Health Insurance Matrix 01/01/18-12/31/18

Transcription

1 Employee Contributions Family Monthly : $ Bi-Weekly : $71.84 Monthly : $ Bi-Weekly : $ Monthly : $ Bi-Weekly : $ Monthly : $ Bi-Weekly : $ Employee Contributions Individual Monthly : $55.53 Bi-Weekly : $27.77 Monthly : $ Bi-Weekly : $63.24 Monthly : $ Bi-Weekly : $92.82 Monthly : $ Bi-Weekly : $ Office Visits Preventive care - including routine physical, gynecological, well child, school, camp, sports, Routine OB-GYN Exams Primary Care Physician: $0 after Specialist: $0 Primary Care Physician: $25 Specialist: $25 Primary Care Physician: $25 Specialist: $25 In Network : $25 In Network : $0 (one per calendar year) Pap Smears Included as part of the physical exam Included as part of the physical exam Included as part of the physical exam Included as part of the physical exam Routine Colonoscopy Chiropractic Services Diagnostic Laboratory and X-Rays High Tech Radiology - CT Scans, MRIs, and PET Scans Dependent Coverage $25 co-payment $25 co-payment $75 co-payment (No Deductible) Only charged twice annually per member $75 co-payment Only charged twice annually per member In Network : $25 (20 visits) In Network : $75 co-payment Page 1 of 5

2 Emergency Room Visits No (waived if admitted or for observation) (waived if admitted or for observation) (waived if admitted or for observation stay) Mental Health Counseling $25 co-payment - Individual Therapy $25 co-payment - Individual Therapy Doctor Selection HMO Network HMO Network HMO Network In Network : $25 co-payment - Individual Therapy In Network : CareLink Out-of-Network : All Others Pre-Existing Condition No restriction No restriction No restriction No restriction Out-of-Area Emergency Care Non-Emergency Hospital Admission Prescription Drugs Retail (Any participating pharmacy) Coverage through OptumRX ( ) Prescription Drugs Mail Order - 90-Day Supply Coverage through OptumRX ( ) Dental Care, Routine Exams, Cleaning After After N/A N/A N/A N/A Page 2 of 5

3 Pediatric Preventive Dental Coverage for Dependent Children under age 12 Calendar Year Deductibles Calendar Year Out-of- Pocket Maximum: includes all medical and prescription copayments, and coinsurance. For most services, you must meet a before services are provided: $1,500 for an individual, or $3,000 for a family. If enrolled in a family contract the entire family must be satisfied before Tufts Health Plan will begin to pay claims for any family member. $2,500 for each member, or $5,000 for all family members covered under the same membership For some services, you must meet a before services are provided: $1,000 for each member, or $2,000 $5,000 for each member, or $10,000 N/A $2,500 for each member, or $5,000 Out-of-Network : Not Covered In Network : N/A Out of Network : $500 for each member, or $1,000 for all family members covered under the same membership $2,500 for each member, or $5,000 for all family members covered under the same membership Inpatient Hospital Services - Semi-Private Room Inpatient Hospital Services - Private Room Yes Yes Yes Yes When medically necessary When medically necessary When medically necessary When medically necessary Inpatient Hospital Care & Surgery after the. $1,000 for each member, or $2,000 for all family members covered under $500 co-payment per admission In Network : $500 co-payment Page 3 of 5

4 Outpatient (Day) Surgery Hospital or Surgical Facility Outpatient (Day) Surgery Office Setting Lifetime Maximum (Catastrophic Illness) Optical--through EyeMed $250 co-pay per visit Applicable Office Visit Copay Applies Applicable Office Visit Copay Applies In Network: $250 co-payment Out-of-Network: 20% co-insurance In Network : Applicable Office Visit Copay Applies None None None None Durable Medical Equipment 20% cost share 20% cost share 20% cost share In Network: 20% cost share Out of network: 20% cost share after Diabetic Equipment 20% cost share. providers and are covered in full after magnifying aids - after benefit. (No Deductible) providers and are covered in full after benefit (No ). providers and are covered in full benefit providers and are covered in full (In- Network) or 20% coinsurance (Out-of- Page 4 of 5

5 Wellness Plans Weight Loss Benefit: $150 per year per Weight Loss Benefit: $150 per year Weight Loss Benefit: $150 per year Weight Loss Benefit: $150 per year per per per week Programs at UMASS Massage: week Programs at UMASS Massage: week Programs at UMASS Massage: week Programs at UMASS Massage: 25% off usual and customary 25% off usual and customary 25% off usual and customary 25% off usual and customary or $15 per 15 minutes Acupuncture: or $15 per 15 minutes Acupuncture: or $15 per 15 minutes Acupuncture: or $15 per 15 minutes Acupuncture: 25% off usual and customary 25% off usual and customary 25% off usual and customary 25% off usual and customary Unique Features Allergy Injections: Deductible applies Disorder Treatment: 100% after - no limit (Physical and Occupational): 100% - Covered up to 30 visits each per calendar year Allergy Injections: $5 copay Disorder Treatment: 100% after - no limit (Physical and Occupational): 100% - Covered up to 30 visits each per calendar year Allergy Injections: $5 copay Disorder Treatment: $25 copayment - no limit (Physical and Occupational): $25 copayment - Covered up to 30 visits each per calendar year Hospitals 100% of all MA, NH, and RI hospitals 100% of all MA, NH, and RI hospitals 100% of all MA, NH, and RI hospitals Allergy Injections: In-Network: $5 co-payment Disorder Treatment: In-Network: $25 copayment - no limit (Physical and Occupational): In-Network: $25 co-payment - Covered up to 30 visits each per calendar year National network of providers and hospitals For a complete description of benefits, please refer to your plan certificate (booklet). In case of a discrepancy, the plan certificate will prevail. Page 5 of 5