No Charge (Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")

Transcription

1 City of Los Angeles Custom Access+ HMO SaveNet (Narrow) Zero Admit 15 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Highlights: A description of the prescription drug coverage is provided separately THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This plan has a special network including a limited number of Physicians, Independent Practice Associations (IPAs) and Medical Groups and a limited Service Area which includes only certain counties and cities as described in the Evidence of Coverage and Access+ HMO Comparison. You must live and/or work in this limited Service Area in order to enroll in this Plan Effective January 1, 2016 Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum $500 per Individual / $1,000 per 2-persons / $1,500 per Family LIFETIME BENEFIT MAXIMUM Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits for children under age 5 Physician and specialist office visits for members age 5 and older $15 per visit (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services) Outpatient X-ray, pathology and laboratory Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) Access+ Specialist SM Benefits 1 Office visit, Examination or Other Consultation (Self-referred office visits and consultations only) $30 per visit Preventive Health Benefits Preventive Health Services (As required by applicable federal and California law.) OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery Center 2 Outpatient surgery in a hospital Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care) Inpatient Medically Necessary skilled nursing Services including Subacute Care 3, 4 EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission (The ER copayment does not apply if the $100 per visit member is directly admitted to the hospital for inpatient services) Emergency room Physician Services AMBULANCE SERVICES Emergency or authorized transport PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits A description of your outpatient prescription drug coverage is provided separately. If you do not have the separate drug summary that goes with this benefit summary, please contact your benefits administrator or call the Member Services number on your identification card. An independent member of the Blue Shield Association

2 PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (Separate office visit copay may apply) Orthotic equipment and devices (Separate office visit copay may apply) DURABLE MEDICAL EQUIPMENT Breast pump Other Durable Medical Equipment (member share is based upon allowed charges) MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 5, 6 Inpatient Hospital Services Residential Care Inpatient Physician Services Routine Outpatient Mental Health and Substance Abuse Services for children under age 5 (includes professional/physician visits) Routine Outpatient Mental Health Services and Substance Abuse Services for members $15 per visit age 5 and older (includes professional/physician visits) Non-Routine Outpatient Mental Health and Substance Abuse Services (includes behavioral health treatment, electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization programs and transcranial magnetic stimulation.) HOME HEALTH SERVICES Home health care agency Services (up to 100 visits per Calendar Year) Medical supplies (See "Prescription Drug Coverage" for specialty drugs) OTHER Hospice Program Benefits Routine home care Inpatient Respite Care 24-hour Continuous Home Care General Inpatient care Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits (For inpatient hospital services, see "Hospitalization Services.") Abortion services 8 Family Planning and Infertility Benefits Counseling and consulting 7 Infertility Services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT). Tubal ligation Vasectomy 8 Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Office location (Copayment applies to all places of services, including professional and facility settings) $15 per visit Speech Therapy Benefits Office Visit (Copayment applies to all places of services, including professional and facility settings) $15 per visit Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for testing supplies see Outpatient Prescription Drug Benefits.) Diabetes self-management training $15 per visit Urgent Care Benefits (BlueCard Program) Urgent Services outside your Personal Physician Service Area $15 per visit Optional Benefits Optional dental, vision, hearing aid, infertility, chiropractic or chiropractic and acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 1 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health and substance abuse services must be provided by a MHSA network participating provider. 2 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 3 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan deductible has been met. 4 Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities.

3 5 Mental health and Substance Abuse services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. 6 Inpatient services for acute detoxification are covered under the medical benefits; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield participating providers. 7 Includes insertion of IUD, as well as injectable and implantable contraceptives for women. 8 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Plan designs may be modified to ensure compliance with state and federal requirements. A44726 (1/15) MP032515

4 City of Los Angeles Custom Access+ HMO and Access+ HMO SaveNet Plans Outpatient Prescription Drug Coverage (For groups of 300 and above) THIS DRUG COVERAGE SUMMARY IS ADDED TO BE COMBINED WITH THE ACCESS+ HMO OR ADDED ADVANTAGE POS PLANS UNIFORM HEALTH PLAN BENEFITS AND COVERAGE MATRIX. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Blue Shield of California Highlight: 3-Tier/Incentive Formulary $0 Calendar Year Brand-Name Drug Deductible $10 Formulary Generic/$20 Formulary Brand Name/$40 Non-Formulary Brand Name Drug - Retail Pharmacy $20 Formulary Generic/$40 Formulary Brand Name/$80 Non-Formulary Brand-Name Drug - Mail Service Covered Services DEDUCTIBLES (Prescription drug coverage benefits are not subject to the medical plan deductible.) Calendar Year Brand Name Drug Deductible PRESCRIPTION DRUG COVERAGE 1,2 Member Copayment Participating Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive Drugs and Devices 3 $0 per prescription Formulary Generic Drugs $10 per prescription Formulary Brand Name Drugs 4, 5 $20 per prescription Non-Formulary Brand Name Drugs 4, 5 $40 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive Drugs and Devices 3 $0 per prescription Formulary Generic Drugs $20 per prescription Formulary Brand Name Drugs 4, 5 $40 per prescription Non-Formulary Brand Name Drugs 4, 5 $80 per prescription Specialty Pharmacies (up to a 30-day supply) 6 Specialty Drugs 7 Formulary Generic Drugs Formulary Brand Name Drugs $10 per prescription $20 per prescription Non-Formulary Brand Name Drugs $40 per prescription 1 Amounts paid through copayments and any applicable brand-name drug deductible accrues to the member's medical calendar-year out-of-pocket maximum. Please refer to the Evidence of Coverage and Plan Contract for exact terms and conditions of coverage. Please note that if you switch from another plan, your prescription drug deductible credit, if applicable, from the previous plan during the calendar year will not carry forward to your new plan. 2 Drugs obtained at a Non-Participating Pharmacy are not covered, unless Medically Necessary for a covered emergency. 3 Contraceptive Drugs and Devices covered under the outpatient prescription drug benefits will not be subject to the applicable calendar-year brand-name drug deductible. If a brand-name contraceptive is requested when a generic equivalent is available, the member will be responsible for paying the difference between the cost to Blue Shield for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment. 4 Select formulary and non-formulary drugs require prior authorization by Blue Shield for Medical Necessity, or when effective, lower cost alternatives are available. 5 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in cost to Blue Shield between the brand-name drug and its generic drug equivalent. An independent member of the Blue Shield Association

5 6 Specialty Drugs are specific Drugs used to treat complex or chronic conditions which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the patient or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy and may require prior authorization for Medical Necessity by Blue Shield. Infused or Intravenous (IV) medications are not included as Specialty Drugs. 7 Specialty drugs are covered only when dispensed by select pharmacies in the Specialty Pharmacy Network unless Medically Necessary for a covered emergency. Note: This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. Important Prescription Drug Information You can find details about your drug coverage three ways: 1. Check your Evidence of Coverage. 2. Go to blueshieldca.com and log onto My Health Plan from the home page. 3. Call Member Services at the number listed on your Blue Shield member ID card. At Blue Shield of California, we're dedicated to providing you with valuable resources for managing your drug coverage. Go online to the Pharmacy section of blueshieldca.com and select the Drug Database and Formulary to access a variety of useful drug information that can affect your out-of-pocket expenses, such as: Look up non-formulary drugs with formulary or generic equivalents; Look up drugs that require step therapy or prior authorization; Find specifics about your prescription copayments; Find local network pharmacies to fill your prescriptions. TIPS! Using the convenient mail service pharmacy can save you time and money. If you take a consistent dose of a covered maintenance drug for a chronic condition, such as diabetes or high blood pressure, you can receive up to a 90-day supply through the mail service pharmacy with a reduced copayment. Call the mail service pharmacy at (866) Members using TTY equipment can call TTY/TDD Plan designs may be modified to ensure compliance with state and federal requirements. A16149-d (1/15) MP032515

6 City of Los Angeles Chiropractic and Acupuncture Benefits Additional coverage for your Access+ HMO and Access+ HMO SaveNet Plans Blue Shield Chiropractic and Acupuncture Care coverage lets you self-refer to a network of more than 3,310 licensed chiropractors and more than 1,245 licensed acupuncturists. Benefits are provided through a contract with American Specialty Health Plans of California, Inc. (ASH Plans). How the Program Works You can visit any participating chiropractors or acupuncturists in California from the ASH Plans network without a referral from your Access+ HMO Personal Physician. Simply call a participating provider to schedule an initial exam. At the time of your first visit, you ll present your Blue Shield identification card and pay only your copayment. Because participating chiropractors and acupuncturists bill ASH Plans directly, you ll never have to file claim forms. If you need further treatment, the participating chiropractor or acupuncturist will submit a proposed treatment plan to ASH Plans and obtain the necessary authorization from ASH Plans to continue treatment up to the calendar-year maximum of 50 combined visits. What s Covered The plan covers medically necessary chiropractic and acupuncture services including: Initial and subsequent examinations Office visits and adjustments (subject to annual limits) Adjunctive therapies X-rays (chiropractic only) Benefit Plan Design Calendar-year Maximum Calendar-year Deductible 50 Combined Visits Calendar-year Chiropractic Appliances Benefit 1,2 $50 Covered Services Acupuncture Services Chiropractic Services Out-of-network Coverage 1. Chiropractic appliances are covered up to a maximum of $50 in a calendar-year as authorized by ASH Plans. Member Copayment $15 per visit $15 per visit 2. As authorized by ASH Plans, this allowance is applied toward the purchase of items determined necessary, such as supports, collars, pillows, heel lifts, ice packs, cushions, orthotics, rib belts and home traction units. Friendly Customer Service Helpful ASH Plans Member Services representatives are available at (800) Monday through Friday from 6 a.m. to 5 p.m. to answer questions, assist with problems, or help locate a participating chiropractor or acupuncturist. This document is only a summary for informational purposes. It is not a contract. Please refer to the Evidence of Coverage and the Group Health Service Agreement for the exact terms and conditions of coverage. An independent member of the Blue Shield Association A17273 (01/15) MP032515

7 City of Los Angeles Additional Hearing Aid and Ancillary Equipment Benefit Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix) Additional coverage for your Access+ HMO and Access+ HMO SaveNet Plans How the Plan Works In addition to the benefits set forth in the Benefit Summary (Uniform Benefits and Coverage Matrix), your group has added hearing aid benefits to your benefit plan. Coverage includes hearing aid services, subject to the conditions and limitations listed below. Services provided in this hearing aid Services Benefit and hearing aid expenses in excess of the maximum allowance are not included in the calculation of the Subscriber s Maximum Calendar-Year Out-of-Pocket Responsibility. Coverage Details The hearing aid allowance includes: A hearing aid instrument, monaural or binaural, including ear mold(s) Visit for fitting, counseling, and adjustments The initial battery Cords Other ancillary equipment Benefit Plan Design Plan Options Benefit Allowance Access+ HMO and Access+ HMO SaveNet Plans One hearing aid per ear every 24 months The following services and supplies are not covered: Purchase of batteries or other ancillary equipment, except those covered under the terms of the initial hearing aid purchase Charges for a hearing aid which exceed specifications prescribed for correction of a hearing loss Replacement parts for hearing aids, repair of hearing aid after the covered warranty period and replacement of a hearing aid more than once in any period of 24 months Surgically implanted hearing devices All benefits are subject to the general provisions, limitations and exclusions listed in your Evidence of Coverage An independent member of the Blue Shield Association A45833 (01/15) MP032515

8 Blue Shield of California Vision Plan Custom Vision 10/10/130 Exam copayment $10, materials copayment $10, frame allowance $130 City of Los Angeles Custom Benefit Summary Effective January 1, 2016 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Using your vision plan With this vision plan, you have access to an extensive network of vision providers in California and nationwide 1. Many of the providers are conveniently located in optical centers at retail stores 2 such as LensCrafters, Sears, Target Optical, Wal-Mart (wholesale 3 ), and Costco (warehouse 3, membership required). You also can use an online network provider for 24/7 access to contact lenses. When you use a network provider other than an online provider, many of your eyecare services are provided at no additional charge. What your vision plan covers Covered services and eyewear Comprehensive Examination - every 12 months Coverage when provided by network providers (after applicable copayment) Maximum payment when provided by non-network provider Copayments are not applicable to out of network benefits Ophthalmologic 100% up to a maximum of $49 Optometric 100% up to a maximum of $49 Lenses 4 - every 24 months 5 Single Vision 100% up to a maximum of $35 Bifocal 100% up to a maximum of $49 Trifocal 100% up to a maximum of $74 Lenticular or Aphakic Monofocal 100% up to a maximum of $120 Lenticular or Aphakic Multifocal 100% up to a maximum of $200 Polycarbonate Lenses for Dependent Children (to age 19) 100% N/A Progressive Lenses (no-line bifocals) 100% after copay + $65 up to a maximum of $49 Frame - every 24 months up to a maximum of $130 3 up to a maximum of $50 Contact Lenses 6 - every 24 months 5 Non-Elective (Medically Necessary) - Hard 7 100% up to a maximum of $250 Non-Elective (Medically Necessary) - Soft 7 100% up to a maximum of $250 Elective (Cosmetic/Convenience) - Hard/Soft up to a maximum of $130 up to a maximum of $92 Diabetes Management Referral 8 100% Not Covered An Independent Licensee of the Blue Shield Association Custom (1/16

9 Accessing your vision benefits is easy, just follow these steps: 1. Prior to receiving a service, review your benefit information outlined in the chart on the previous page. 2. Call and make an appointment with a network provider. 3. Alternatively, login to MESVisionOptics.com to access the online network provider to purchase contact lenses online using your benefits. You will be reimbursed for your expenses up to the maximum payment allowed (see table on previous page). Note that when your dependents submit a claim form for reimbursement, payment will be made to you. Be sure to use your Blue Shield member identification number when filling out the form. Or: If you use a non-network provider, you're required to pay the provider's bill at the time of service. You can get reimbursement by obtaining a claim form from your employer or by logging on to blueshieldca.com. Click Member Forms and select the Vision Benefit Claim Form (C ) link. Complete and submit the claim form with the itemized receipt and a copy of your prescription to: Blue Shield of California P.O. Box Santa Ana, CA Your vision coverage is underwritten by Blue Shield of California and administered by a contracted vision plan administrator. Find a network provider nearest you by going to the Find a Provider section on blueshieldca.com, or calling Member Services at (877) You'll find a complete listing of ophthalmologists, optometrists, and opticians. 1 Nationwide vision providers are available by arrangement through a contracted vision plan administrator. 2 Availability of retail store locations varies by state. Refer to blueshieldcavision.com for out-of-state retail locations. 3 When the network provider uses wholesale or warehouse pricing, the maximum allowable frame allowance will be as follows: wholesale allowance: $84.91, warehouse allowance $ Network providers using wholesale or warehouse pricing are identified in the Directory of Network Vision Providers. You pay any cost above the allowed amount. 4 Fit any frame with an eye size less than 61 mm. 5 A change in standard lenses (excludes unusual lenses, such as oversize, no-line bifocal, or a material other than ordinary plastic) or contact lenses is covered per 12-month period if required by qualified prescription change, defined as a change in prescription of 0.50 diopters or more in one or both eyes; a shift in axis of astigmatism of 15 degrees; a difference in vertical prism greater than one prism diopter; or a change in lens type. 6 In lieu of lenses and frame. 7 A report from the provider and prior authorization from a contracted vision plan administrator is required. 8 The diabetes disease management referral program is available to employees who enroll in both Blue Shield medical and vision coverage.