Correction Services at Davis Vision Participating Laser Vision Correction Providers: Up to 25% off the participating provider's usual and customary fees or 5% off any participating provider's advertised specials, whichever is less. Additional Eyewear Discount - Members selecting non-covered materials (i.e., second pair of eyeglasses, sunglasses, etc.) will receive up to a 20% courtesy discount and up to a 10% discount on disposable contacts at most participating providers. * Not available at non-participating providers 3 Polycarbonate lenses for dependent children, monocular patients, and patients with prescriptions greater than or equal to +/ diopters are covered at no cost.

9 Frequently Asked Questions Below find answers to some frequently asked questions about how your IBC Vision benefit program works. Who are the participating providers in the IBC Vision network? Our administrator, Davis Vision, contracts with a national network of providers including ophthalmologists, optometrists and opticians. They are primarily licensed providers in private practice and in some retail locations, such as Wal-Mart Vision Center and For Eyes. Please go to to locate a participating 'Vision Provider' through the 'Find a Doctor' feature, or once enrolled, call the number on your Identification card. If a retail location such as Wal-Mart Vision Center is in the network, does that mean the doctor located in that store is in the network? No. When going to a retail location such as Wal-Mart Vision Center for eyewear purchases, you should always confirm the participation status of the on-site doctor who provides the eye exam, since each provider contracts separately with Davis Vision. Please Note: Coverage for routine eye exam, if available, would be included under your medical benefit. What are the advantages of using a participating provider? Quality service standards: all participating providers have been extensively reviewed and credentialed to NCQA standards to ensure that stringent standards for quality service are maintained. Paid-in-full benefit available: in addition to their own selection of frames, most participating providers have available the Davis Collection of Frames. This allows you to utilize the paid-in-full benefit available through your IBC Vision Program when frames are selected from the Collection with standard lenses - single, bifocal, trifocal or lenticular. Spectacle lens options discount: additional services such as anti-reflective coating and Transitions lenses (photochromic) are available at a discounted price. Eyewear quality and value: most eyewear (lenses, coatings, and frames) is fabricated on site at one of Davis Vision's Regional Fabrication Centers. This allows Davis to monitor quality assurance and costs associated with the fabrication process, thereby creating the most value for you, our member. Warranty: Unconditional one-year breakage warranty to repair or replace frames or lenses purchased at a participating provider for a period of one year. This warranty applies to all spectacle lenses, Davis Vision Collection of Frames and regional/national retailer frames, when the Collection is not available. Will I need a claim form to receive services from a participating provider? No, you will not need a claim form for in-network services. The process is simple. Here's what to do: Call the participating provider of your choice and schedule an appointment. Identify yourself as a member of IBC Vision, administered by Davis Vision. Provide the office with your ID number located on your Identification card and the name and date of birth of any covered dependent needing services. It's that easy! The provider's office will verify your eligibility for services, and no claim forms are required! Will I be able to choose any frame available at a participating provider? Yes, you may apply the amount of your frame benefit toward any available frame that you choose. You can maximize your benefit by selecting frames from the Davis Collection of Frames, which offers you the ability to have a paid in full pair of frames. The Collection is available at most participating providers. The 'Find a Doctor' feature on also indicates the participating doctors that have the Davis Collection of Frames available. What types of frames are included in the Davis Collection of Frames? The Davis Collection includes frames for men and women, adults and children. The collection includes many notable designer name frames that have passed rigorous inspections, such as Perry Ellis, Steve Madden, Alfred Sung, Converse, Bongo, Club Med, Catherine Deneuve, Scooby-Doo!, Garfield and Harley-Davidson. This frame collection is typically updated twice a year. How soon will I receive my glasses after they are ordered? Your provider will advise you when to return to his/her office to pick up your new prescription eyeglasses. Delivery of your new eyeglasses to your participating provider from the fabrication center is generally within two to five business days of the doctor's submission of your order. More delivery time may be needed when out-of-stock frames, ARC (anti-reflective coatings), specialized prescriptions or a participating provider's frame is selected. What if my vision care provider does not participate in the network? You may receive covered services from a non-participating provider, although you can receive the greatest value and maximize your benefit dollars if you select a provider who participates in the network. If you choose a non-participating provider, you pay the provider directly for all charges and then submit a Direct Reimbursement Claim Form. Covered services will be paid directly to you based on your out-of-network benefits. You are responsible for any balances.

10 Where do I send the Direct Reimbursement Claim Form? Mail your completed Direct Reimbursement Claim Form with receipts attached to: Vision Care Processing Unit P. O. Box 1525 Latham, NY To obtain a claim form, please visit and click on 'Forms'. The IBC Vision Direct Reimbursement Claim Form is located on this Forms page under the Claims section. How do I purchase replacement contact lenses through the Lens 123 Program? Enrolled members who have utilized their covered benefit may call LENS 123 ( ) to register and set up your Lens 123 account. The Customer Service Representative will explain to you how to order replacement contact lenses and receive them in the mail. Lens 123 is an easy and convenient way to order replacement contact lenses. For additional information, go to Benefits are underwritten or administered by Keystone Health Plan East, a subsidiary of Independence Blue Crossindependent licensees of the Blue Cross and Blue Shield Association.

11 PAISBOA HBT Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning on or after 11/01/2015 Coverage for: FAMILY PlanType: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling ASK-BLUE. Important Questions Answers Why this Matters: What is the overall deductible? $0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? No. Yes. For participating providers $6,350 person / $12,700 family. Premiums and health care this plan doesn't cover. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit. Is there an overall annual limit on what the plan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. See or call ASK-BLUE for a list of participating providers. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? Are there services this plan doesn't cover? Yes. Electronic referral required. Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan's permission before you see the specialist. Some of the services this plan doesn't cover are listed in the Excluded Services & Other Covered Services section. See your policy or plan document for additional information about excluded services. Questions: Call ASK-BLUE or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call ASK-BLUE to request a copy of 8

12 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your Cost If You Use a Referred Provider an Out Of Network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $10 copayment Not Covered none Specialist visit $15 copayment Not Covered PCP referral required. Other practitioner office visit Covered No Charge. Up to 60 consecutive days per condition covered, after significant improvement Not Covered Spinal Manipulations covered up to 60 consecutive visits per benefit period subject to significant improvement. PCP referral required. Preventive care / screening / immunization No Charge Not Covered Age and frequency schedules may apply. Diagnostic test (x-ray, blood work) No Charge Not Covered PCP referral required for x-rays. Requisition form required for lab work. Imaging (CT/PET scans, MRIs) No Charge Not Covered Precertification required. Generic drugs Not Covered Not Covered none Preferred brand drugs Not Covered Not Covered none If you need drugs to treat your illness or condition Non-preferred brand drugs Not Covered Not Covered none of 8

13 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Your Cost If You Use a Referred Provider an Out Of Network Provider Specialty drugs Covered No Charge Not Covered Facility fee (e.g., ambulatory surgery center) $100 copayment Not Covered Limitations & Exceptions This cost share amount is for specialty injectable or infusion therapy drugs covered by the medical benefit. These drugs are typically administered by a health care professional in an office or outpatient facility. Self-administered specialty drugs follow the applicable retail prescription cost-share under the FutureScripts Specialty Pharmacy Program. Priorauthorization required. A complete list of drugs requiring prior-authorization is available at Some outpatient surgeries require precertification. A complete list of surgeries requiring precertification is available at Physician/surgeon fees Covered Not Covered none Emergency room services Covered with a $150 copayment Covered with a $150 copayment Your costs for Emergency Room services are waived if you are admitted to the hospital. Emergency medical Covered No Charge Covered No Charge transportation when medically when medically necessary necessary none Your costs for urgent care are based on care received Urgent care $105 copayment Not Covered at a designated urgent care center or facility, not your physician's office. Costs may vary depending on where you receive care. Facility fee (e.g., hospital room) $240 copayment per admission Not Covered Precertification required. Physician/surgeon fee No Charge Not Covered Precertification required. Mental/Behavioral health outpatient services Not Covered Not Covered none Mental/Behavioral health inpatient services Not Covered Not Covered none Substance abuse disorder outpatient services $15 copayment Not Covered Precertification required. Substance abuse disorder inpatient services Prenatal and postnatal care $240 copayment per admission Covered with a $15 copayment for first Not Covered Not Covered Precertification required. Your cost is for first OB visit only of 8

14 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use a Referred Provider an Out Of Network Provider Limitations & Exceptions visit. Subsequent visits to your OB/GYN covered No Charge. Inpatient admission covered with a $240 copayment per admission Delivery and all inpatient services No Charge Not Covered Pre-notification requested. Home health care No Charge Not Covered Precertification required. Covered No Charge. Rehabilitation services Up to 60 consecutive days per condition Speech/Physical/Occupational: Up to 60 consecutive covered, after Not Covered days per condition covered, subject to significant significant improvement. PCP referral required. improvement Habilitation services Skilled nursing care Durable medical equipment Covered No Charge. Up to 60 consecutive days per condition covered, after significant improvement Covered No Charge up to 180 days per calendar year All purchases and rentals (including repairs and replacements) are covered No Charge Not Covered Not Covered Not Covered Speech/Physical/Occupational: Up to 60 consecutive days per condition covered, subject to significant improvement. PCP referral required. Precertification required. Precertification required for selected items. A complete list is available at Hospice service No Charge Not Covered none $15 copayment (once Eye exam every two calendar Not Covered Once every two calendar years. years) Glasses Not Covered Not Covered none Dental check-up Not Covered Not Covered none of 8

15 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Cosmetic surgery Dental care (Adult) Hearing aids Infertility treatment (See Benefit Long-term care Booklet/Member handbook for limitations) Non-emergency care when traveling outside Routine foot care Weight loss programs the U.S. (For details, see Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric surgery Chiropractic care Private-duty nursing Routine eye care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium,which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: Your health plan is subject to Employee Retirement Income Security Act (ERISA) requirements. If you are dissatisfied with a denial of coverage for claims under your plan, you may contact IBC at ASK-BLUE. You may also contact the U.S. Dept. of Labor Employee Benefits Security Administration at As an alternative, the Pennsylvania Department of Insurance can also provide assistance. Please contact them at Does this Coverage Provide Minimum Essential Coverage? of 8

16 The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provide minimum essential coverage. To see examples of how this plan might cover costs for a sample medical situation, see the next page of 8

17 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan Pays $7,370 Patient Pays $170 Sample Care Costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient Pays Deductibles $0 Copays $0 Coinsurance $0 Limits or exclusions $170 Total $170 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan Pays $4,240 Patient Pays $1,160 Sample Care Costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient Pays Deductibles $0 Copays $230 Coinsurance $0 Limits or exclusions $930 Total $1, of 8

18 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium,the more you ll pay in out-ofpocket costs, such as copayments, deductibles and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts(hras) that help you pay outof-pocket expenses. Questions: Call ASK-BLUE or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call ASK-BLUE to request a copy of 8