IU Health Plans Silver Enhanced Plus Dental & Vision CSR 94. Schedule of Benefits

Transcription

1 IU Health Plans Silver Enhanced Plus Dental & Vision CSR 94 Schedule of s Schedule of s / 1 The Schedule of s is a summary of your s and Cost Sharing. The definitions stated in your Contract apply to this Schedule of s. Services provided by Non-Participating Providers are Non-Covered Services unless specifically covered under this Contract. You are responsible for all expenses for Non-Covered Services. Plan Year [date] through [December 31, 2016] : The is the amount you must pay for Covered Services in a Plan Year before we will pay s for Covered Services. The applies to all Covered Services except for Preventive Care, office visits with your Primary Care Physician, Maternity - Prenatal & Postnatal Care, Urgent Care Center Services, and Tier 1 & Tier 2 Prescription Drugs. Copayments do not apply toward the. Your payments for Non-Covered Services do not apply toward the. Per Covered Per Family $150 per Plan Year $300 per Plan Year Out of Pocket Maximum: The Out of Pocket Maximum is the maximum amount that you will pay for Covered Services in a Plan Year. The Out of Pocket Maximum includes the, Copayments and Coinsurance amounts you pay in a Plan Year for Covered Services. Your payments for Non-Covered Services do not apply toward the Out of Pocket Maximum. Once the Out of Pocket Maximum is satisfied, no additional Copayments or Coinsurance apply for the remainder of the Plan Year. Out of Pocket Maximum Per Covered $500 per Plan Year Per Family $1,000 per Plan Year Adult Dental and Adult Vision Coverage Does Not Accrue to Individual &/or Family s or Out-of-Pocket Maximums. Cost Sharing and Limitations: Cost Sharing is the Copayment and Coinsurance that you must pay for Covered Services. Some Covered Services are subject to limitations. Health Care Services received from Non-Participating Providers are Non-Covered Services unless the Contract specifically provides otherwise. See Article 6 Section B of the Contract for additional information on when Health Care Services received from Non-Participating Providers may be Covered Services. If Health Care Services received from Non-Participating Providers are determined to be Covered Services, the services are subject to the same s, Copayments, Coinsurance and limitations as Covered Services received from Participating Providers.

2 Ambulance Services Behavioral Health Services Office Visits Outpatient Services Inpatient Services Substance Abuse Disorder Outpatient Services Substance Abuse Disorder Inpatient Services Dental Services for Accidental Injury Diabetic Equipment, Education and Supplies $10 Copayment per visit $200 Copayment per admission after $200 Copayment per admission after Copayments/Coinsurance based on setting where Covered Services are received. For information on equipment and supplies, please refer to the "Medical Supplies, Durable Medical Equipment, and Appliances" provision in this Schedule. For information on Diabetic education, please refer to the Specialty Physician" or "Primary Care Physician" provisions in this Schedule. For information on Prescription Drug Coverage, please refer to the "Prescription Drugs" provision in this Schedule. Diagnostic Services Laboratory Services Radiology Services

3 X-ray Services Emergency Services Emergency Room - Cost Sharing after waived if admitted Urgent Care Center Services $100 Copayment per visit after $40 Copayment per visit Home Care Services Home Care Visits - limited to a maximum of 90 visits per Covered Per Year Private Nursing Visits - limited to a maximum of 82 visits per Covered Per Year and 164 visits per Covered per lifetime Hospice Services Inpatient Services Inpatient Facility Services Inpatient Physician and Surgical Services Physical Medicine and Day Rehabilitation - limited to a maximum of 60 days per Covered Per Year Inpatient Skilled Nursing Facility Services - limited to a maximum of 90 days per Covered Per Year $200 Copayment per admission after Maternity Services Prenatal and Postnatal Care Delivery and Inpatient Services $10 Copayment per visit $200 Copayment per admission after Medical Supplies, Durable Medical Equipment and Appliances Medical Supplies Durable Medical Equipment Prosthetics

4 Orthotic Devices Outpatient Services Outpatient Facility Outpatient Surgery Physician/Surgical Services Physician Visits Primary Care Physician Specialty Physician Preventive Care Services Surgical Services Telehealth Services Temporomandibular or Craniomandibular Joint Disorder and Craniomandibular Jaw Disorder $10 Copayment per visit No charge cost sharing based on service type and rendering provider Therapy Services Outpatient Rehabilitative Physical Medicine Services - limited to a maximum of 60 visits per Covered Per Year Physical Therapy - limited to a maximum of 20 visits per Covered Per Year Speech Therapy - limited to a maximum of 20 visits per Covered Per Year Occupational Therapy - limited to a maximum of 20 visits per Covered Per Year Manipulation Therapy limited to a maximum of 12 visits per Covered Per Year Rehabilitation Services Cardiac Rehabilitation - limited to a maximum of 36 visits per Covered Per Year Pulmonary Rehabilitation - limited to a maximum of 20 visits per Covered Per Year

5 Therapy Services Outpatient Habilitative Physical Therapy - limited to a maximum of 20 visits per Covered Per Year Speech Therapy - limited to a maximum of 20 visits per Covered Per Year Occupational Therapy - limited to a maximum of 20 visits per Covered Per Year Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services: The Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services benefits or requirements described below do not apply to the following. Cornea and kidney transplants, and Any Covered Services, related to a Covered Transplant Procedure, received prior to or after the Transplant Period. Please note that the initial evaluation and any necessary additional testing to determine your eligibility as a candidate for transplant by your Provider and the harvest and storage of bone marrow/stem cells is included in the Covered Transplant Procedure benefit regardless of the date of service. The above Health Care Services are covered as Inpatient Services, Outpatient Services or Physician Home Visits and Office Services depending on where the service is performed, subject to Cost Sharing.

6 Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services Transplant Period Starts one day prior to a Covered Transplant Procedure and continues for the applicable case rate/global time period. The number of days will vary depending on the type of transplant received and the Participating Provider Agreement. Contact the Case Manager for specific Participating Provider information for Health Care Services received at or coordinated by a Participating Provider Facility or starts one day prior to a Covered Transplant Procedure and continues to the date of discharge at a Non- Participating Provider Facility. Not applicable Covered Transplant Procedure during the Transplant Period During the Transplant Period, no Copayment/Coinsurance up to the Allowed Amount. Prior to and after the Transplant Period, Covered Services will be paid as Inpatient Services, Outpatient Services or Physician Home Visits and Office Services depending where the Health Care Service is performed. Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services - Professional and Ancillary (non-hospital) Providers Covered Transplant Procedure During the Transplant Period No Copayment/Coinsurance up to the Allowed Amount

7 Transportation and Lodging Covered, as approved by the Contract, up to a $10,000 benefit limit Unrelated Donor Searches for Bone Marrow/Stem Cell Transplants for a Covered Transplant Procedure Covered, as approved by the Contract, up to a $30,000 benefit limit Live Donor Health Services Prescription Drugs Retail 30 day supply Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand Name) Tier 4 (Non-Preferred Brand Name) Tier 5 (Specialty) Tier 6 (Preventive) Covered as determined by the Contract $5 Copayment per Prescription Order $15 Copayment per Prescription Order 20% Coinsurance after 30% Coinsurance after 30% Coinsurance after No charge Mail Order 90 day supply Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand Name) Tier 4 (Non-Preferred Brand Name) $15 Copayment per Prescription Order $45 Copayment per Prescription Order 20% Coinsurance after 30% Coinsurance after

8 Tier 5 (Specialty) Tier 6 (Preventive) 30% Coinsurance after No charge Pediatric Vision (persons under age 19) Eye exam - limited to 1 exam per Covered per Year Eyeglass Lenses - limited to 1 set of lenses per Covered per Year Eyeglass Frames - limited to 1 set of frames per Covered Per Year Contact Lenses includes materials only, covered once per Per Year in lieu of eyeglasses Conventional Extended Wear Disposables Daily Wear / Disposables No charge No charge No charge for Provider Designated Frames No charge for designated contact lenses One pair annually from selection of designated contact lenses Up to 6 month supply of monthly or 2 week disposable, single vision spherical or toric contact lenses Up to 3 month supply of daily disposable, single vision spherical contact lenses Adult Vision Service Member Cost In-Network Vision Services Provided by Non-Participating Providers (reimbursements only available for Enrollees beginning on the first day of the month after the Enrollee obtains the age of 19) Exam with Dilation as Necessary limited to 1 exam per Enrollee per Year. Exam Options: $10 copay Standard Contact Lens Fit and Follow-Up Up to $55 Premium Contact Lens Fit and Follow-Up 10% off retail price Fundus Photography Up to $39

9 Adult Vision Service Frames (any available frame at any Participating Provider location) limited to 1 set per Enrollee per Year. Standard Plastic Lenses limited to 1 set of lenses per Enrollee per Year. Single Vision Bifocal Trifocal Lenticular Standard Progressive Lens Premium Lens Options: Member Cost In-Network $0 copay; $130 allowance, 20% off balance over $130 $20 copay $20 copay $20 copay $20 copay $85 copay See premium price list at eyemed.com UV Treatment $15 Tint (solid or gradient) $15 Standard Plastic Scratch Coating $0 copay Standard Polycarbonate Adults $40 Standard Anti-Reflective Coating $45 Polarized 20% off retail price Photocromatic/Transitions Plastic $75 Premium Anti-Reflective Other Add-Ons Contact Lenses allowance includes materials only, covered once per Enrollee per Year. See premium price list at eyemed.com 20% off retail price Conventional $0 copay; $130 allowance, 15% balance over $130 Disposable Medically Necessary $0 copay; $130 allowance, plus balance over $130 $0 copay, paid in full * The Enrollee s reimbursement will be the lesser of the listed amount or the Enrollee s actual cost for receiving the adult vision service from the Non-Participating Provider. The reimbursement allowance applies to a single service and provides no remaining balance for future use within the stated time period.

10 Additional Discounts on Vision Services: (1) Enrollees receive a 0% discount on items not covered by us at Participating Providers. Discount does not apply to a Participating Provider s professional services or contact lenses. Discounts cannot be combined with any other discounts or promotional offers. Discounts do not apply to certain brand name Vision Materials in which the manufacturer imposes a no-discount practice. Discounts do not apply to items covered by another group benefit plan providing vision services. (2) Enrollees receive 15% off retail price or 5% off promotional price for Lasik or Photo Refractive Keratectomy (PRK) from the US Laser Network, owned and operated by LCA Vision. (3) After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the Enrollee. Details are available at [ The contact lens benefit allowance is not applicable to this service. (4) Reimbursement for certain adult vision services from Non-Participating Providers: If an Enrollee elects to receive the following adult vision services from a Non- Participating Provider, the Enrollee must pay the Non-Participating Provider rendering the service in full. The Enrollee s cost for receiving such adult vision services from the Non-Participating Provider will qualify for a limited amount of reimbursement. The Enrollee must submit to us a completed Non-Participating Provider Form (or Out-of- Network Form ) along with a copy of their receipt in order to receive a reimbursement. The Enrollee s reimbursement will be the lesser of the listed amount or the Enrollee s actual cost for receiving the Covered Service from the Non-Participating Provider. Pediatric High (for members under age 19) Routine/Preventive Services Diagnostic and Preventive Services exams, cleanings, fluoride, and space maintainers Member Cost Share Emergency Palliative Treatment to temporarily 0% relieve pain Radiographs X-rays 0% Sealants to prevent decay of permanent teeth 0% Basic Services Minor Restorative Services fillings and crown repair 50% 0%

11 Oral Surgery Services extractions and dental surgery Member Cost Share 50% Endodontic Services root canals 50% Periodontic Services to treat gum disease 50% Relines and Repairs to bridges and dentures 50% Other Basic Services misc. services 50% Major Services Prosthodontic Services bridges, dentures and implants 50% Major Restorative Services crowns 50% Orthodontic Services Orthodontic Services braces when medically necessary 50% In-Network Out-of-Pocket Maximum An Out-of-Pocket Maximum is the maximum amount that you or an Eligible will pay for Covered Services provided to an Eligible throughout a Year. The In-Network Out-of- Pocket Maximum shall be $350 per Year if this Certificate covers one Eligible, or $700 per Year if this Certificate covers two or more Eligible s. Any Copayments, s or other out-of-pocket expenses paid by you or an Eligible for In-Network EHB Covered Services provided to an Eligible shall count toward that In-Network Out-of-Pocket Maximum. The In-Network Out-of-Pocket Maximum will not include any amounts paid for the following: (i) premiums; (ii) payments made by you or an Eligible for non-covered Services; or (iii) payments made by you or an Eligible to Out-of- Network Dentists. Once the applicable In-Network Out-of-Pocket Maximum is reached for the Year, all In-Network EHB Covered Services provided to an Eligible will be covered at 100% of the Maximum Approved Fee. Out-of-Network Out-of-Pocket Maximum There is no annual Out-of-Pocket Maximum for Out-of- Network EHB Covered Services. You will be responsible for all Copayments, s and Balanced Billing Amounts associated with all Out-of-Network EHB Covered Services provided to you or your Eligible Dependent throughout the Year. Annual and Lifetime Maximum Payments For all EHB Covered Services provided to individuals under the age of 19, there are no annual or lifetime Maximum Payments. s for EHB Covered Services $50 per person per Year limited to a maximum of $150 for all individuals covered by this Certificate per Year. The does not apply to diagnostic and preventive services, emergency palliative treatment, radiographs, sealants and orthodontics.

12 Waiting Period for EHB Covered Services There are no waiting periods for individuals under the age of 19 seeking EHB Covered Services. Adult (for members age 19 and older) Routine/Preventive Services Diagnostic and Preventive Services exams, cleanings, fluoride, and space maintainers Member Cost Share Emergency Palliative Treatment to temporarily 0% relieve pain Radiographs X-rays 0% Sealants to prevent decay of permanent teeth 0% Basic Services Minor Restorative Services fillings and crown repair 50% Oral Surgery Services extractions and dental surgery 50% Endodontic Services root canals 50% Periodontic Services to treat gum disease 50% Relines and Repairs to bridges and dentures 50% Major Restorative Services crowns 50% Other Basic Services misc. services 50% Major Services 0% Prosthodontic Services bridges, dentures and implants 50% Maximum Payment - $750 per person total per benefit year on diagnostic & preventive, basic services, and major services. - $50 deductible per person total per benefit year on all services except diagnostic and preventive services, emergency palliative treatment, sealants, and brush biopsy.