Health Options Program

Transcription

1 Pennsylvania Public School Employees Retirement System (PSERS) Health Options Program 2016 Managed Care Plans for Medicare-Eligible and Non-Medicare-Eligible Members Southeast PENNSYLVANIA Bucks Chester Delaware Montgomery Philadelphia

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3 2016 Monthly Costs if You Are Eligible for Medicare (Excluding Premium Assistance) SINGLE COVERAGE 2-PERSON COVERAGE Aetna Medicare 15 Special PPO $379 $749 Independence Blue Cross Keystone 65 Select HMO $335 $661 Highmark Freedom Blue PPO $363 $ Monthly Costs if You Are NOT Eligible for Medicare (Excluding Premium Assistance) SINGLE COVERAGE 2-PERSON COVERAGE Aetna PPO Plan $1,147 $2,285 Independence Blue Cross Keystone East HMO $1,629 $3,248 Highmark PPOBlue (80-70 Plan) $1,150 $2,973 1

4 2016 Plan Options if You Are Eligible for Medicare HOW MUCH YOU WILL PAY IN 2016 AETNA MEDICARE 15 SPECIAL PPO MEDICAL PLAN In-Network Out-of-Network In-Network Only INDEPENDENCE BLUE CROSS- KEYSTONE 65 SELECT HMO Annual Deductible $0 $0 $0 Annual Out-of-Pocket Maximum $6,700 $10,000 $6,700 Doctor Visits $15 15% $15-PCP; $20-specialist Outpatient Surgery $0 15% $0 Emergency Room $50 (waived if admitted) $50 (waived if admitted) $40 (waived if admitted) Diagnostic Testing $15 15% $0 Outpatient Therapy $15 15% $20 Durable Medical Equipment 15% 15% $0 Outpatient Mental Health $15 15% $25 Hospitalization $0 15% $0 Inpatient Mental Health $0 15% $0; 190-day lifetime maximum in a Medicare approved mental health facility Physical Exams $0 15% $0 Ob/Gyn Exams $0 15% $0 (routine every two years) Mammograms $0 15% $0 Vision Exam/Hearing Exams Prescription Lenses (once every 24 months) Hearing Aids (once every 36 months) $0 (once every 12 months) 15% (once every 12 months) $20 100% after $100 allowance 100% after $100 allowance 100% after $500 allowance Covered under Tru Hearing Dental Care $15 cleaning/exam every 6 months PRESCRIPTION DRUGS (30-day supply) Mail Order (90-day supply) (30-day supply) Mail Order (90-day supply) Annual Deductible $0 $0 $0 $0 Initial Coverage up to a Total Drug Cost of $3,310 Generic drugs $5 $10 $5 (preferred only) $10 (preferred only) Preferred brand-name drugs $30* $60* $30 $60 Non-preferred brand-name drugs $60* $120* $50 $100 Specialty drugs 33% 33% 33% 33% Coverage Gap to TrOOP Maximum of $4,850 Generic drugs $5 preferred; 58% non-preferred $10 preferred; 58% non-preferred $5 (preferred only) $10 (preferred only) Brand-name drugs 45% (plan pays 5% and manufacturer discounts 50%) 45% (plan pays 5% and manufacturer discounts 50%) Specialty drugs 58% for generic drugs; 45% for brand-name drugs (plan pays 5% and manufacturer discounts 50%) 58% for generic drugs; 45% for brand-name drugs (plan pays 5% and manufacturer discounts 50%) Catastrophic Coverage Generic drugs The greater of 5% or $2.95 The greater of 5% or $2.95 Brand-name drugs The greater of 5% or $7.40 The greater of 5% or $7.40 * Copay also applies to some high-cost generics. 2

5 HOW MUCH YOU WILL PAY IN 2016 HIGHMARK FREEDOM BLUE PPO MEDICAL PLAN In-Network Out-of-Network Annual Deductible $0 $0 Annual Out-of-Pocket Maximum $3,400 (combined in- and out-of-network) Doctor Visits $10-PCP; $15-specialist 20% Outpatient Surgery $0 20% Emergency Room $50 (waived if admitted) $50 (waived if admitted) Diagnostic Testing $0 20% Outpatient Therapy $15 20% Durable Medical Equipment 15% 50% Outpatient Mental Health $15 20% Hospitalization $0 20% Inpatient Mental Health $0 20% Physical Exams $0 (office visit copay may apply) $0 (office visit copay may apply) Ob/Gyn Exams $0 (office visit copay may apply) $0 (office visit copay may apply) Mammograms $0 $0 Vision Exam/Hearing Exams $0-vision; $15-hearing 20% Prescription Lenses (once every 24 months) Hearing Aids (once every 36 months) Dental Care PRESCRIPTION DRUGS $0 for standard lenses and frames or contacts (annually); 100% after $100 allowance for nonstandard frames or specialty contacts 100% after $100 allowance 100% after $500 allowance (combined in- and out-of-network) $20 for exam & cleaning; $20 for x-rays; 50% for restorative services and dentures (subject to frequency limitations) (31-day supply) Annual Deductible $0 $0 Initial Coverage up to a Total Drug Cost of $3,310 Generic drugs $10 $25 Preferred brand-name drugs $30 $75 Non-preferred brand-name drugs $60 $150 Specialty drugs 33% 33% Coverage Gap to TrOOP Maximum of $4,850 Generic drugs $10 $25 50% for periodic exams, cleanings, x-rays, fillings as needed and dentures Mail Order (90-day supply) Brand-name drugs 45% (plan pays 5% and manufacturer discounts 50%) Specialty drugs 58% for generic drugs; 45% for brand-name drugs (plan pays 5% and manufacturer discounts 50%) Catastrophic Coverage Generic drugs The greater of 5% or $2.95 Brand-name drugs The greater of 5% or $7.40 3

6 2016 Plan Options if You Are NOT Eligible for Medicare HOW MUCH YOU WILL PAY IN 2016 AETNA PPO PLAN MEDICAL In-Network Out-of-Network In-Network Only Annual Deductible Annual Out-of-Pocket Maximum $1,500/individual $3,000/family $4,000/individual $8,000/family $1,500/individual $3,000/family $4,000/individual $8,000/family INDEPENDENCE BLUE CROSS- KEYSTONE EAST HMO $0 $6,600/individual; $13,200/family Doctor Visits 20%; no deductible 40% $15/visit-PCP; $30/visit-specialist $0-preventive care Outpatient Surgery 20%; no deductible 40% $50 Emergency Room 20%; no deductible 20%; no deductible $100 Diagnostic Testing 20% 40% $30-routine radiology/diagnostic; $60-MRI/MRA, CT/CTA scan, PET scan Outpatient Therapy 20%; no deductible 40% $30 Durable Medical Equipment 50%; $2,500 max/member/ 50%; $2,500 max/ year member/year 30% Outpatient Mental Health 20%; no deductible 40% $30 Hospitalization 20% 40% $100/day to $500/admission maximum Inpatient Mental Health 20% 40% $100/day to $500/admission maximum Physical Exams 0%; no deductible 40% $15-PCP; $30-specialist Ob/Gyn Exams 0%; no deductible 40% $0-routine gyn; $15-initial ob office visit Mammograms 0%; no deductible 40% $0 Vision Exam/Hearing Exams 0%; no deductible for Vision 1 per 24 months; 20% no deductible for 40% Vision (routine)-$30 once every 2 years Hearing- Hearing 1 per 24 months Prescription Lenses (once every 24 months) 100% after $100 allowance (Davis Vision network) Hearing Aids (once every 36 months) Dental Care PRESCRIPTION DRUGS Annual Deductible $200/individual $600/family $200/individual $600/family $0 Annual Maximum No maximum No maximum No maximum Generic drugs 30% 50% after in-network copay $15 Brand-name drugs 30%-formulary 50%-non-formulary 50% after applicable in-network copay $35-formulary $50-non-formulary Mail Order (90-day supply) Generic drugs 30% $30 Brand-name drugs 30%-formulary 50%-non-formulary $70-formulary $100-non-formulary 4

7 HOW MUCH YOU WILL PAY IN 2016 HIGHMARK PPOBLUE (80-70 PLAN) MEDICAL In-Network Out-of-Network Annual Deductible $100/individual; $300/family $500/individual; $1,500/family Annual Out-of-Pocket Maximum $10,000 No maximum Doctor Visits $20/visit-PCP; $40/visit-specialist 30% Outpatient Surgery 20% 30% Emergency Room $100 (waived if admitted) $100 (waived if admitted) Diagnostic Testing 20% 30% Outpatient Therapy $40/visit to 60-visit maximum* 30% to 60-visit maximum* Durable Medical Equipment 20% 30% Outpatient Mental Health $0 30% Hospitalization 20% 30% Inpatient Mental Health 20% 30% Physical Exams PCP-$20/visit; Specialist-$40/visit Ob/Gyn Exams $40/visit 30%-routine (no deductible) Mammograms 20% 30% Vision Exam/Hearing Exams Prescription Lenses (once every 24 months) Hearing Aids (once every 36 months) Dental Care PRESCRIPTION DRUGS Annual Deductible $0 Annual Maximum No maximum Generic drugs 30% (mandatory generic) Brand-name drugs 50% Mail Order (90-day supply) Generic drugs 30% (mandatory generic) Brand-name drugs 50% * Combined in- and out-of-network maximum 5

8 This brochure provides only a summary of benefits under these plans. It does not provide details about what is covered or limitations that may apply. More information is included in the Evidence of Coverage (for a Medicare Advantage plan) or the Benefit Description (for a plan for non-medicare-eligible members). In addition, you can call the HOP Administration Unit at and request an information packet for any of these plans. EFFECTIVE JANUARY 1, 2016