POS Plans. Administered by Optima Health Plan BENEFIT INFORMATION GUIDE

Transcription

1 POS Plans Administered by Optima Health Plan BENEFIT INFORMATION GUIDE v7.2016

2 If you are considering Optima Health or are new to the plan and do not have a member ID card, please call us toll-free at Visit to: View a list of Plan providers Change your Plan primary care physician (PCP) Update your home address, phone number, or address Order a new member ID card or print member ID card View your claims history View your benefits View your authorizations Download member forms Learn about member discounts Manage your pharmacy benefit (if administered by Optima Health) Research drug options and pricing Choose to receive your Explanation of Benefits (EOB) electronically Research conditions, treatment options, and hospital quality You will need to register on optimahealth.com/members in order to access your secure member information, as well as special tools available only to Optima Health members. Member Services Call the number listed on the back of your member ID card. Office hours: Mon. Fri. 8 a.m. to 6 p.m. After business hours, please leave a message. After Hours Nurse Advice Line Call the number listed on the back of your member ID card. Behavioral Health Services Language services for non-english speaking members Call the number listed on the back of your member ID card to access language services. TDD line for the hearing impaired Optima Health uses the Virginia Relay Service Optima Health Mobile App MyOptima On the Go? Download the Optima Health Mobile App MyOptima to your smartphone or tablet and access your member ID card, benefits, claims, and more, anywhere, anytime, anyplace. Optima Individual Health Plans Customer Service (for current members) For new sales inquiries and quotes: Phone: Website: optimahealth.com/individual members@optimahealth.com Please note: Members who register and sign in to optimahealth.com can contact Member Services securely using the Contact Us form. Mail Optima Health Member Services 4417 Corporation Lane Virginia Beach, VA 23462

3 Table of Contents Section 1: Uniform Summary of Benefits and Coverage (SBC)... 3 Section 2: Welcome to Optima Health...25 Section 3: Summary of Benefits (SOB)...55 Section 4: Pharmacy Information (Note: Mail Order Pharmacy is now managed by OptumRx) Section 5: eha ioral ealth Information Section 6: Other Health Insurance Information Section 7: Additional Resources Group Name: City of VA Beach and VA Beach City Public Schools Effective Date: 01/01/2018 1

4 2

5 3 Uniform Summary of Benefits and Coverage (SBC)

6 4

7 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018 POS Premier Coverage for: Individual/Family Plan Type: POS VA Beach Schools/City The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit optimahealth.com or call For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? $850/Individual or $1,700/family in-network. $1,700/Individual or $3,400/family out-of-network Yes. Preventive care, Vision Care and Materials are covered before you meet your deductible. No. For in-network providers $3,000 individual / $6,000 family. For outof-network providers, $4,500 individual / $9,000 family Premiums, balance-billed charges, healthcare this plan doesn t cover, ancillary drug charges and preauthorization penalties. Yes. See optimahealth.com or call for a list of network providers. No. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at You don t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don t count toward the out of pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. 1 of 6 5

8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) In-Network Provider (You will pay the least) $20 copayment/sqcn Deductible does not apply $40 copayment/all other Deductible does not apply $40 copayment/sqcn Deductible does not apply $60 copayment/all other Deductible does not apply No charge Deductible does not apply Imaging (CT/PET scans, MRIs) 15% coinsurance Selected Generic drugs (Tier 1) Selected brand and other generic drugs (Tier 2) Non-selected brand drugs (Tier 3) What You Will Pay Out-of-Network Provider (You will pay the most) 40% coinsurance --none-- 40% coinsurance --none-- 40% coinsurance 15% coinsurance 40% coinsurance --none-- $10 copayment/preferred network/$25 copayment retail /$25 copayment mail order $25 copayment/preferred network/$45 copayment retail /$60 copayment mail order 25% Coinsurance: $50 max preferred network/$75 max retail/$125 max mail order 40% coinsurance $10 copayment/preferred network/$25 copayment retail / mail order not covered $25 copayment/preferred network/$45 copayment retail / mail order not covered 25% Coinsurance: $50 max preferred network/$75 max retail/ mail order not covered Specialty drugs (Tier 4) 25% coinsurance retail 25% coinsurance retail Limitations, Exceptions, & Other Important Information You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Benefits may be denied or reduced without pre-authorization Coverage is limited to maximum $150 ancillary cap per prescription per month in addition to applicable Copayment/Coinsurance. Coverage is limited to FDA-approved prescription drugs. If brand drugs are used when a generic is available, you must pay the difference in cost plus the Copayment or Coinsurance amount. Covers up to a 31-day supply (retail); 31- to 90-day supply (mail order). Not all drugs are available through a mail order program. * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com. 6 2 of 6

9 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant If you need help recovering or have other special health needs Services You May Need In-Network Provider (You will pay the least) $200 max/ mail order not covered What You Will Pay Out-of-Network Provider (You will pay the most) $200 max/ mail order not covered Limitations, Exceptions, & Other Important Information Facility fee (e.g., ambulatory Benefits may be denied or reduced without 15% coinsurance 40% coinsurance surgery center) pre-authorization Physician/surgeon fees 15% coinsurance 40% coinsurance --none-- Emergency room care 15% coinsurance 15% coinsurance --none-- No charge/vb Volunteer Benefits may be denied or reduced without Emergency medical Rescue Squad, deductible 15% coinsurance pre-authorization for use other than emergency transportation does not apply services 15% coinsurance/all other Urgent care 15% coinsurance 40% coinsurance --none-- Facility fee (e.g., hospital room) 15% coinsurance 40% coinsurance Benefits may be denied or reduced without pre-authorization. Physician/surgeon fees 15% coinsurance 40% coinsurance --none-- Outpatient services $20 copayment/sqcn Deductible does not apply $40 copayment/all other Deductible does not apply 40% coinsurance Inpatient services 15% coinsurance 40% coinsurance Benefits may be denied or reduced without pre-authorization for intensive outpatient program, partial hospitalization services, electroconvulsive therapy, and Transcranial Magnetic Stimulation. No coverage for residential treatment Benefits may be denied or reduced without pre-authorization for all inpatient services. Office visits $350 global copayment 40% coinsurance Benefits may be denied or reduced without Childbirth/delivery professional pre-authorization for prenatal services. Cost 15% coinsurance 40% coinsurance services sharing does not apply to certain preventive services. Maternity care may include tests and Childbirth/delivery facility 15% coinsurance 40% coinsurance services described elsewhere in this SBC (i.e. services ultrasound). Benefits may be denied or reduced without Home health care 15% coinsurance 40% coinsurance pre-authorization. 100 combined visits/plan year Rehabilitation services 15% coinsurance 40% coinsurance Benefits may be denied or reduced without * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com. 7 3 of 6

10 Common Medical Event If your child needs dental or eye care Services You May Need In-Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Habilitation services Not covered Not covered --none-- Skilled nursing care 15% coinsurance 40% coinsurance Durable medical equipment 15% coinsurance 40% coinsurance Hospice services 15% coinsurance 40% coinsurance Children s eye exam Children s glasses $20 copayment/spectacles $40 copayment/contact lenses Deductible does not apply Allowances: $100/spectacles $95/contact lenses Deductible does not apply $40 reimbursement Deductible does not apply Not covered Children s dental check-up Not covered Not covered --none-- Limitations, Exceptions, & Other Important Information pre-authorization. 30 combined visits/plan year for PT, OT. 30 visits/plan year for ST Benefits may be denied or reduced without pre-authorization. 100 combined days/plan year Benefits may be denied or reduced without pre-authorization for single items over $750, all rental items, and repair and replacement. Benefits may be denied or reduced without pre-authorization. Coverage limited to one exam/plan year from participating EyeMed providers Coverage limited to one pair/plan year from participating EyeMed providers Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Habilitation services Private-duty nursing Bariatric surgery Infertility treatment Routine foot care Cosmetic surgery Long-term care Weight loss programs Dental care (Adult) Pediatric dental check-up Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Chiropractic care Non-emergency care when traveling outside the Routine eye care (Adult) Hearing aids U.S. (under out-of-network benefit) * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com. 8 4 of 6

11 Your Rights to Continue Coverage: For more information on your rights to continue coverage, contact the plan at There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, at or 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 Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Member Services at the number on the back of your member ID card. You may also contact the Department of Labor's Employee Benefits Security Administration at EBSA (3272) or or your state department of insurance at the Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, P.O. Box 1157, Richmond, VA, 23218, or bureauofinsurance@scc.virginia.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, P.O. Box 1157, Richmond, VA, 23218, , or bureauofinsurance@scc.virginia.gov. Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next section. * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com. 9 5 of 6

12 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $850 Specialist copayment $350 Hospital (facility) coinsurance 15% Other coinsurance 15% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $850 Copayments $430 Coinsurance $1,500 What isn t covered Limits or exclusions $0 The total Peg would pay is $2,780 The plan s overall deductible $850 Specialist copayment $40 Hospital (facility) coinsurance 15% Other coinsurance 15% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $850 Copayments $875 Coinsurance $120 What isn t covered Limits or exclusions $55 The total Joe would pay is $1,900 The plan s overall deductible $850 Specialist copayment $40 Hospital (facility) coinsurance 15% Other coinsurance 15% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $850 Copayments $120 Coinsurance $160 What isn t covered Limits or exclusions $0 The total Mia would pay is $1,130 Note: These numbers assume the patient does not participate in the plan s wellness program. If you participate in the plan s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: The plan would be responsible for the other costs of these EXAMPLE covered services of 6

13 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018 POS Standard Coverage for: Individual/Family Plan Type: POS VA Beach Schools/City The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit optimahealth.com or call For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call to request a copy. Important Questions Answers Why This Matters: $1,350/Individual or $2,700/family What is the overall in-network. $2,600/Individual or deductible? $5,200/family out-of-network Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? Yes. Preventive care, Vision Care and Materials are covered before you meet your deductible. No. For in-network providers $3,500 individual / $7,000 family. For outof-network providers, $5,500 individual / $11,000 family Premiums, balance-billed charges, healthcare this plan doesn t cover, ancillary drug charges and preauthorization penalties. Yes. See optimahealth.com or call for a list of network providers. No. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible has to be met before the plan begins to pay. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at You don t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don t count toward the out of pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. 1 of 6 11

14 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) In-Network Provider (You will pay the least) 10% Coinsurance/SQCN 20% Coinsurance/all other 10% Coinsurance/SQCN 20% Coinsurance/all other No charge Deductible does not apply Imaging (CT/PET scans, MRIs) 20% coinsurance Selected Generic drugs (Tier 1) Selected brand and other generic drugs (Tier 2) Non-selected brand drugs (Tier 3) Specialty drugs (Tier 4) What You Will Pay Out-of-Network Provider (You will pay the most) 50% coinsurance --none-- 50% coinsurance --none-- 50% coinsurance 20% coinsurance 50% coinsurance --none-- $10 copayment/preferred network/$25 copayment retail /$25 copayment mail order $25 copayment/preferred network/$45 copayment retail /$60 copayment mail order 25% Coinsurance: $50 max preferred network/$75 max retail/$125 max mail order 25% coinsurance retail $200 max/ mail order not covered 50% coinsurance $10 copayment/preferred network/$25 copayment retail / mail order not covered $25 copayment/preferred network/$45 copayment retail / mail order not covered 25% Coinsurance: $50 max preferred network/$75 max retail/ mail order not covered 25% coinsurance retail $200 max/ mail order not covered Limitations, Exceptions, & Other Important Information You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Benefits may be denied or reduced without pre-authorization Medical deductible applies. Coverage is limited to maximum $150 ancillary cap per prescription per month in addition to applicable Copayment/Coinsurance. Coverage is limited to FDA-approved prescription drugs. If brand drugs are used when a generic is available, you must pay the difference in cost plus the Copayment or Coinsurance amount. Covers up to a 31-day supply (retail); 31- to 90-day supply (mail order). Not all drugs are available through a mail order program. Facility fee (e.g., ambulatory Benefits may be denied or reduced without 20% coinsurance 50% coinsurance surgery center) pre-authorization Physician/surgeon fees 20% coinsurance 50% coinsurance --none-- * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com of 6

15 Common Medical Event If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant If you need help recovering or have other special health needs Services You May Need In-Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Emergency room care 20% coinsurance 20% coinsurance --none-- No charge/vb Volunteer Benefits may be denied or reduced without Emergency medical Rescue Squad, deductible 20% coinsurance pre-authorization for use other than emergency transportation does not apply services 20% coinsurance/all other Urgent care 20% coinsurance 50% coinsurance --none-- Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance Benefits may be denied or reduced without pre-authorization. Physician/surgeon fees 20% coinsurance 50% coinsurance --none-- Outpatient services 10% Coinsurance/SQCN 20% Coinsurance/all other 50% coinsurance Inpatient services 20% coinsurance 50% coinsurance Office visits Childbirth/delivery professional services Childbirth/delivery facility services 10% Coinsurance/SQCN 20% Coinsurance/all other 50% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance Home health care 20% coinsurance 50% coinsurance Rehabilitation services 20% coinsurance 50% coinsurance Habilitation services Not covered Not covered --none-- Skilled nursing care 20% coinsurance 50% coinsurance Benefits may be denied or reduced without pre-authorization for intensive outpatient program, partial hospitalization services, electroconvulsive therapy, and Transcranial Magnetic Stimulation. No coverage for residential treatment Benefits may be denied or reduced without pre-authorization for all inpatient services. Benefits may be denied or reduced without pre-authorization for prenatal services. Cost sharing does not apply to certain preventive services. Maternity care may include tests and services described elsewhere in this SBC (i.e. ultrasound). Benefits may be denied or reduced without pre-authorization. 100 combined visits/plan year Benefits may be denied or reduced without pre-authorization. 30 combined visits/plan year for PT, OT. 30 visits/plan year for ST Benefits may be denied or reduced without pre-authorization. 100 combined days/plan * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com of 6

16 Common Medical Event If your child needs dental or eye care Services You May Need In-Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Durable medical equipment 20% coinsurance 50% coinsurance Hospice services 20% coinsurance 50% coinsurance Children s eye exam Children s glasses $20 copayment/spectacles $40 copayment/contact lenses Deductible does not apply Allowances: $100/spectacles $95/contact lenses Deductible does not apply $40 reimbursement Deductible does not apply Not covered Children s dental check-up Not covered Not covered --none-- Limitations, Exceptions, & Other Important Information year Benefits may be denied or reduced without pre-authorization for single items over $750, all rental items, and repair and replacement. Benefits may be denied or reduced without pre-authorization. Coverage limited to one exam/plan year from participating EyeMed providers Coverage limited to one pair/plan year from participating EyeMed providers Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Habilitation services Private-duty nursing Bariatric surgery Infertility treatment Routine foot care Cosmetic surgery Long-term care Weight loss programs Dental care (Adult) Pediatric dental check-up * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com of 6

17 Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Chiropractic care Non-emergency care when traveling outside the Routine eye care (Adult) Hearing aids U.S. (under out-of-network benefit) Your Rights to Continue Coverage: For more information on your rights to continue coverage, contact the plan at There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, at or bureauofinsurance@scc.virginia.gov; 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 Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Member Services at the number on the back of your member ID card. You may also contact the Department of Labor's Employee Benefits Security Administration at EBSA (3272) or or your state department of insurance at the Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, P.O. Box 1157, Richmond, VA, 23218, or bureauofinsurance@scc.virginia.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, P.O. Box 1157, Richmond, VA, 23218, , or bureauofinsurance@scc.virginia.gov. Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next section. * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com of 6

18 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $1350 Specialist coinsurance 10% Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $1,350 Copayments $40 Coinsurance $2,110 What isn t covered Limits or exclusions $0 The total Peg would pay is $3,500 The plan s overall deductible $1350 Specialist coinsurance 10% Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $1,350 Copayments $635 Coinsurance $135 What isn t covered Limits or exclusions $55 The total Joe would pay is $2,175 The plan s overall deductible $1350 Specialist coinsurance 10% Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $1,095 Copayments $0 Coinsurance $240 What isn t covered Limits or exclusions $0 The total Mia would pay is $1,335 Note: These numbers assume the patient does not participate in the plan s wellness program. If you participate in the plan s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: The plan would be responsible for the other costs of these EXAMPLE covered services of 6

19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018 POS Basic Coverage for: Individual/Family Plan Type: POS VA Beach Schools/City The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit optimahealth.com or call For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call to request a copy. Important Questions Answers Why This Matters: $2,000/Individual or $4,000/family What is the overall in-network. $4,000/Individual or deductible? $8,000/family out-of-network Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? Yes. Preventive care, Vision Care and Materials are covered before you meet your deductible. No. For in-network providers $4,000 individual / $8,000 family (not to exceed $7,350 for one individual). For out-of-network providers, $6,500 individual / $13,000 family Premiums, balance-billed charges, healthcare this plan doesn t cover, ancillary drug charges and preauthorization penalties. Yes. See optimahealth.com or call for a list of network providers. No. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible has to be met before the plan begins to pay. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at You don t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don t count toward the out of pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. 1 of 6 17

20 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) In-Network Provider (You will pay the least) 15% Coinsurance/SQCN 25% Coinsurance/all other 15% Coinsurance/SQCN 25% Coinsurance/all other No charge Deductible does not apply Imaging (CT/PET scans, MRIs) 25% coinsurance Selected Generic drugs (Tier 1) Selected brand and other generic drugs (Tier 2) Non-selected brand drugs (Tier 3) Specialty drugs (Tier 4) Facility fee (e.g., ambulatory surgery center) What You Will Pay Out-of-Network Provider (You will pay the most) 50% coinsurance --none-- 50% coinsurance --none-- 50% coinsurance 25% coinsurance 50% coinsurance --none-- $10 copayment/preferred network/$25 copayment retail /$25 copayment mail order $25 copayment/preferred network/$45 copayment retail /$60 copayment mail order 25% Coinsurance: $50 max preferred network/$75 max retail/$125 max mail order 25% coinsurance retail $200 max/ mail order not covered 50% coinsurance $10 copayment/preferred network/$25 copayment retail / mail order not covered $25 copayment/preferred network/$45 copayment retail / mail order not covered 25% Coinsurance: $50 max preferred network/$75 max retail/ mail order not covered 25% coinsurance retail $200 max/ mail order not covered 25% coinsurance 50% coinsurance Limitations, Exceptions, & Other Important Information You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Benefits may be denied or reduced without pre-authorization Medical deductible applies. Coverage is limited to maximum $150 ancillary cap per prescription per month in addition to applicable Copayment/Coinsurance. Coverage is limited to FDA-approved prescription drugs. If brand drugs are used when a generic is available, you must pay the difference in cost plus the Copayment or Coinsurance amount. Covers up to a 31-day supply (retail); 31- to 90-day supply (mail order). Not all drugs are available through a mail order program. Benefits may be denied or reduced without pre-authorization * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com of 6

21 Common Medical Event If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant If you need help recovering or have other special health needs What You Will Pay Out-of-Network Limitations, Exceptions, & Other Important Services You May Need In-Network Provider Provider Information (You will pay the least) (You will pay the most) Physician/surgeon fees 25% coinsurance 50% coinsurance --none-- Emergency room care 25% coinsurance 25% coinsurance --none-- No charge/vb Volunteer Benefits may be denied or reduced without Emergency medical Rescue Squad, deductible 25% coinsurance pre-authorization for use other than emergency transportation does not apply services 25% coinsurance/all other Urgent care 25% coinsurance 50% coinsurance --none-- Facility fee (e.g., hospital room) 25% coinsurance 50% coinsurance Benefits may be denied or reduced without pre-authorization. Physician/surgeon fees 25% coinsurance 50% coinsurance --none-- Outpatient services 15% Coinsurance/SQCN 25% Coinsurance/all other 50% coinsurance Inpatient services 25% coinsurance 50% coinsurance Office visits Childbirth/delivery professional services Childbirth/delivery facility services 15% Coinsurance/SQCN 25% Coinsurance/all other 50% coinsurance 25% coinsurance 50% coinsurance 25% coinsurance 50% coinsurance Home health care 25% coinsurance 50% coinsurance Benefits may be denied or reduced without pre-authorization for intensive outpatient program, partial hospitalization services, electroconvulsive therapy, and Transcranial Magnetic Stimulation. No coverage for residential treatment Benefits may be denied or reduced without pre-authorization for all inpatient services. Benefits may be denied or reduced without pre-authorization for prenatal services. Cost sharing does not apply to certain preventive services. Maternity care may include tests and services described elsewhere in this SBC (i.e. ultrasound). Benefits may be denied or reduced without pre-authorization. 100 combined visits/plan year Rehabilitation services 25% coinsurance 50% coinsurance Benefits may be denied or reduced without pre-authorization. 30 combined visits/plan year for PT, OT. 30 visits/plan year for ST Habilitation services Not covered Not covered --none-- Skilled nursing care 25% coinsurance 50% coinsurance Benefits may be denied or reduced without * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com of 6

22 Common Medical Event If your child needs dental or eye care Services You May Need In-Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Durable medical equipment 25% coinsurance 50% coinsurance Hospice services 25% coinsurance 50% coinsurance Children s eye exam Children s glasses $20 copayment/spectacles $40 copayment/contact lenses Deductible does not apply Allowances: $100/spectacles $95/contact lenses Deductible does not apply $40 reimbursement Deductible does not apply Not covered Children s dental check-up Not covered Not covered --none-- Limitations, Exceptions, & Other Important Information pre-authorization. 100 combined days/plan year Benefits may be denied or reduced without pre-authorization for single items over $750, all rental items, and repair and replacement. Benefits may be denied or reduced without pre-authorization. Coverage limited to one exam/plan year from participating EyeMed providers Coverage limited to one pair/plan year from participating EyeMed providers Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Habilitation services Private-duty nursing Bariatric surgery Infertility treatment Routine foot care Cosmetic surgery Long-term care Weight loss programs Dental care (Adult) Pediatric dental check-up Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Chiropractic care Non-emergency care when traveling outside the Routine eye care (Adult) Hearing aids U.S. (under out-of-network benefit) Your Rights to Continue Coverage: For more information on your rights to continue coverage, contact the plan at There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, at or bureauofinsurance@scc.virginia.gov; 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 Other coverage options * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com of 6

23 may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Member Services at the number on the back of your member ID card. You may also contact the Department of Labor's Employee Benefits Security Administration at EBSA (3272) or or your state department of insurance at the Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, P.O. Box 1157, Richmond, VA, 23218, or bureauofinsurance@scc.virginia.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Virginia State Corporation Commission, Life & Health Division, Bureau of Insurance, P.O. Box 1157, Richmond, VA, 23218, , or bureauofinsurance@scc.virginia.gov. Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next section. * For more information about limitations and exceptions, see the plan or policy document at optimahealth.com of 6

24 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $2000 Specialist coinsurance 15% Hospital (facility) coinsurance 25% Other coinsurance 25% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $2,000 Copayments $40 Coinsurance $1,960 What isn t covered Limits or exclusions $0 The total Peg would pay is $4,000 The plan s overall deductible $2000 Specialist coinsurance 15% Hospital (facility) coinsurance 25% Other coinsurance 25% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $2,000 Copayments $635 Coinsurance $195 What isn t covered Limits or exclusions $55 The total Joe would pay is $2,885 The plan s overall deductible $2000 Specialist coinsurance 15% Hospital (facility) coinsurance 25% Other coinsurance 25% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $1,030 Copayments $0 Coinsurance $310 What isn t covered Limits or exclusions $0 The total Mia would pay is $1,340 Note: These numbers assume the patient does not participate in the plan s wellness program. If you participate in the plan s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: The plan would be responsible for the other costs of these EXAMPLE covered services of 6

25 Optima Health Alternative Language Options for Notices and other Written Information English: This Notice has Important Information. This notice has important information about your application or coverage through Optima Health. Look for key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call Amharic: ይህ ማስታወቂያ ጠቃሚ መረጃ አለው ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም በOptima Health በኩል ስለሚኖርዎት ሽፋን ጠቃሚ መረጃ አለው በዚህ ማስታወቂያ ላይ ያሉትን ቁልፍ የሆኑ ቀናቶችን ያስተውሉ የጤና ሽፋንዎትን ለማስቀጠል ወይም ወጪዎትን ለማገዝ እንዲቻል በተወሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ሊያስፈልግዎ ይችላል በራስዎ ቋንቋ ያለምንም ክፍያ ይህን መረጃም ሆነ ድጋፍ የማግኘት መብት አለዎት ይደውሉ Arabic: یحتوي ھذا الا خطار على معلومات مھمة. یحتوي ھذا الا خطار على معلومات مھمة تتعلق بطلبك أو ببرنامج التغطیة الخاص بك لدى شركة التا مین الصحي.Optima Health ابحث عن التواریخ الري یسیة في ھذا الا خطار فقد تحتاج إلى اتخاذ أي إجراء قبل حلول المواعید النھاي یة للحفاظ على برنامج التغطیة الصحیة أو الحصول على مساعدة في التكالیف. ولدیك الحق في الحصول على ھذه المعلومات والمساعدة بلغتك بدون أي تكلفة. ی رجى الاتصال Bengali/Bangla: এই ব ত র প ণ তথ র য়ছ এই পন Optima Health ( অ ম হলথ)-এর ম ধ ম দ খল কর আপন র দরখ ব কভ রজর উপর র প ণ তথ র য়ছ এই ব ত উ খ কর র প ণ ত রখ ল দখ নন আপন র হলথ কভ রজ বজ য় র খ র জন ব খ রচর ব ষয় সহ য়ত ল ভর জন আপন ক নদ সময়স ম র মধ ব ব হণ ক রত হত প র বন খ রচ আপন র ম ত ভ ষ য় এই তথ এব সহ য়ত প ওয় র অধক র আপন র র য়ছ. কল Chinese (Mandarin): 该通知含有重要信息 本通知含有关于 Optima Health 申请或保险的重要信息 请仔细查看本通知中的关键日期 您需要在截止期之前采取相应的行动, 从而保障您的保险继续有效, 能够为您提供报销 您有权免费获取信息的中文版, 并可以免费获取到相关的中文帮助 請撥電話 French: Cet avis a d'importantes informations. Cet avis a d'importantes informations sur votre demande ou la couverture par l'intermédiaire de Optima Health. Rechercher les dates clés dans le présent avis. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l aide dans votre langue à aucun coût. Appelez German: Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Optima Health. Suchen Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter Hindi: इस स चन म महत वप णर ज नक र नहत ह इस स चन म Optima Health क म ध यम स आपक आव दन य कवर ज क ब र म महत वप णर ज नक र नहत ह इस स चन म नहत महत वप णर तथय क द ख आपक ल गत क स थ अपन स व स थ य क कवर ज रखन य सह यत क लए न त समय स म म क ररव ई करन क ज रत ह सकत ह आपक प स बन कस ल गत क अपन भ ष म इस ज नक र और सह यत क करन क अ धक र ह क ल Ibo: Ọkwa a nwere Ozi Dị Mkpa. Ọkwa a nwere ozi dị mkpa maka akwụkwọ anamachọihe ma ọ bụ mkpuchi gị sitere na Optima Health (Ahụike Optima). Chọọ ụbọchị ndị dị mkpa n'ọkwa a. Ị nwere ike ịme ihe tupu ụfọdụ ụbọchị iji dowe mkpuchi ahụike gị ma ọ bụ enyemaka n'ụgwọ. Ị nwere ike ikike ịnweta ozi na enyemaka a n'asụsụ gị na akwụghị ụgwọ ọ bụla. Kpọ

26 Korean: 이공지는매우중요한정보입니다. 이공지는옵티마핼스를통한귀하께적용되는지원이나보험에대한매우중요한정보입니다. 이공지의주요날짜를 찾아보십시오. 귀하께서는귀하의건강보험이나비용에관한도움에관련된특정마감일을지켜야만합니다. 귀하께서는따로비용없이귀하의언어로이정보와도움을받을 권리가있습니다. 로전화하십시오 Kru/Bassa: Náùm pò wùɖù nà kɛ kpà ɖɛ mìù. Ɔ mɔ ɖɛ kpà ɖɛ ɓá nì dyí kánà-kánà dyì ɖé Optima Health mú. Mɔ tì kpà ɖɛ ɓè nì ɖé náùm pò wùɖùɔ mú. Mɔ tì kpà ɖɛ ɓè nì ɖé náùm pò wùɖùɔ mú. M ɓè ɖé ɓɛ m ké náùm pò pòɔ ɔ mù pó dyì. Ɔ jù kè m dyì ɖɛ ɓɛà nyùɛn, m wíɖíɔ mù ɓì ɖì dyì. Wà ɓì ɖì ɓɛ wà kè náùm pó wùdù nà kɛ Ɓàsɔ wùɖù mù pò. Sebel Navajo: Díí saad ílíinii baa hane. Naaltsoos ni ííníłtsoozígíí éí doodago kwe é Optima Health nik é ésti ígíí bína ídíłkidgo díí kwe é hazhó ó baa ákonínízin dooleeł. Yoołkááł yę ędą ą nich į é élyaago biká ígíí hádídíí įįł. Díí niké ésti ígíí éi doodago béeso da bee níká a doowołígíí bikáa go da át ée dooleeł áko t áadoo bee e e aahí baa yíłkaahgo tsxį į łgo hasht e díílííł níi da dooleeł. Bee haz áanii hólǫ díí kót éego yaa halne ígíí bee níká a doowołgo dóó t áá nizaadk ehjí bee nił hodoonih t áadoo bą ą h ílíní. Átah ánǫ t í ígíí bee baa áháyą ągéé bich į bibéésh bee hane í hwéédilní Persian/Farsi: این اعلامیھ حاوی اطلاعات مھمی است. این اعلامیھ حاوی اطلاعات مھمی درباره درخواست شما و پوشش Optima Health است. بھ تاریخ ھای کلیدی عنوان شده در این اعلامیھ دقت کنید. ممکن است لازم باشد تا یک تاریخ مقرر خاص اقدام کنید تا پوشش بیمھ تان حفظ شود یا در رابطھ با ھزینھ ھا بھ شما کمک شود. شما از این حق برخوردار ھستید تا این اطلاعات و ھرگونھ راھنمایی دیگر را بھ زبان خودتان و بھ صورت رایگان دریافت کنید Russian: В данном уведомлении содержится важная информация. В данном уведомлении содержится важная информация о Вашей заявке или страховом покрытии в компании Optima Health. Обратите внимание на важные дaты, указанные в данном уведомлении. Если Вы хотите продолжать пользоваться мед.страхованием или получить помощь с оплатой, возможно, Вам потребуется принять решение до определенной даты. У Вас есть право на бесплатное получение данной информации и помощи на родном языке. Звоните по телефону Spanish: Este Aviso contiene información importante. Este aviso contiene información importante acerca de su solicitud o cobertura a través de Optima Health. Preste atención a las fechas clave que contiene este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al Tagalog: Ang Paunawang Ito ay Naglalaman ng Mahalagang Impormasyon. Ang paunawang ito ay naglalaman ng mahalagang impormasyon tungkol sa inyong aplikasyon o saklaw sa pamamagitan ng Optima Health. Hanapin ang mahahalagang petsa na nakasaad sa paunawang ito. Maaaring kailanganin ninyong gumawa ng hakbang bago sumapit ang ilang partikular na takdang petsa upang mapanatili ang inyong saklaw na pangkalusugan o tulong sa mga gastusin. Mayroon kayong karapatan na matanggap ang impormasyong ito at makakuha ng tulong sa inyong wika nang walang bayad. Tumawag sa Urdu: اس نوڻس میں اہم اطلاع موجود ہے اس نوڻس میں آپ کی درخواست یا Optima Health کے ذریعے کوریج کے حوالے سے اہم اطلاع موجود ہے اس نوڻس میں درج کلیدی تاریخوں کو ذہن میں رکھیں آپ کے لیے ضروری ہے کہ مخصوص ڈیڈلاي نوں سے قبل اس حوالے سے کوي ی ایکشن لیں تاکه آپ کی کوریج براي ے صحت اور لاگت کے حوالے سے معاملات طے رہیں آپ اس اطلاع تک رساي ی اور بغیر کسی خرچ کے اپنی زبان میں اس بابت جاننے Vietnamese: Thông báo này có thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn đăng ký hoặc về bảo hiểm của quý vị thông qua Optima Health. Quý vị hãy xem những ngày quan trọng trong thông báo này. Quý vị có thể cần đưa ra hành động trước ngày hết hạn cụ thể để duy trì bảo hiểm sức khỏe của quý vị hoặc hỗ trợ thanh toán cho các chi phí. Quý vị có quyền nhận được thông tin và sự hỗ trợ này theo ngôn ngữ mà quý vị muốn mà không phải trả thêm chi phí nào. Xin gọi số Yoruba: Àkíyèsí yìí ní Àlàyé Pàtàkì. Àkíyèsí yìí ní àlàyé pàtàkì nípa ohun tí o bèèrè fún tàbí gbígbà ìtọ jú nípasẹ Optima Health. Wo àwọn ọjọ tó ṣe kókó nínú àkíyèsí yìí. O lè nílò láti gbé ìgbésẹ nípa gbèdéke kan láti ṣètọ jú ìlera rẹ tàbí ṣèrànw ọ nípa iye òwó. O ní ẹ tọ láti gba àlàyé yìí àti ìrànwọ yìí ní èdè rẹ láìsan owó. Pè sórí

27 25 Welcome to Optima Health

28 26

29 Welcome to Optima Health Our Plans This Benefit Information Guide outlines basic information and answers to common questions about the POS health plan. Remember, specific infor such as copay, coinsurance and applicable deductibles is referenced in your specific plan benefit, a benefit structure that is chosen by your employer. Refer to your employer plan-specific document located in this book for more details. This Benefit Information Guide answers frequently asked questions about primary care physicians (PCPs), referrals, emergencies, urgent care, and more. POS Pla Optima POS is a plan in which you choose a primary care physician (PCP). Referrals are not required. The Plan features in-network and out-of-network benefit options: In-network/ PHCS network: The in-network benefit option means you can lower your out-of-pocket costs by seeing a Plan primary care physician, specialist, therapist and other healthcare professionals who have met all of Optima Health's credentialing requirements, and are part of the Plan network. The network gives you the option to receive your health care from the extended out-of-area PHCS network. This network is available outside of the Optima Health network. Out-of-network: If you choose to use your out-of-network benefit option for covered services, it means you and your family members can select the doctor or medical facility you want for most covered services, regardless of whether or not they are Plan providers. Remember your out-of-pocket costs will be higher when you use outof- benefits. Provider Network Optima Health members can receive care from any provider they choose; however, coverage will depend upon the plan you have and the participation status of the doctor you choose to see. It is important to understand your plan and your plan's network in order to ensure your care is covered by Optima Health. Participating Providers Doctors, hospitals and other healthcare professionals who sign an agreement with Optima Health are participating, or in-network, providers. These providers have agreed to accept a set fee for services rendered to our health plan members. Non-participating Providers Doctors, hospitals and other healthcare professionals who do not have a signed agreement with Optima Health are considered non-participating, or out-of-network, providers. These providers can charge whatever they want for their services. Typically, when plan members who have out-of-network benefits receive covered services from these out-of-network providers, we will pay a set percentage of the amount we pay in-network providers for the same service. The member will pay the rest. If what the out-of-network providers charge is more than what Optima Health pays, they can bill you, the member, for the difference between the two amounts. 27

30 28

31 29

32 30

33 31

34 32

35 33

36 34

37 35

38 ge 36

39 37

40 38

41 39

42 40

43 41

44 42

45 43

46 44

47 Health and Preventive Services Overview Personal Health Assessment & Health Coaching Healthy Publications (Continued) 45

48 Health and Preventive Services 3K\VLFLDQ QRWL FDWLRQV 3K\VLFLDQV UHFHLYH PRQWKO\ OLVWV RI WKHLU SDWLHQWV RXU PHPEHUV ZKR ZHUH UHPLQGHG WKURXJK WKH 3,0 6\VWHP DQG KDYH VWLOO QRW FRPSOHWHG WKHLU SUHYHQWLYH VFUHHQLQJV 46

49 Health and Preventive Services Healthy Programs Healthy Habits Healthy You 47

50 Health and Preventive Services 7DL &KL 4LJRQJ 6KLEDVKL 5HJXODU SUDFWLFH RI WKH PRYHPHQWV RI 7DL &KL 4LJRQJ 6KLEDVKL WHDFKHV WKH ERG\ WR PHQWDOO\ DQG SK\VLFDOO\ UHOD[ 7KH PRYHPHQWV HQKDQFH EORRG À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

51 49

52 50

53 51

54 52

55 53

56 54

57 55 Summary of Benefits

58 56

59 Optima Health Point of Service (POS) PREMIER PLAN 57

60 OPTIMA POINT OF SERVICE (POS) PREMIER 2018 SUMMARY OF BENEFITS City of Virginia Beach & Virginia Beach City Public Schools This document is not a contract or policy with Optima Health. It is a summary of benefits and services available through the Plan. If there are any differences between this summary and the employer group Plan Document, the provisions of those documents will prevail for all benefits, conditions, limitations and exclusions. Deductibles per Calendar Year 3 Maximum Out of Pocket Limit per Calendar Year Deductibles, Maximum Out of Pocket Limits OPTIMA NETWORK / PHCS NETWORK $ 850 per Individual $ 1,700 per Family OUT OF NETWORK $1,700 per Individual $3,400 per Family $3,000 per Individual 4 $4,500 per Individual 5 $6,000 per Family 4 $9,000 per Family 5 Physician Services Includes Covered Services performed in the Physician s office during the Physician office visit. Includes, but is not limited to, office consults and exams; In office surgery; In office lab, x ray, injections, and diagnostic and treatment services. Family planning services including injectables and vasectomy; Physical, Occupational, and Speech Therapy; Cardiac, Pulmonary, and Vascular Rehabilitation Services; Chemo, Radiation, IV, and Respiratory therapy services; Dialysis treatments. Pre Authorization is required for in office surgery 6 Physician Office Visits OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK MDLIVE Services $10 Copayment then covered at 100% Not Applicable Sentara Quality Care Network (SQCN) Primary Care Physician (PCP) Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider copay. $20 Copayment then covered at 100% After Deductible Covered at 60% Non Sentara Quality Care Network (SQCN) Primary Care Physician (PCP) Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who reside in those areas and choose a Non SQCN provider will pay the higher copay. $40 Copayment then covered at 100% Sentara Quality Care Network (SQCN) Specialist Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider copay. $40 Copayment then covered at 100% After Deductible Covered at 60% Non Sentara Quality Care Network (SQCN) Specialist Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who reside in those areas and choose a Non SQCN provider will pay the higher copay. $60 Copayment then covered at 100% ADMINISTERED BY OPTIMA HEALTH PLAN 58 Plus2080p_0114 1

61 Preventive Care 10 Routine Annual Physical Exams Well Baby Exams Annual GYN Exams and Pap Smears 11 PSA Tests Colorectal Cancer Tests Routine Adult and Childhood Immunizations Screening Colonoscopy Screening Mammograms (including 3 D mammograms) Women s Preventive Services Short Term Therapy Services 7 Physical Therapy Occupational Therapy Pre Authorization is required. 6 Physical and Occupational Therapy are limited to a maximum combined benefit with In Network and Out of Network benefits and for all places of service of 30 visits per condition. 7 Copayment or Coinsurance applies at any place of service. Speech Therapy Pre Authorization is required. 6 Speech Therapy is limited to a maximum combined benefit with In Network and Out of Network benefits and for all places of service of 30 visits per condition. 7 Copayment or Coinsurance applies at any place of service. Short Term Rehabilitation Services 7 Cardiac Rehabilitation Pulmonary Rehabilitation Vascular Rehabilitation Vestibular Rehabilitation Pre Authorization is required. 6 Services are limited to a maximum combined benefit with In Network and Out of Network benefits and for all places of service of 90 consecutive days per condition. 7 Copayment or Coinsurance applies at any place of service. Other Outpatient Treatments Chemotherapy Radiation Therapy IV Therapy Inhalation Therapy Physician Services OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK Covered at 100% After Deductible Covered at 60% Outpatient Therapy and Rehabilitation Services OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK After Deductible Covered at 85% After Deductible Covered at 60% After Deductible Covered at 85% After Deductible Covered at 60% OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK After Deductible Covered at 85% After Deductible Covered at 60% OPTIMA NETWORK / PHCS NETWORK Physician s Office Visit: $20 Copayment Specialist office visit: $40 Copayment Outpatient Facility: After Deductible Covered at 85% OUT OF NETWORK Physician s Office Visit: Covered at 60% Specialist office visit: Covered at 60% Outpatient Facility: After Deductible Covered at 60% ADMINISTERED BY OPTIMA HEALTH PLAN 59 Plus2080p_0114 2

62 Other Outpatient Treatments Pre Authorized Injectable and Infused Medications Includes injectable and infused medications, biologics, and IV therapy medications that require prior authorization. Coinsurance applies when medications are provided in a Physician s office, outpatient facility, or in the Member s home as part of Skilled Home Health Care Services benefit. Coinsurance is in addition to any applicable office visit or outpatient facility Copayment or Coinsurance. Outpatient Dialysis Services Dialysis Services Copayment or Coinsurance applies at any place of service. Outpatient Surgery Outpatient Surgery Pre Authorization is required. 6 Coinsurance or Copayment applies to services provided in a free standing ambulatory surgery center or hospital outpatient surgical facility. Outpatient Therapy and Rehabilitation Services OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK After Deductible Covered at 85% After Deductible Covered at 60% Outpatient Dialysis Services OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK After Deductible Covered at 85% After Deductible Covered at 60% Outpatient Surgery OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK After Deductible Covered at 85% After Deductible Covered at 60% Outpatient Diagnostic Procedures Copayment or Coinsurance will apply when a procedure is performed in a free standing outpatient facility or lab, or a hospital outpatient facility or lab. Outpatient Diagnostic Procedures OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK Outpatient Diagnostic Procedures After Deductible Covered at 85% After Deductible Covered at 60% Outpatient X Ray Ultrasound Doppler Studies After Deductible Covered at 85% After Deductible Covered at 60% Outpatient Lab Work After Deductible Covered at 85% After Deductible Covered at 60% Outpatient Advanced Imaging and Testing Procedures Outpatient Advanced Imaging and Testing Procedures OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) Positron Emission Tomography (PET Scans) Computerized Axial Tomography (CT Scans) Computerized Axial Tomography Angiogram (CTA Scans) Pre Authorization is required. 6 Copayment or Coinsurance applies to procedures done in a free standing outpatient facility or a hospital outpatient facility. After Deductible Covered at 85% After Deductible Covered at 60% ADMINISTERED BY OPTIMA HEALTH PLAN 60 Plus2080p_0114 3

63 Maternity Care Maternity Care 8,10,11 Pre Authorization is required for prenatal services. 6 Includes prenatal, delivery, postnatal, postpartum services, and home health visits. Copayment or Coinsurance is in addition to any applicable inpatient hospital Copayment or Coinsurance. Maternity Care OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK $350 Copayment, then covered at 100% After Deductible Covered at 60% Inpatient Services Inpatient Hospital Services Pre Authorization is required. 6 Transplants are covered at contracted facilities only. Skilled Nursing Facilities/Services 7 Pre Authorization is required. 6 Following inpatient hospital care or in lieu of hospitalization. Covered Services include up to 100 days combined in and out of network per calendar year that in the Plan s judgment requires Skilled Nursing Facility Services. 7 Ambulance Services Ambulance Services 9 Pre Authorization is required for non emergent transportation only. Includes air and ground ambulance for emergency transportation, or non emergent transportation that is Medically Necessary and Pre Authorized by the Plan. Copayment or Coinsurance is applied per transport each way. Emergency Services Emergency Services 9 Pre Authorization is not required. Includes Emergency Services, Physician, and Ancillary Services provided in an emergency department facility. Coinsurance waived for facility charges if admitted. Inpatient copayment / coinsurance will apply if admitted. Inpatient Services OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK After Deductible Covered at 85% After Deductible Covered at 60% After Deductible Covered at 85% After Deductible Covered at 60% Ambulance Services OPTIMA NETWORK / PHCS NETWORK Covered at 85% *If transported by a Virginia Beach Volunteer Rescue Squad Covered at 100% OUT OF NETWORK Covered at 85% Emergency Services OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK After Deductible Covered at 85% After Deductible covered at 85% ADMINISTERED BY OPTIMA HEALTH PLAN 61 Plus2080p_0114 4

64 Urgent Care Center Services Urgent Care Center Services OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK Urgent Care Services 9 Pre Authorization is not required. Covered at 85% Covered at 60% Includes Urgent Care Services, Physician services, and other Ancillary Services received at an Urgent Care facility. If You are transferred to an emergency department from an Urgent Care center, You 1 will pay an Emergency Services Copayment or Coinsurance. Mental/Behavioral Health Care Includes inpatient and outpatient services for the treatment of mental health and substance abuse. Also includes services for Biologically Based Mental Illnesses for the following diagnoses: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive compulsive disorder, attention deficit hyperactivity disorder, autism, and drug and alcoholism addiction. Mental/Behavioral Health Care OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK Inpatient Services After Deductible Covered at 85% After Deductible Covered at 60% Pre Authorization is required. 6 Residential Treatment is not covered. Sentara Quality Care Network (SQCN) Outpatient Services Pre Authorization may be required. 6 SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider copay. $20 Copayment then covered at 100% Covered at 60% Non Sentara Quality Care Network (SQCN) Outpatient Services Pre Authorization may be required. 6 SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who reside in those areas and choose a Non SQCN provider will pay the higher copay. $40 Copayment then covered at 100% Other Covered Services Allergy Care Includes Allergy testing, Injections, Serum and RAST testing. Other Covered Services OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK Covered at 85% After Deductible Covered at 60% ADMINISTERED BY OPTIMA HEALTH PLAN 62 Plus2080p_0114 5

65 Other Covered Services Autism Spectrum Disorder Pre Authorization is required. 6 Covered Services include diagnosis and treatment of Autism Spectrum Disorder in children from age two through 10. Autism Spectrum Disorder means any pervasive developmental disorder, including (i) autistic disorder, (ii) Asperger s Syndrome, (iii) Rett syndrome, (iv) childhood disintegrative disorder, or (v) Pervasive Developmental Disorder Not Otherwise Specified, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. Diagnosis of autism spectrum disorder means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder. Treatment for autism spectrum disorder shall be identified in a treatment plan and includes the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary: (i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) therapeutic care, and (vi) applied behavioral analysis when provided or supervised by a board certified behavioral analyst licensed by the Board of Medicine. Other Covered Services OPTIMA NETWORK / PHCS NETWORK Coverage for Autism Spectrum Disorder will not be subject to any visit limits, and will be neither different nor separate from coverage for any other illness, condition, or disorder for purposes of determining Deductibles, lifetime dollar limits, Copayment and Coinsurance factors, and benefit year maximum for Deductibles and Copayment and Coinsurance factors. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of treatment or service listed on the Summary of Benefits. OUT OF NETWORK Coverage for Autism Spectrum Disorder will not be subject to any visit limits, and will be neither different nor separate from coverage for any other illness, condition, or disorder for purposes of determining Deductibles, lifetime dollar limits, Copayment and Coinsurance factors, and benefit year maximum for Deductibles and Copayment and Coinsurance factors. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of treatment or service listed on the Summary of Benefits. Applied behavioral analysis means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. Coverage for applied behavioral analysis under this benefit is limited to an annual maximum benefit of $35, ADMINISTERED BY OPTIMA HEALTH PLAN 63 Plus2080p_0114 6

66 Other Covered Services Prosthetic Limbs and Components 7 Pre Authorization is required. 6 Services include coverage for medically necessary prosthetic devices. This also includes repair, fitting, replacement and components. Other Covered Services OPTIMA NETWORK / PHCS NETWORK OUT OF NETWORK After Deductible Covered at 85% After Deductible Covered at 60% Definitions: Component means the materials and equipment needed to ensure the comfort and functioning of a prosthetic device. Limb means an arm, a hand, a foot, or any portion of an arm, hand, a leg or foot. Prosthetic device means an artificial device to replace, in whole or in part, a limb. Prosthetic device coverage does not mean or include repair and replacement due to enrollee neglect, misuse, or abuse. Coverage also does not mean or include prosthetic devices designed primarily for an athletic purpose. Chiropractic Care 7 Optima Health contracts with American Specialty Health Group (ASH) to administer this benefit 6. Pre Authorization is required by ASH for all chiropractic care services. 6 To receive services, contact ASH's Member Services at Representatives are available from 8:00 AM to 9:00 PM Monday Friday. Coverage is limited to a combined maximum benefit with in and out of network benefits of 30 visits per Person, per calendar year. This benefit also includes coverage of Chiropractic appliances up to a combined maximum benefit with in and out of network benefits of 1 appliance per Person per calendar year when medically necessary. For providers not in the ASH network the Member will be responsible for payment of all charges in excess of ASH s allowable charge in addition to any coinsurance amount. Allowable charge is the lesser of the provider s actual charge or ASH s In Network fee schedule for the same services. Covered at 85% of ASH s fee schedule Covered at 60% of ASH s fee schedule ADMINISTERED BY OPTIMA HEALTH PLAN 64 Plus2080p_0114 7

67 Other Covered Services Diabetic Supplies and Equipment Includes FDA approved equipment and supplies for the treatment of diabetes and in person outpatient self management training and education including medical nutrition therapy. Insulin, syringes, and needles are covered under the Plan s Prescription Drug Benefit for the applicable Copayment or Coinsurance per 31 day supply. An annual diabetic eye exam is covered from an Optima Health Plan Provider, a participating EyeMed Provider, or a Non Plan Provider at the applicable office visit Copayment or Coinsurance amount. Other Covered Services OPTIMA NETWORK / PHCS NETWORK Blood glucose monitoring equipment and supplies including home glucose monitors, lancets, blood glucose test strips, and insulin pump infusion sets if prescribed by your physician: Covered at 100% Insulin pumps: Covered at 100%. Outpatient self management training and education, including medical nutritional therapy: Covered at 100% OUT OF NETWORK Blood glucose monitoring equipment and supplies including home glucose monitors, lancets, blood glucose test strips, and insulin pump infusion sets if prescribed by your physician: Covered at 60% Insulin pumps: Covered at 60%. Outpatient self management training and education, including medical nutritional therapy: Covered at 60% For more information about how to access this benefit for meters, strips and lancets, please call one of the following providers: Home Care Delivered: EdgePark Medical Supplies: You may also call or SENTARA for information on educational classes. Durable Medical Equipment (DME) and Supplies 7 Orthopedic Devices and Prosthetic Appliances 7 Pre Authorization is required for single items over $ Pre Authorization is required for all rental items. 6 Pre Authorization is required for repair and replacement. 6 Covered Services include durable medical equipment, orthopedic devices, prosthetic appliances other than artificial limbs, colostomy, ileostomy and tracheostomy supplies, suction and urinary catheters, and repair/replacement. Early Intervention Services Pre Authorization is required. 6 Covered for Dependents from birth to age three who are certified as eligible by the Virginia Department of Behavioral Health and Developmental Services. After Deductible Covered at 85% After Deductible Covered at 60% Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of service. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of service. Covered Services include: Medically Necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices. ADMINISTERED BY OPTIMA HEALTH PLAN 65 Plus2080p_0114 8

68 Other Covered Services Family Planning Depo Provera Injection: Other Covered Services OPTIMA NETWORK / PHCS NETWORK Covered at 100% OUT OF NETWORK After Deductible Covered at 60% Lunelle Injection: Tubal Ligation: Pre authorization required Hearing Aid Rider Pre Authorization is required. 6 Covered up to $1250 per hearing aid. Includes replacement every 36 months. Vasectomy: Covered at 100% Covered at 100% After Deductible Covered at 100% Subject to any applicable outpatient/inpatient surgery copayment After Deductible $40 Copayment per visit After Deductible Covered at 60% After Deductible Covered at 60% After Deductible Covered at 60% Subject to any applicable outpatient/inpatient surgery copayment After Deductible Covered at 60% Batteries are not covered. Home Health Care Skilled Services 7 Pre Authorization is required. 6 Services are covered up to a maximum combined benefit with In Network and Out of Network benefits of 100 visits per calendar year for Members who are home bound, and in the Plan s judgment require Home Health Skilled Services. 7 After Deductible Covered at 85% After Deductible Covered at 60% You will pay a separate outpatient therapy Copayment or Coinsurance amount for physical, occupational, and speech therapy visits received at home. Therapy visits received at home will count toward Your Plan s annual outpatient therapy benefit limits. You will pay a separate outpatient rehabilitation services Copayment or Coinsurance amount for cardiac, pulmonary, vascular, and vestibular rehabilitation visits received at home. Rehabilitation visits received at home will count toward Your Plan s annual outpatient rehabilitation benefit limits. Hospice Care After Deductible Covered at 85% After Deductible Covered at 60% Pre Authorization is required. 6 ADMINISTERED BY OPTIMA HEALTH PLAN 66 Plus2080p_0114 9

69 Other Covered Services Vision Care and Materials 7 Optima Health contracts with EyeMed Vision Care to administer this benefit. Coverage includes one examination every 12 months when done by a participating EyeMed Provider. To locate a participating EyeMed provider, please call or visit Medical conditions related to the eye, such as glaucoma, are covered under the medical plan. Other Covered Services OPTIMA NETWORK / PHCS NETWORK Spectacle Exam: $20 Copayment then covered at 100% OR Contact Lens Exam: $40 Copayment then covered at 100% Limited to one exam every 12 months (from the date of last exam) by a participating EyeMed Provider Materials By a participating EyeMed Provider: Lenses (single vision, bifocal, trifocal) covered in full. Frames: Covered in full up to $100 retail Contact Lenses (in lieu of glasses) covered in full up to $95 retail. If you choose contact lenses when they are not medically indicated, you will receive an allowance of $95 toward the purchase price. (Contact lenses are deemed medically necessary following cataract surgery, to correct extreme visual acuity problems not correctable with spectacle lenses, or if you have certain conditions of anisometropia or keratoconus). If contact lenses are obtained, they are in lieu of spectacles. OUT OF NETWORK For eye examinations from Out of Network providers, Members will be reimbursed up to $40 for an eye examination only every 12 months (from date of last exam). No coverage for eyeglasses/contacts out of network. Telemedicine Services Telemedicine Services means the use of interactive audio, video, or other electronic media used for the purpose of diagnosis, consultation, or treatment. Telemedicine services do not include an audio only telephone, electronic mail message, or facsimile transmission. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of treatment or service. Your out of pocket deductible, copayment, or coinsurance amounts will not exceed the deductible, copayment or coinsurance amount You would have paid if the same services were provided through face to face diagnosis, consultation, or treatment. ADMINISTERED BY OPTIMA HEALTH PLAN 67 Plus2080p_0114 1

70 Premier POS Outpatient Prescription Drug Rider Schedule of Benefits This schedule of benefits describes Your outpatient prescription drug coverage. All drugs must be Food and Drug Administration (FDA) approved and you must have a prescription. You will need to pay Your Copayment or Coinsurance when you fill your prescription at the pharmacy. If Your Plan has a Deductible you must meet that amount before your coverage begins. Some drugs require Pre-Authorization by Your Physician, and some quantities may be limited. Your drug coverage has specific Exclusions and Limitations, so please read the next few pages carefully. Optima Health s Pharmacy and Therapeutics Committee places covered drugs into the following Tiers. You will pay Your Copayment or Coinsurance depending on which Tier Your Drug is in. This Plan has a closed formulary and covers a specific list of drugs and medications. Drugs not included on the Plan s formulary will be excluded from coverage. Selected Generic (Tier 1) includes commonly prescribed generic drugs. Other drugs may be included in Tier 1 if the Plan recognizes they show documented long-term decreases in illness. Selected Brand & Other Generic (Tier 2) includes brand-name drugs, and some generic drugs with higher costs than Tier 1 generics, that are considered by the Plan to be standard therapy. Non-Selected Brand (Tier 3) includes brand name drugs not included by the Plan on Tier 1 or Tier 2. These may include single source brand name drugs that do not have a generic equivalent or a therapeutic equivalent. Drugs on this tier may be higher in cost than equivalent drugs, or drugs determined to be no more effective than equivalent drugs on lower tiers. Specialty Drugs (Tier 4) includes those drugs classified by the Plan as Specialty Drugs. Tier 4 also includes covered compound prescription medications. Specialty Drugs have unique uses and are generally prescribed for people with complex or ongoing medical conditions. Specialty Drugs typically require special dosing, administration, and additional education and support from a health care professional. Specialty Drugs include the following: Medications that treat certain patient populations including those with rare diseases; Medications that require close medical and pharmacy management and monitoring; Medications that require special handling and/or storage; Medications derived from biotechnology and/or blood derived drugs or small molecules; and Medications that can be delivered via injection, infusion, inhalation, or oral administration. Specialty Drugs are only available through Proprium Pharmacy at or (toll free). Specialty Drugs will be delivered to Your home address from Our Specialty mail order pharmacy. If You have a question or need to find out if Your drug is considered a Specialty Drug please call Member Services at the number on Your Optima Health ID Card. You can also log onto optimahealth.com for a list of Specialty Drugs. A compound prescription medication is used to meet the needs of a specific individual and must have at least one ingredient requiring a physician s authorization by State or Federal Law. Compound prescriptions can usually be filled at Your local pharmacy. Your Copayment, Coinsurance, and Deductible amounts for each Tier are listed on the following page. Your Maximum Out-of-Pocket Amount is also listed. If You need help please call Member Services or log on to optimahealth.com to find out which of the following Tiers Your drug is in. ADMINISTERED BY OPTIMA HEALTH PLAN 68

71 Premier POS Outpatient Prescription Drug Rider Schedule of Benefits Maximum Out-of-Pocket Limit Maximum Out-of- Outpatient Prescription Drug Copayments or Coinsurance apply to the Plan s Maximum Medical Pocket Limit Out-of-Pocket Limit Ancillary charges which result from a request for a brand name outpatient prescription drug when a generic drug is available are not Covered, do not count toward the Plan s Maximum Out-of- Pocket Limit and must continue to be paid after the maximum out-of-pocket Limit has been met. Copayments and Coinsurances For a single Copayment or Coinsurance charge You may receive up to a consecutive 31-day supply of a covered drug. A Copayment is a flat dollar amount. A Coinsurance is a percent of Optima Health s Allowable Charge. Certain prescription drugs will be covered at a generic product level established by the Plan. If a generic product level has been established for a drug and You or Your prescribing Physician requests the brand-name drug or a higher costing generic, You must pay the difference between the cost of the dispensed drug and the generic product level in addition to the Copayment charge (not to exceed $150 per each 31-day supply prescription). PREFERRED NETWORK You will pay a lower Copayment if you fill your prescriptions at a Walgreens, Walmart or Sam s Club Preferred Pharmacy. Selected Generic (Tier 1) $10 Copayment (or the plan s negotiated cost of the drug, if less) Selected Brand & Other Generic (Tier 2) $25 Copayment (or the plan s negotiated cost of the drug, if less) Non-Selected Brand (Tier 3) Covered at 75% (maximum $50) Non-Preferred Pharmacy (all retail other than Walgreens, Walmart or Sam s Club) Selected Generic (Tier 1) $25 Copayment (or the plan s negotiated cost of the drug, if less) Selected Brand & Other Generic (Tier 2) $45 Copayment (or the plan s negotiated cost of the drug, if less) Non-Selected Brand (Tier 3) Covered at 75% (maximum $75) Specialty Drugs (Tier 4) Covered at 75% (maximum $200) Mail Order Pharmacy Benefit Copayments and Coinsurances Some Outpatient prescription drugs are available through the Plan s Mail Order Provider. This does not include Tier 4 Specialty Drugs. You may call OptumRx Home Delivery at to find out if a drug is available. If Your drug is available You may purchase up to a 90-day supply for the Copayment or Coinsurance amount. Selected Generic (Tier 1) $25 Copayment (or the plan s negotiated cost of the drug, if less) Selected Brand & Other Generic (Tier 2) $60 Copayment (or the plan s negotiated cost of the drug, if less) Non-Selected Brand (Tier 3) Covered at 75% (maximum $125) Specialty Drugs (Tier 4) No 90 day mail order benefits are available for Tier 4 Specialty Drugs Non-formulary requests. You have the right to request a non-formulary prescription drug if You believe that You need a prescription drug that is not on the Plan s list of covered drugs (formulary), or You have been receiving a specific nonformulary prescription drug for at least six months previous to the development or revision of the formulary and Your prescribing physician has determined that the formulary drug is inappropriate for Your condition or that changing drug therapy presents a significant health risk to You. Your physician must complete a medical necessity form and deliver it to the Optima Health pharmacy authorization department. After reasonable investigation and consultation with the prescribing physician, Optima Health will make a determination. Optima Health will act on such requests within one business day of receipt of the request. You will be responsible for all applicable Copayments, Coinsurance, or Deductibles depending upon which Tier a drug is placed in by the Plan. ADMINISTERED BY OPTIMA HEALTH PLAN 69

72 Notes The Covered Services herein are subject to the terms and conditions set forth in the Plan Document. Words that are capitalized are defined terms listed in the Definitions section of the Plan Document. Optima Health has an internal claims appeal process and an external review process. Please look in Your Plan Document for details about how to file a complaint or an appeal. Under certain circumstances Your coverage can be terminated. However, Your Coverage can only be rescinded for fraud or intentional misrepresentation of material fact. Please look in Your Plan Document in the section on When Your Coverage Will End. For Optima Health plans that require that You choose a primary care provider (PCP), You have the right to choose any PCP who participates in our network and who is available to accept new patients. For children, You may choose a pediatrician as the PCP. 1. You or Your means the Subscriber and each family member who is a Covered Person under the Plan. 2. Copayment and Coinsurance are out of pocket amounts You pay directly to a Provider for a Covered Service. A Copayment is a flat dollar amount. A Coinsurance is a percent of Optima Health s Allowable Charge (AC) for the Covered Service You receive. Allowable Charge is the amount Optima Health determines should be paid to a Provider for a Covered Service. When You use In Network benefits from Plan Providers Allowable Charge is the Provider s contracted rate with Optima Health or the Provider s actual charge for the service, whichever is less. Plan Providers accept this amount as payment in full. Medically Necessary Covered Services provided by a Non Plan Provider during an Emergency, or during an authorized Admission to a Plan Facility, will be Covered under In Network benefits. All other Covered Services received from Non Plan Providers will be Covered under Your Out of Network benefits. When You use Out of Network benefits from Non Plan Providers Allowable Charge may be a negotiated rate; or if there is no negotiated rate Allowable Charge is Optima Health s In Network contracted rate for the same service performed by the same type of Provider or the Provider s actual charge for the service, whichever is less. Non Plan Providers may not accept this amount as payment in full. If You use a Non Plan Provider who charges more than our allowable amount the Provider may balance bill You for the difference. You will have to pay the difference to the Provider in addition to Your Copayment or Coinsurance amount. Charges from Non Plan Providers will be higher than the Plan s Allowable Charge so You will usually pay more out of pocket when You use Out of Network benefits. 3. Deductible means the dollar amount You must pay out of pocket each calendar year for Covered Services before the Plan begins to pay for Your benefits. Your Plan may have different Deductibles to meet for In Network Covered Services and for Out of Network Covered Services. Amounts applied to an In Network Deductible will apply toward the Plan s In Network Maximum Out of Pocket Limit. Amounts applied to an Out of Network Deductible will apply toward the Plan s Out of Network Maximum Out of Pocket Limit. Amounts which You are required to pay for outpatient prescription drugs, preventive vision, or vision materials, will not be applied to any Deductible amount in the Plan. Deductibles will not be reimbursed under the Plan. Any part of the calendar year Deductible that is satisfied in the last three months of a calendar year can be carried forward to the next calendar year. 4. Maximum Out of Pocket Limit for In Network Benefits means the total dollar amount You pay out of pocket for most In Network Covered Services during a calendar year. Your Plan has a separate out of pocket limit for Covered Services You receive under the Plan s Out of Network Benefits. Copayments and Coinsurance amounts that You pay for most In Network Covered Services will count toward Your In Network Maximum Out of Pocket Limit. If a service does not count toward Your Maximum Out of Pocket Limit You must continue to pay Your Copayments, Coinsurance and any other charges for these services after Your Maximum Out of Pocket Limit has been met. Copayments, Coinsurance, or any other charges for the following will not count toward Your In Network Maximum Out of Pocket Limit: 1) Amounts You pay for services not covered under Your Plan; 2) Amounts You pay for Out of Network Benefits; 3) Amounts You pay for Vision care; 4) Amounts You pay for any benefits covered under a plan rider; 5) Amounts You pay for Reduction Mammoplasty benefits, except for procedures associated with reconstructive breast surgery following mastectomy; 6) Ancillary charges which result from Your request for a brand name outpatient prescription drug when a generic drug is available. Ancillary charges are not Covered Services; 7) Amounts You pay for any services after a benefit limit has been reached; 8) Amounts You pay as a penalty for failure to comply with the Plan s Pre authorization procedures; 9) Amounts applied to Your Out of Network Deductible. ADMINISTERED BY OPTIMA HEALTH PLAN 70 Plus2080p_0114 9

73 5. Maximum Out of Pocket Limit for Out of Network Benefits means the total dollar amount You will pay during a calendar year for most Out of Network Covered Services. Your Plan has a separate out of pocket limit for Covered Services You receive under the Plan s In Network Benefits. Copayments and Coinsurance amounts that You pay for most Out of Network Covered Services will count toward Your Out of Network Maximum Out of Pocket Limit. If a service does not count toward Your Maximum Out of Pocket Limit You must continue to pay Your Copayments or Coinsurance for these services after Your Maximum Out of Pocket Limit has been met. Copayments, Coinsurance, or any other charges for the following will not count toward Your Out of Network Maximum Out of Pocket Limit: 1) Amounts You pay for services not covered under Your Plan; 2) Amounts You pay for In Network Benefits; 3) Amounts You pay for Vision care; 4) Amounts You pay for any benefits covered under a plan rider; 5) Amounts You pay for Reduction Mammoplasty benefits, except for procedures associated with reconstructive breast surgery following mastectomy; 6) Ancillary charges which result from Your request for a brand name outpatient prescription drug when a generic drug is available. Ancillary charges are not Covered Services; 7) Amounts You pay for any services after a benefit limit has been reached; 8) Amounts You pay as a penalty for failure to comply with the Plan s Pre authorization procedures; 9) Amounts applied to Your In Network Deductible; 10) Amounts that exceed the Plan s Allowable Charge for a Covered Service 6. This benefit requires Pre Authorization before You receive services. Your benefits for Covered Services may be reduced or denied if You do not comply with the Plan's Pre Authorization requirements. The Plan may also apply a penalty of up to $500 to any benefits paid for Covered Services if You do not comply with the Plan s Pre Authorization requirements. 7. Coverage for this benefit or service is limited by a dollar amount and/or visit or day limits as stated. Maximum amounts are combined maximums of both In Network and Out Of Network Covered Services unless otherwise stated. The Plan will not cover any additional services after the limits have been reached. You will be responsible for payment for all services after a benefit limit has been reached. Amounts You pay for any services after a benefit limit has been reached are excluded from Coverage and will not count toward Your Maximum Out of Pocket Maximum Limit. 8. Coverage for obstetrical services as an inpatient in a general hospital or obstetrical services by a physician shall provide such benefits with durational limits, deductibles, coinsurance factors, and Copayments that are no less favorable than for physical illness generally. If the Plan charges a Global Copayment for prenatal, delivery, and postpartum services You are entitled to a refund from the Delivering Obstetrician if the total amount of the Global Copayment for prenatal, delivery, and postpartum services is more than the total Copayments You would have paid on a per visit or per procedure basis. 9. All Emergency, Urgent Care, Ambulance, and Emergency Mental/Behavioral Health Services may be subject to Retrospective Review to determine the Plan s responsibility for payment. If the Plan determines that the condition treated was not an Emergency Service, the Plan will have no responsibility for the cost of the treatment and You will be solely responsible for payment. Members who receive Emergency Services from Non Plan Providers may be responsible for charges in excess of what would have been paid had the Emergency Services been received from Plan Providers. In no event will the Plan be responsible for payment for services from Non Plan Providers where the service would not have been covered had the member received care from a Plan Provider. 10. Preventive Care includes recommended preventive care services under the Patient Protection and Affordable Care Act (PPACA) listed below. You may be responsible for an office visit copayment or coinsurance when you receive preventive care. Some services may be administered under Your prescription drug benefit under the Plan. 1) Evidence based items or services that have in effect a rating of A or B in the recommendations of the U.S. Preventive Services Task Force as of September 23, 2010, with respect to the individual involved; 2) Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. For purposes of this subdivision, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention; 3) With respect to infants, children, and adolescents, evidence informed preventive care and screenings in the Recommendations for Preventive Pediatric Health by the American Academy of Pediatrics and the Recommended Uniform Screening Panels by the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children; and ADMINISTERED BY OPTIMA HEALTH PLAN 71 Plus2080p_

74 4) With respect to women, evidence informed preventive care and screenings recommended in comprehensive guidelines supported by the Health Resources and Services Administration. Services include well woman visits, screening for gestational diabetes, human papillomavirus, testing (HPV), counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus (HIV), FDA approved contraception methods, sterilization procedures, and patient education and counseling for women, breastfeeding support, supplies, and counseling, screening and counseling for interpersonal and domestic violence. 11. You do not need prior authorization from Optima Health or from any other person (including a Primary Care Provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre approved treatment plan, or procedures for making referrals. Look in Your Plan Document in the Utilization Management section for more information on Pre Authorization. ADMINISTERED BY OPTIMA HEALTH PLAN 72 Plus2080p_

75 Optima Health Point of Service (POS) STANDARD PLAN 73

76 OPTIMA POINT OF SERVICE (POS) STANDARD 2018 Summary of Benefits City of Virginia Beach & Virginia Beach City Public Schools This document is not a contract or policy with Optima Health. It is a summary of benefits and services available through the Plan. If there are any differences between this summary and the employer group Plan Document, the provisions of those documents will prevail for all benefits, conditions, limitations and exclusions. This plan is a Qualified High Deductible plan compatible with a Health Savings Account. Deductibles per Calendar Year 3 Maximum Out of Pocket Limit per Calendar Year Deductibles, Maximum Out of Pocket Limits OptimaNetwork/PHCS Network $1,350 Employee only coverage $2,700 per Family Out of Network $2,600 Employee only coverage $5,200 per Family $3,500 Employee only coverage $5,500 Employee only coverage 5 $7,000 Family 4 $11,000 per Family 5 Physician Services Includes Covered Services performed in the Physician s office during the Physician office visit. Includes, but is not limited to, office consults and exams; In office surgery; In office lab, x ray, injections, and diagnostic and treatment services. Family planning services including injectables and vasectomy; Physical, Occupational, and Speech Therapy; Cardiac, Pulmonary, and Vascular Rehabilitation Services; Chemo, Radiation, IV, and Respiratory therapy services; Dialysis treatments. Pre Authorization is required for in office surgery 6. Physician Office Visits OptimaNetwork/PHCS Network MDLIVE Services After Deductible Covered at 90% Not applicable Out of Network Sentara Quality Care Network (SQCN) Primary Care Physician (PCP) Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. Non Sentara Quality Care Network (SQCN) Primary Care Physician (PCP) Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who reside in those areas and choose a Non SQCN provider will pay the higher coinsurance. Sentara Quality Care Network (SQCN) Specialist Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. Non Sentara Quality Care Network (SQCN) Specialist Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who reside in those areas and choose a Non SQCN provider will pay the higher coinsurance. After Deductible Covered at 90% After Deductible Covered at 80% After Deductible Covered at 90% After Deductible Covered at 80% After Deductible Covered at 50% After Deductible Covered at 50% ADMINISTERED BY OPTIMA HEALTH PLAN 74 EqPl250080_0114 1

77 Preventive Care 10 Routine Annual Physical Exams Well Baby Exams Annual GYN Exams and Pap Smears 11 PSA Tests Colorectal Cancer Tests Routine Adult and Childhood Immunizations Screening Colonoscopy Screening Mammograms (including 3 D mammograms) Women s Preventive Services Short Term Therapy Services 7 Physical Therapy Occupational Therapy Pre Authorization is required. 6 Physical and Occupational Therapy are limited to a maximum combined benefit with In Network and Out of Network benefits and for all places of service of 30 visits per condition. 7 Copayment or Coinsurance applies at any place of service. Speech Therapy Pre Authorization is required. 6 Speech Therapy is limited to a maximum combined benefit with In Network and Out of Network benefits and for all places of service of 30 visits per condition. 7 Copayment or Coinsurance applies at any place of service. Short Term Rehabilitation Services 7 Cardiac Rehabilitation Pulmonary Rehabilitation Vascular Rehabilitation Vestibular Rehabilitation Pre Authorization is required. 6 Services are limited to a maximum combined benefit with In Network and Out of Network benefits and for all places of service of 90 consecutive days per condition. 7 Copayment or Coinsurance applies at any place of service. Other Outpatient Treatments Chemotherapy Radiation Therapy IV Therapy Inhalation Therapy Physician Services Optima Network/PHCS Network Out of Network Covered at 100% After Deductible Covered at 50% Outpatient Therapy and Rehabilitation Services Optima Network/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% After Deductible Covered at 80% After Deductible Covered at 50% Optima Network/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% Optima Network/PHCS Network Out of Network After Deductible covered at 80% After Deductible covered at 50% ADMINISTERED BY OPTIMA HEALTH PLAN 75 EqPl250080_0114 2

78 Other Outpatient Treatments Pre Authorized Injectable and Infused Medications Includes injectable and infused medications, biologics, and IV therapy medications that require prior authorization. Coinsurance applies when medications are provided in a Physician s office, outpatient facility, or in the Member s home as part of Skilled Home Health Care Services benefit. Coinsurance is in addition to any applicable office visit or outpatient facility Copayment or Coinsurance. Outpatient Dialysis Services Dialysis Services Copayment or Coinsurance applies at any place of service. Outpatient Surgery Outpatient Surgery Pre Authorization is required. 6 Coinsurance or Copayment applies to services provided in a free standing ambulatory surgery center or hospital outpatient surgical facility. Outpatient Therapy and Rehabilitation Services Optima Network/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% Outpatient Dialysis Services OptimaNetwork/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% Outpatient Surgery OptimaNetwork/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% Outpatient Diagnostic Procedures Copayment or Coinsurance will apply when a procedure is performed in a free standing outpatient facility or lab, or a hospital outpatient facility or lab. Outpatient Diagnostic Procedures Optima Network/PHCS Network Out of Network Outpatient Diagnostic Procedures After Deductible Covered at 80% After Deductible Covered at 50% Outpatient X Ray Ultrasound Doppler Studies After Deductible Covered at 80% After Deductible Covered at 50% Outpatient Lab Work After Deductible Covered at 80% After Deductible Covered at 50% Outpatient Advanced Imaging and Testing Procedures Outpatient Advanced Imaging and Testing Procedures OptimaNetwork/PHCS Network Out of Network Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) Positron Emission Tomography (PET Scans) Computerized Axial Tomography (CT Scans) Computerized Axial Tomography Angiogram (CTA Scans) Pre Authorization is required. 6 Copayment or Coinsurance applies to procedures done in a free standing outpatient facility or a hospital outpatient facility. After Deductible Covered at 80% After Deductible Covered at 50% ADMINISTERED BY OPTIMA HEALTH PLAN 76 EqPl250080_0114 3

79 Maternity Care Maternity Care 8,10,11 Pre Authorization is required for prenatal services. 6 Includes prenatal, delivery, postnatal, postpartum services, and home health visits. Copayment or Coinsurance is in addition to any applicable inpatient hospital Copayment or Coinsurance. Sentara Quality Care Network (SQCN) SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. Non Sentara Quality Care Network (SQCN) SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. Maternity Care OptimaNetwork/PHCS Network After Deductible Covered at 90% After Deductible Covered at 80% Out of Network After Deductible Covered at 50% Inpatient Services Inpatient Hospital Services Pre Authorization is required. 6 Transplants are covered at contracted facilities only. Skilled Nursing Facilities/Services 7 Pre Authorization is required. 6 Following inpatient hospital care or in lieu of hospitalization. Covered Services include up to 100 days combined in and out of network per calendar year that in the Plan s judgment requires Skilled Nursing Facility Services. 7 Ambulance Services Ambulance Services 9 Pre Authorization is required for nonemergent transportation only. 6 Includes air and ground ambulance for emergency transportation, or non emergent transportation that is Medically Necessary and Pre Authorized by the Plan. Copayment or Coinsurance is applied per transport each way. Inpatient Services Optima Network/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% After Deductible Covered at 80% After Deductible Covered at 50% Ambulance Services OptimaNetwork/PHCS Network After Deductible Covered at 80% *If transported by a Virginia Beach Volunteer Rescue Squad Covered at 100% Out of Network After Deductible Covered at 80% ADMINISTERED BY OPTIMA HEALTH PLAN 77 EqPl250080_0114 4

80 Emergency Services Emergency Services 9 Pre Authorization is not required. Includes Emergency Services, Physician, and Ancillary Services provided in an emergency department facility. Coinsurance waived for facility charges if admitted. Inpatient copayment / coinsurance will apply if admitted. Urgent Care Center Services Urgent Care Services 9 Pre Authorization is not required. Includes Urgent Care Services, Physician services, and other Ancillary Services received at an Urgent Care facility. If You 1 are transferred to an emergency department from an Urgent Care center, You 1 will pay an Emergency Services Copayment or Coinsurance. Emergency Services OptimaNetwork/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 80% Urgent Care Center Services Optima Network/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% Mental/Behavioral Health Care Includes inpatient and outpatient services for the treatment of mental health and substance abuse. Also includes services for Biologically Based Mental Illnesses for the following diagnoses: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive compulsive disorder, attention deficit hyperactivity disorder, autism, and drug and alcoholism addiction. Mental/Behavioral Health Care Inpatient Services Pre Authorization is required. 6 Residential treatment is not covered. Sentara Quality Care Network (SQCN) Outpatient Services Pre Authorization may be required. 6 SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. OptimaNetwork/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% After Deductible Covered at 90% After Deductible Covered at 50% Non Sentara Quality Care Network (SQCN) Outpatient Services Pre Authorization may be required. 6 SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who reside in those areas and choose a Non SQCN provider will pay the higher coinsurance. After Deductible Covered at 80% ADMINISTERED BY OPTIMA HEALTH PLAN 78 EqPl250080_0114 5

81 Other Covered Services Allergy Care Includes Allergy testing, Injections, Serum and RAST testing. Other Covered Services Optima Network/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% Autism Spectrum Disorder Pre Authorization is required. 6 Covered Services include diagnosis and treatment of Autism Spectrum Disorder in children from age two through 10. Autism Spectrum Disorder means any pervasive developmental disorder, including (i) autistic disorder, (ii) Asperger s Syndrome, (iii) Rett syndrome, (iv) childhood disintegrative disorder, or (v) Pervasive Developmental Disorder Not Otherwise Specified, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. Diagnosis of autism spectrum disorder means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder. Treatment for autism spectrum disorder shall be identified in a treatment plan and includes the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary: (i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) therapeutic care, and (vi) applied behavioral analysis when provided or supervised by a board certified behavioral analyst licensed by the Board of Medicine. Applied behavioral analysis means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. Coverage for applied behavioral analysis under this benefit is limited to an annual maximum benefit of $35, Coverage for Autism Spectrum Disorder will not be subject to any visit limits, and will be neither different nor separate from coverage for any other illness, condition, or disorder for purposes of determining Deductibles, lifetime dollar limits, Copayment and Coinsurance factors, and benefit year maximum for Deductibles and Copayment and Coinsurance factors. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of treatment or service listed on the Summary of Benefits. Coverage for Autism Spectrum Disorder will not be subject to any visit limits, and will be neither different nor separate from coverage for any other illness, condition, or disorder for purposes of determining Deductibles, lifetime dollar limits, Copayment and Coinsurance factors, and benefit year maximum for Deductibles and Copayment and Coinsurance factors. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of treatment or service listed on the Summary of Benefits. ADMINISTERED BY OPTIMA HEALTH PLAN 79 EqPl250080_0114 6

82 Other Covered Services Prosthetic Limbs and Components 7 Pre Authorization is required. 6 Services include coverage for medically necessary prosthetic devices. This also includes repair, fitting, replacement and components. Other Covered Services Optima Network/PHCS Network Out of Network After Deductible Covered at 80% After Deductible Covered at 50% Definitions: Component means the materials and equipment needed to ensure the comfort and functioning of a prosthetic device. Limb means an arm, a hand, a foot, or any portion of an arm, hand, a leg or foot. Prosthetic device means an artificial device to replace, in whole or in part, a limb. Prosthetic device coverage does not mean or include repair and replacement due to enrollee neglect, misuse, or abuse. Coverage also does not mean or include prosthetic devices designed primarily for an athletic purpose. Chiropractic Care 7 Optima Health contracts with American Specialty Health Networks (ASHN) to administer this benefit 6. Pre Authorization is required by ASHN for all chiropractic care services. 6 To receive services, contact ASHN's Member Services at Representatives are available from 8:00 AM to 9:00 PM Monday Friday. Coverage is limited to a combined maximum benefit with in and out of network benefits of 30 visits per Person, per calendar year. This benefit also includes coverage of Chiropractic appliances up to a combined maximum benefit with in and out ofnetwork benefits of 1 appliance per Person per calendar year when medically necessary. For providers not in the ASHN network the Member will be responsible for payment of all charges in excess of ASHN s allowable charge in addition to any coinsurance amount. Allowable charge is the lesser of the provider s actual charge or ASHN s in network fee schedule for the same services. After Deductible Covered at 80% of ASHN fee schedule After Deductible Covered at 50 % of ASHN fee schedule ADMINISTERED BY OPTIMA HEALTH PLAN 80 EqPl250080_0114 7

83 Other Covered Services Diabetic Supplies and Equipment Includes FDA approved equipment and supplies for the treatment of diabetes and in person outpatient self management training and education including medical nutrition therapy. Insulin, syringes, and needles are covered under the Plan s Prescription Drug Benefit for the applicable Copayment or Coinsurance per 31 day supply. An annual diabetic eye exam is covered from an Optima Health Plan Provider, a participating EyeMed Provider, or a Non Plan Provider at the applicable office visit Copayment or Coinsurance amount. For more information about how to access this benefit for meters, strips and lancets, please call one of the following providers: Other Covered Services Optima Network/PHCS Network Blood glucose monitoring equipment and supplies including home glucose monitors, lancets, blood glucose test strips, and insulin pump infusion sets if prescribed by your physician: After Deductible Covered at 100% Insulin pumps: After Deductible covered at 100% Outpatient self management training and education, including medical nutritional therapy: After Deductible covered at 100% Out of Network Blood glucose monitoring equipment and supplies including home glucose monitors, lancets, blood glucose test strips, and insulin pump infusion sets if prescribed by your physician: After Deductible Covered at 50% Insulin pumps: After Deductible covered at: 50% Outpatient self management training and education, including medical nutritional therapy: After Deductible covered at: 50% Home Care Delivered at EdgePark Medical Supplies at You may also call or SENTARA for information on educational classes. Durable Medical Equipment (DME) and Supplies 7 Orthopedic Devices and Prosthetic Appliances 7 Pre Authorization is required for single items over $ Pre Authorization is required for all rental items. 6 Pre Authorization is required for repair and replacement. 6 Covered Services include durable medical equipment, orthopedic devices, prosthetic appliances other than artificial limbs, colostomy, ileostomy, and tracheostomy supplies, suction and urinary catheters, and repair/replacement. After Deductible Covered at 80% After Deductible Covered at 50% Early Intervention Services Pre Authorization is required. 6 Covered for Dependents from birth to age three who are certified as eligible by the Virginia Department of Behavioral Health and Developmental Services. Covered Services include: Medically Necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of service. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of service. ADMINISTERED BY OPTIMA HEALTH PLAN 81 EqPl250080_0114 8

84 Other Covered Services Family Planning Depo Provera Injection: Other Covered Services Optima Network/PHCS Network Covered at 100% Out of Network After Deductible Covered at 50% Lunelle Injection: Tubal Ligation: Pre authorization required Covered at 100% Covered at 100% After Deductible Covered at 50% After Deductible Covered at 50% Hearing Aid Rider Pre Authorization is required. 6 Covered up to $1250 per hearing aid. Includes replacement every 36 months. Vasectomy: Batteries are not covered. Home Health Care Skilled Services 7 Pre Authorization is required. 6 Services are covered up to a maximum combined benefit with In Network and Out of Network benefits of 100 visits per calendar year for Members who are home bound, and in the Plan s judgment require Home Health Skilled Services. 7 You will pay a separate outpatient therapy Copayment or Coinsurance amount for physical, occupational, and speech therapy visits received at home. Therapy visits received at home will count toward Your Plan s annual outpatient therapy benefit limits. You will pay a separate outpatient rehabilitation services Copayment or Coinsurance amount for cardiac, pulmonary, vascular, and vestibular rehabilitation visits received at home. Rehabilitation visits received at home will count toward Your Plan s annual outpatient rehabilitation benefit limits. After Deductible Covered at 100% Subject to any applicable outpatient/inpatient surgery copayment After Deductible Covered at 50% Subject to any applicable outpatient/inpatient surgery copayment/coinsurance. After Deductible Covered at 80% After Deductible Covered at 50% After Deductible Covered at 80% After Deductible Covered at 50% Hospice Care After Deductible Covered at 80% After Deductible Covered at 50% Pre Authorization is required. 6 ADMINISTERED BY OPTIMA HEALTH PLAN 82 EqPl250080_0114 9

85 Other Covered Services Vision Care and Materials 7 Optima Health contracts with EyeMed Vision Care to administer this benefit. Medical conditions related to the eye, such as glaucoma, are covered under the medical plan. Coverage includes one examination every 12 months when done by a participating EyeMed Provider. To locate a participating EyeMed provider, please call or visit Other Covered Services Optima Network/PHCS Network Spectacle Exam: $20 Copayment then covered at 100% OR Contact Lens Exam: $40 Copayment then covered at 100% Limited to one exam every 12 months (from the date of last exam) by a participating EyeMed Provider. Materials By a participating EyeMed Provider: Lenses (single vision, bifocal, trifocal) covered in full. Frames: Covered in full up to $100 retail Contact Lenses (in lieu of glasses) covered in full up to $95 retail. Out of Network For eye examinations from Out of Network providers, Members will be reimbursed up to $40 for an eye examination (once every 12 months from date of last exam). No coverage for eyeglasses/contacts out of network. Telemedicine Services Telemedicine Services means the use of interactive audio, video, or other electronic media used for the purpose of diagnosis, consultation, or treatment. Telemedicine services do not include an audio only telephone, electronic mail message, or facsimile transmission. If you choose contact lenses when they are not medically indicated, you will receive an allowance of $95 toward the purchase price. (Contact lenses are deemed medically necessary following cataract surgery, to correct extreme visual acuity problems not correctable with spectacle lenses, or if you have certain conditions of anisometropia or keratoconus). If contact lenses are obtained, they are in lieu of spectacles. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of treatment or service. Your out of pocket deductible, copayment, or coinsurance amounts will not exceed the deductible, copayment or coinsurance amount You would have paid if the same services were provided through face to face diagnosis, consultation, or treatment. ADMINISTERED BY OPTIMA HEALTH PLAN 83 EqPl250080_0114 1

86 Standard POS Outpatient Prescription Drug Rider Schedule of Benefits This schedule of benefits describes Your outpatient prescription drug coverage. All drugs must be Food and Drug Administration (FDA) approved and you must have a prescription. You will need to pay Your Copayment or Coinsurance when you fill your prescription at the pharmacy. If Your Plan has a Deductible you must meet that amount before your coverage begins. Some drugs require Pre-Authorization by Your Physician, and some quantities may be limited. Your drug coverage has specific Exclusions and Limitations, so please read the next few pages carefully. Optima Health s Pharmacy and Therapeutics Committee places covered drugs into the following Tiers. You will pay Your Copayment or Coinsurance depending on which Tier Your Drug is in. This Plan has a closed formulary and covers a specific list of drugs and medications. Drugs not included on the Plan s formulary will be excluded from coverage. Selected Generic (Tier 1) includes commonly prescribed generic drugs. Other drugs may be included in Tier 1 if the Plan recognizes they show documented long-term decreases in illness. Selected Brand & Other Generic (Tier 2) includes brand-name drugs, and some generic drugs with higher costs than Tier 1 generics, that are considered by the Plan to be standard therapy. Non-Selected Brand (Tier 3) includes brand name drugs not included by the Plan on Tier 1 or Tier 2. These may include single source brand name drugs that do not have a generic equivalent or a therapeutic equivalent. Drugs on this tier may be higher in cost than equivalent drugs, or drugs determined to be no more effective than equivalent drugs on lower tiers. Specialty Drugs (Tier 4) includes those drugs classified by the Plan as Specialty Drugs. Tier 4 also includes covered compound prescription medications. Specialty Drugs have unique uses and are generally prescribed for people with complex or ongoing medical conditions. Specialty Drugs typically require special dosing, administration, and additional education and support from a health care professional. Specialty Drugs include the following: Medications that treat certain patient populations including those with rare diseases; Medications that require close medical and pharmacy management and monitoring; Medications that require special handling and/or storage; Medications derived from biotechnology and/or blood derived drugs or small molecules; and Medications that can be delivered via injection, infusion, inhalation, or oral administration. Specialty Drugs are only available through Proprium Pharmacy at or (toll free). Specialty Drugs will be delivered to Your home address from Our Specialty mail order pharmacy. If You have a question or need to find out if Your drug is considered a Specialty Drug please call Member Services at the number on Your Optima Health ID Card. You can also log onto optimahealth.com for a list of Specialty Drugs. A compound prescription medication is used to meet the needs of a specific individual and must have at least one ingredient requiring a physician s authorization by State or Federal Law. Compound prescriptions can usually be filled at Your local pharmacy. Your Copayment, Coinsurance, and Deductible amounts for each Tier are listed on the following page. Your Maximum Out-of-Pocket Amount is also listed. If You need help please call Member Services or log on to optimahealth.com to find out which of the following Tiers Your drug is in. ADMINISTERED BY OPTIMA HEALTH PLAN 84

87 Standard POS Outpatient Prescription Drug Rider Schedule of Benefits Deductibles and Maximum Out-of-Pocket Limit You must meet the medical Deductible listed on the Your Plan s Schedule of Benefits. Maximum Out-of-Pocket Outpatient Prescription Drug Copayments or Coinsurance apply to the Plan s Maximum Medical Out-of-Pocket Limit. Ancillary charges which result from a request for a brand name outpatient prescription drug when a generic drug is available are not Covered, do not count toward the Plan s Maximum Out-of-Pocket Limit and must continue to be paid after the maximum out-of-pocket Limit has been met. Copayments and Coinsurances For a single Copayment or Coinsurance charge You may receive up to a consecutive 31-day supply of a covered drug. A Copayment is a flat dollar amount. A Coinsurance is a percent of Optima Health s Allowable Charge. Certain prescription drugs will be covered at a generic product level established by the Plan. If a generic product level has been established for a drug and You or Your prescribing Physician requests the brand-name drug or a higher costing generic, You must pay the difference between the cost of the dispensed drug and the generic product level in addition to the Copayment charge (not to exceed $150 per each 31-day supply prescription). PREFERRED NETWORK You will pay a lower Copayment if you fill your prescriptions at a Walgreens, Walmart or Sam s Club Preferred Pharmacy. Selected Generic (Tier 1) After Deductible $10 Copayment (or the plan s negotiated cost of the drug, if less) Selected Brand & Other Generic After Deductible $25 Copayment (or the plan s negotiated cost of the drug, if less) (Tier 2) Non-Selected Brand (Tier 3) After Deductible Covered at 75% (maximum $50) Non-Preferred Pharmacy (all retail other than Walgreens, Walmart or Sam s Club) Selected Generic (Tier 1) After Deductible $25 Copayment (or the plan s negotiated cost of the drug, if less) Selected Brand & Other Generic After Deductible $45 Copayment (or the plan s negotiated cost of the drug, if less) (Tier 2) Non-Selected Brand (Tier 3) After Deductible Covered at 75% (maximum $75) Specialty Drugs (Tier 4) After Deductible Covered at 75% (maximum $200) PLEASE NOTE: Prescription medications used to prevent any of the following medical conditions are not subject to the deductible including medications for Hypertension, high cholesterol, diabetes, asthma, osteoporosis, stroke, prenatal nutrient deficiency. Mail Order Pharmacy Benefit Copayments and Coinsurances Some Outpatient prescription drugs are available through the Plan s Mail Order Provider. This does not include Tier 4 Specialty Drugs. You may call OptumRx Home Delivery at to find out if a drug is available. If Your drug is available You may purchase up to a 90-day supply for the Copayment or Coinsurance amount. Selected Generic (Tier 1) After Deductible $25 Copayment (or the plan s negotiated cost of the drug, if less) Selected Brand & Other Generic After Deductible $60 Copayment (or the plan s negotiated cost of the drug, if less) (Tier 2) Non-Selected Brand (Tier 3) After Deductible Covered at 75% (maximum $125) Specialty Drugs (Tier 4) No 90 day mail order benefits are available for Tier 4 Specialty Drugs Non-formulary requests. You have the right to request a non-formulary prescription drug if You believe that You need a prescription drug that is not on the Plan s list of covered drugs (formulary), or You have been receiving a specific non-formulary prescription drug for at least six months previous to the development or revision of the formulary and Your prescribing physician has determined that the formulary drug is inappropriate for Your condition or that changing drug therapy presents a significant health risk to You. Your physician must complete a medical necessity form and deliver it to the Optima Health pharmacy authorization department. After reasonable investigation and consultation with the prescribing physician, Optima Health will make a determination. Optima Health will act on such requests within one business day of receipt of the request. You will be responsible for all applicable Copayments, Coinsurance, or Deductibles depending upon which Tier a drug is placed in by the Plan. ADMINISTERED BY OPTIMA HEALTH PLAN 85

88 Notes The Covered Services herein are subject to the terms and conditions set forth in the Plan Document. Words that are capitalized are defined terms listed in the Definitions section of the Plan Document. Optima Health has an internal claims appeal process and an external review process. Please look in Your Plan Document for details about how to file a complaint or an appeal. Under certain circumstances Your coverage can be terminated. However, Your Coverage can only be rescinded for fraud or intentional misrepresentation of material fact. Please look in Your Plan Document in the section on When Your Coverage Will End. For Optima Health plans that require that You choose a primary care provider (PCP), You have the right to choose any PCP who participates in our network and who is available to accept new patients. For children, You may choose a pediatrician as the PCP. 1. You or Your means the Subscriber and each family member who is a Covered Person under the Plan. 2. Copayment and Coinsurance are out of pocket amounts You pay directly to a Provider for a Covered Service. A Copayment is a flat dollar amount. A Coinsurance is a percent of Optima Health s Allowable Charge (AC) for the Covered Service You receive. Allowable Charge is the amount Optima Health determines should be paid to a Provider for a Covered Service. When You use In Network benefits from Plan Providers Allowable Charge is the Provider s contracted rate with Optima Health or the Provider s actual charge for the service, whichever is less. Plan Providers accept this amount as payment in full. Medically Necessary Covered Services provided by a Non Plan Provider during an Emergency at a Plan Facility, or during an authorized Admission to a Plan Facility, will be Covered under In Network benefits. All other Covered Services received from Non Plan Providers will be Covered under Your Out of Network benefits. When You use Out of Network benefits from Non Plan Providers the Allowable Charge may be a negotiated rate; or if there is no negotiated rate the Allowable Charge is Optima Health s In Network contracted rate for the same service performed by the same type of Provider or the Provider s actual charge for the service, whichever is less. Non Plan Providers may not accept this amount as payment in full. If You use a Non Plan Provider who charges more than Optima Health s allowable amount the Provider may balance bill You for the difference. You will have to pay the difference to the Provider in addition to Your Copayment or Coinsurance amount. Charges from Non Plan Providers will be higher than the Plan s Allowable Charge so You will usually pay more out of pocket when You use Out of Network benefits. 3. Deductible means the dollar amount You must pay out of pocket each calendar year for Covered Services before the Plan begins to pay for Your benefits. If You have individual coverage You must satisfy the individual member Deductible before Coverage begins. If You have family coverage You must satisfy the family coverage Deductible. Your Plan has a non embedded individual deductible. Non embedded means if one covered family member meets the individual member deductible his or her benefits will not begin until the entire family deductible is satisfied. Once the total family coverage deductible is met benefits are available for all covered family members. A Plan may have separate individual and family Deductibles for In Network Covered Services and for Out of Network Services. Deductibles will not be reimbursed under the Plan. The Deductible does not apply to Preventive Care Visits and Screenings, Preventive Drugs, or Preventive Vision Services and You are required to pay Your office visit Copayment or Coinsurance only. Amounts applied to Your In Network Deductible will apply toward Your Plan s In Network Maximum Out of Pocket Limit. Amounts applied to Your Out of Network Deductible will apply toward Your Out of Network Maximum Limit. Should the Federal Government adjust the deductible for high deductible health plans as defined by the Internal Revenue Service, the deductible amount in the Policy will be adjusted accordingly. 4. Maximum Out of Pocket Limit for In Network Benefits means the total dollar amount You pay out of pocket for most In Network Covered Services during a calendar year. Your Plan has a separate out of pocket limit for Covered Services You receive under the Plan s Out of Network Benefits. Copayments and Coinsurance amounts that You pay for most In Network Covered Services will count toward Your In Network Maximum Out of Pocket Limit. Amounts applied to Your In Network Deductible will apply to Your In Network Maximum Out of Pocket Limit. Copayments or Coinsurance for Outpatient Prescription Drug Coverage will count toward Your In Network Maximum Out of Pocket Limit. If a service does not count toward Your Maximum Out of Pocket Limit You must continue to pay Your Copayments, Coinsurance and any other charges for these services after Your Maximum Out of Pocket Limit has been met. Copayments, Coinsurances, or any other charges for the following will not count toward Your In Network Maximum Out of Pocket Limit: 1. Amounts You pay for services not covered under Your Plan; 2. Amounts You pay for Out of Network Benefits; 3. Amounts You pay for Vision care; ADMINISTERED BY OPTIMA HEALTH PLAN 86 EqPl250080_0114 9

89 4. Amounts You pay for any benefits covered under a plan rider; 5. Amounts You pay for Reduction Mammoplasty benefits, except for procedures associated with reconstructive breast surgery following mastectomy; 6. Ancillary charges which result from Your request for a brand name outpatient prescription drug when a generic drug is available. Ancillary charges are not Covered Services; 7. Amounts You pay for any services after a benefit limit has been reached; 8. Amounts You pay as a penalty for failure to comply with the Plan s Pre authorization procedures; 9. Amounts applied to Your Out of Network Deductible. 5. Maximum Out of Pocket Limit for Out of Network Benefits means the total dollar amount You will pay during a calendar year for most Out of Network Covered Services. Your Plan has a separate Out of Pocket limit for Covered Services You receive under the Plan s In Network Benefits. Copayments and Coinsurance amounts that You pay for most Out of Network Covered Services will count toward Your Out of Network Maximum Out of Pocket Limit. Amounts applied to Your Out of Network Deductible will apply to Your Out of Network Maximum Out of Pocket Limit. If a service does not count toward Your Maximum Out of Pocket Limit You must continue to pay Your Copayments or Coinsurance for these services after Your Maximum Out of Pocket Limit has been met. Copayments, Coinsurances, or any other charges for the following will not count toward Your Out of Network Maximum Out of Pocket Limit: 1. Amounts You pay for services not covered under Your Plan; 2. Amounts You pay for In Network Benefits; 3. Amounts You pay for Vision care; 4. Amounts You pay for any benefits covered under a plan rider; 5. Amounts You pay for Reduction Mammoplasty benefits, except for procedures associated with reconstructive breast surgery following mastectomy; 6. Ancillary charges which result from Your request for a brand name outpatient prescription drug when a generic drug is available. Ancillary charges are not Covered Services; 7. Amounts You pay for any services after a benefit limit has been reached; 8. Amounts You pay as a penalty for failure to comply with the Plan s Pre authorization procedures; 9. Amounts applied to Your In Network Deductible; 10. Amounts that exceed the Plan s Allowable Charge for a Covered Service 6. This benefit requires Pre Authorization before You receive services. Your benefits for Covered Services may be reduced or denied if You do not comply with the Plan's Pre Authorization requirements. The Plan may also apply a penalty of up to $500 to any benefits paid for Covered Services if You do not comply with the Plan s Pre Authorization requirements. 7. Coverage for this benefit or service is limited by a dollar amount and/or visit or day limits as stated. Maximum amounts are combined maximums of both In Network and Out Of Network Covered Services unless otherwise stated. The Plan will not cover any additional services after the limits have been reached. You will be responsible for payment for all services after a benefit limit has been reached. Amounts You pay for any services after a benefit limit has been reached are excluded from Coverage and will not count toward Your Maximum Out of Pocket Maximum Limit. 8. Coverage for obstetrical services as an inpatient in a general hospital or obstetrical services by a physician shall provide such benefits with durational limits, deductibles, coinsurance factors, and Copayments that are no less favorable than for physical illness generally. If the Plan charges a Global Copayment for prenatal, delivery, and postpartum services You are entitled to a refund from the Delivering Obstetrician if the total amount of the Global Copayment for prenatal, delivery, and postpartum services is more than the total Copayments You would have paid on a per visit or per procedure basis. 9. All Emergency, Urgent Care, Ambulance, and Emergency Mental/Behavioral Health Services may be subject to Retrospective Review to determine the Plan s responsibility for payment. If the Plan determines that the condition treated was not an Emergency Service, the Plan will have no responsibility for the cost of the treatment and You will be solely responsible for payment. Members who receive Emergency Services from Non Plan Providers may be responsible for charges in excess of what would have been paid had the Emergency Services been received from Plan Providers. In no event will the Plan be responsible for payment for services from Non Plan Providers where the service would not have been covered had the member received care from a Plan Provider. 10. Preventive Care includes recommended preventive care services under the Patient Protection and Affordable Care Act (PPACA) listed below. You may be responsible for an office visit copayment or coinsurance when you receive preventive care Out of Network. Some services may be administered under Your prescription drug benefit under the Plan. 1. Evidence based items or services that have in effect a rating of A or B in the recommendations of the U.S. Preventive Services Task Force as of September 23, 2010, with respect to the individual involved; ADMINISTERED BY OPTIMA HEALTH PLAN 87 EqPl250080_

90 2. Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. For purposes of this subdivision, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention; 3. With respect to infants, children, and adolescents, evidence informed preventive care and screenings in the Recommendations for Preventive Pediatric Health by the American Academy of Pediatrics and the Recommended Uniform Screening Panels by the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children; and 4. With respect to women, evidence informed preventive care and screenings recommended in comprehensive guidelines supported by the Health Resources and Services Administration. Services include well woman visits, screening for gestational diabetes, human papillomavirus, testing (HPV), counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus (HIV), FDA approved contraception methods, sterilization procedures, and patient education and counseling for women, breastfeeding support, supplies, and counseling, screening and counseling for interpersonal and domestic violence. 11. You do not need prior authorization from Optima Health or from any other person (including a Primary Care Provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre approved treatment plan, or procedures for making referrals. Look in Your Plan Document in the Utilization Management section for more information on pre authorization. ADMINISTERED BY OPTIMA HEALTH PLAN 88 EqPl250080_

91 Optima Health Point of Service (POS) BASIC PLAN 89

92 OPTIMA POINT OF SERVICE (POS) BASIC 2018 Summary of Benefits City of Virginia Beach & Virginia Beach City Public Schools This document is not a contract or policy with Optima Health. It is a summary of benefits and services available through the Plan. If there are any differences between this summary and the employer group Plan Document, the provisions of those documents will prevail for all benefits, conditions, limitations and exclusions. This plan is a Qualified High Deductible plan compatible with a Health Savings Account. Deductibles per Calendar Year 3 Maximum Out of Pocket Limit per Calendar Year Deductibles, Maximum Out of Pocket Limits Optima Network / PHCS Network $2,000 Employee only coverage $4,000 per Family $4,000 Employee only coverage 4 $8,000 per Family 4 (not to exceed $7,350 for one individual) Out of Network $ 4,000 Employee only coverage $ 8,000 per Family $ 6,500 Employee only coverage 5 $13,000 per Family 5 Physician Services Includes Covered Services performed in the Physician s office during the Physician office visit. Includes, but is not limited to, office consults and exams; In office surgery; In office lab, x ray, injections, and diagnostic and treatment services. Family planning services including injectables and vasectomy; Physical, Occupational, and Speech Therapy; Cardiac, Pulmonary, and Vascular Rehabilitation Services; Chemo, Radiation, IV, and Respiratory therapy services; Dialysis treatments. Pre Authorization is required for in office surgery 6. Physician Office Visits Optima Network / PHCS Network Out of Network MDLIVE Services After Deductible Covered at 85% Not Applicable Sentara Quality Care Network (SQCN) Primary Care Physician (PCP) Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. After Deductible Covered at 85% After Deductible Covered at 50% Non Sentara Quality Care Network (SQCN) Primary Care Physician (PCP) Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who reside in those areas and choose a Non SQCN provider will pay the higher coinsurance. After Deductible Covered at 75% Sentara Quality Care Network (SQCN) Specialist Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. Non Sentara Quality Care Network (SQCN) Specialist Office Visit SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who reside in those areas and choose a Non SQCN provider will pay the higher coinsurance. After Deductible Covered at 85% After Deductible Covered at 75% After Deductible Covered at 50% ADMINISTERED BY OPTIMA HEALTH PLAN 1 EqPl250080_

93 Preventive Care 10 Routine Annual Physical Exams Well Baby Exams Annual GYN Exams and Pap Smears 11 PSA Tests Colorectal Cancer Tests Routine Adult and Childhood Immunizations Screening Colonoscopy Screening Mammograms (including 3 D mammograms) Women s Preventive Services Physician Services Optima Network / PHCS Network Out of Network Covered at 100% After Deductible Covered at 50% Outpatient Therapy and Rehabilitation Services Short Term Therapy Services 7 Optima Network / PHCS Network Out of Network Physical Therapy Occupational Therapy Pre Authorization is required. 6 After Deductible Covered at 75% After Deductible Covered at 50% Physical and Occupational Therapy are limited to a maximum combined benefit with In Network and Outof Network benefits and for all places of service of 30 visits per condition. 7 Copayment or Coinsurance applies at any place of service. Speech Therapy After Deductible Covered at 75% After Deductible Covered at 50% Pre Authorization is required. 6 Speech Therapy is limited to a maximum combined benefit with In Network and Out of Network benefits and for all places of service of 30 visits per condition. 7 Copayment or Coinsurance applies at any place of service. Short Term Rehabilitation Services 7 Optima Network / PHCS Network Out of Network Cardiac Rehabilitation Pulmonary Rehabilitation Vascular Rehabilitation Vestibular Rehabilitation Pre Authorization is required. 6 Services are limited to a maximum combined benefit with In Network and Out of Network benefits and for all places of service of 90 consecutive days per condition. 7 Copayment or Coinsurance applies at any place of service. After Deductible Covered at 75% After Deductible Covered at 50% Other Outpatient Treatments Chemotherapy Radiation Therapy IV Therapy Inhalation Therapy Optima Network / PHCS Network Out of Network After Deductible Covered at 75% After Deductible Covered at 50% ADMINISTERED BY OPTIMA HEALTH PLAN 2 EqPl250080_

94 Outpatient Therapy and Rehabilitation Services Other Outpatient Treatments Optima Network / PHCS Network Out of Network Pre Authorized Injectable and Infused Medications Includes injectable and infused medications, biologics, and IV therapy medications that require prior authorization. Coinsurance applies when medications are provided in a Physician s office, outpatient facility, or in the Member s home as part of Skilled Home Health Care Services benefit. Coinsurance is in addition to any applicable office visit or outpatient facility Copayment or Coinsurance. After Deductible Covered at 75% After Deductible Covered at 50% Outpatient Dialysis Services Outpatient Dialysis Services Optima Network / PHCS Network Out of Network Dialysis Services After Deductible Covered at 75% After Deductible Covered at 50% Copayment or Coinsurance applies at any place of service. Outpatient Surgery Outpatient Surgery Optima Network / PHCS Network Out of Network Outpatient Surgery Pre Authorization is required. 6 Coinsurance or Copayment applies to services provided in a free standing ambulatory surgery center or hospital outpatient surgical facility. After Deductible Covered at 75% After Deductible Covered at 50% Outpatient Diagnostic Procedures Copayment or Coinsurance will apply when a procedure is performed in a free standing outpatient facility or lab, or a hospital outpatient facility or lab. Outpatient Diagnostic Procedures Optima Network / PHCS Network Out of Network Outpatient Diagnostic Procedures After Deductible Covered at 75% After Deductible Covered at 50% Outpatient X Ray After Deductible Covered at 75% After Deductible Covered at 50% Ultrasound Doppler Studies Outpatient Lab Work After Deductible Covered at 75% After Deductible Covered at 50% Outpatient Advanced Imaging and Testing Procedures Outpatient Advanced Imaging and Testing Procedures Optima Network / PHCS Network Out of Network Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) Positron Emission Tomography (PET Scans) Computerized Axial Tomography (CT Scans) Computerized Axial Tomography Angiogram (CTA Scans) Pre Authorization is required. 6 Copayment or Coinsurance applies to procedures done in a Physician s office, a free standing outpatient facility, or a hospital outpatient facility. After Deductible Covered at 75% After Deductible Covered at 50% ADMINISTERED BY OPTIMA HEALTH PLAN 3 EqPl250080_

95 Maternity Care Maternity Care 8,10,11 Pre Authorization is required for prenatal services. 6 Includes prenatal, delivery, postnatal, postpartum services, and home health visits. Copayment or Coinsurance is in addition to any applicable inpatient hospital Copayment or Coinsurance. Sentara Quality Care Network (SQCN) SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. Maternity Care Optima Network / PHCS Network After Deductible Covered at 85% Out of Network After Deductible Covered at 50% Non Sentara Quality Care Network (SQCN) SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. Inpatient Services Inpatient Hospital Services Pre Authorization is required. 6 Transplants are covered at contracted facilities only. Skilled Nursing Facilities/Services 7 Pre Authorization is required. 6 Following inpatient hospital care or in lieu of hospitalization. Covered Services include up to 100 days combined in and out of network per calendar year that in the Plan s judgment requires Skilled Nursing Facility Services. 7 Ambulance Services Ambulance Services 9 Pre Authorization is required for non emergent transportation only. 6 Includes air and ground ambulance for emergency transportation, or non emergent transportation that is Medically Necessary and Pre Authorized by the Plan. Copayment or Coinsurance is applied per transport each way. After Deductible Covered at 75% Inpatient Services Optima Network / PHCS Network Out of Network After Deductible Covered at 75% After Deductible Covered at 50% After Deductible Covered at 75% After Deductible Covered at 50% Ambulance Services Optima Network / PHCS Network After Deductible Covered at 75% *If transported by a Virginia Beach Volunteer Rescue Squad Covered at 100%. Out of Network After Deductible Covered at 75% ADMINISTERED BY OPTIMA HEALTH PLAN 4 EqPl250080_

96 Emergency Services Emergency Services 9 Pre Authorization is not required. Includes Emergency Services, Physician, and Ancillary Services provided in an emergency department facility. Inpatient copayment / coinsurance will apply if admitted. Emergency Services Optima Network / PHCS Network Out of Network After Deductible Covered at 75% After Deductible Covered at 75% Urgent Care Center Services Urgent Care Center Services Optima Network / PHCS Network Out of Network Urgent Care Services 9 Pre Authorization is not required. After Deductible Covered at 75% After Deductible Covered at 50% Includes Urgent Care Services, Physician services, and other Ancillary Services received at an Urgent Care facility. If You 1 are transferred to an emergency department from an Urgent Care center, You 1 will pay an Emergency Services Copayment or Coinsurance. Mental/Behavioral Health Care Includes inpatient and outpatient services for the treatment of mental health and substance abuse. Also includes services for Biologically Based Mental Illnesses for the following diagnoses: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive compulsive disorder, attention deficit hyperactivity disorder, autism, and drug and alcoholism addiction. Mental/Behavioral Health Care Optima Network / PHCS Network Out of Network Inpatient Services Pre Authorization is required. 6 Residential treatment is not covered. After Deductible Covered at 75% After Deductible Covered at 50% Sentara Quality Care Network (SQCN) Outpatient Services Pre Authorization may be required. 6 SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who do not reside in those areas will pay the SQCN provider coinsurance. After Deductible Covered at 85% After Deductible Covered at 50% Non Sentara Quality Care Network (SQCN) Outpatient Services Pre Authorization may be required. 6 SQCN providers are currently available in Hampton Roads, Charlottesville and Rockingham zip codes only. Members who reside in those areas and choose a Non SQCN provider will pay the higher coinsurance. After Deductible Covered at 75% ADMINISTERED BY OPTIMA HEALTH PLAN 5 EqPl250080_

97 Other Covered Services Allergy Care Includes Allergy testing, Injections, Serum and RAST testing. Other Covered Services Optima Network / PHCS Network Out of Network Copayment/Coinsuranc After Deductible Covered at 75% After Deductible Covered at 50% 2 Autism Spectrum Disorder Pre Authorization is required. 6 Covered Services include diagnosis and treatment of Autism Spectrum Disorder in children from age two through 10. Autism Spectrum Disorder means any pervasive developmental disorder, including (i) autistic disorder, (ii) Asperger s Syndrome, (iii) Rett syndrome, (iv) childhood disintegrative disorder, or (v) Pervasive Developmental Disorder Not Otherwise Specified, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. Diagnosis of autism spectrum disorder means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder. Treatment for autism spectrum disorder shall be identified in a treatment plan and includes the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary: (i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) therapeutic care, and (vi) applied behavioral analysis when provided or supervised by a board certified behavioral analyst licensed by the Board of Medicine. Applied behavioral analysis means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. Coverage for applied behavioral analysis under this benefit is limited to an annual maximum benefit of $35, Coverage for Autism Spectrum Disorder will not be subject to any visit limits, and will be neither different nor separate from coverage for any other illness, condition, or disorder for purposes of determining Deductibles, lifetime dollar limits, Copayment and Coinsurance factors, and benefit year maximum for Deductibles and Copayment and Coinsurance factors. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of treatment or service listed on the Summary of Benefits. Coverage for Autism Spectrum Disorder will not be subject to any visit limits, and will be neither different nor separate from coverage for any other illness, condition, or disorder for purposes of determining Deductibles, lifetime dollar limits, Copayment and Coinsurance factors, and benefit year maximum for Deductibles and Copayment and Coinsurance factors. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of treatment or service listed on Summary of Benefits. ADMINISTERED BY OPTIMA HEALTH PLAN 6 EqPl250080_

98 Other Covered Services Prosthetic Limbs and Components 7 Pre Authorization is required. 6 Services include coverage for medically necessary prosthetic devices. This also includes repair, fitting, replacement and components. Other Covered Services Optima Network / PHCS Network Out of Network After Deductible Covered at 75% After Deductible Covered at 50% Definitions: Component means the materials and equipment needed to ensure the comfort and functioning of a prosthetic device. Limb means an arm, a hand, a foot, or any portion of an arm, hand, a leg or foot. Prosthetic device means an artificial device to replace, in whole or in part, a limb. Prosthetic device coverage does not mean or include repair and replacement due to enrollee neglect, misuse, or abuse. Coverage also does not mean or include prosthetic devices designed primarily for an athletic purpose. Chiropractic Care 7 Optima Health contracts with American Specialty Health Networks (ASHN) to administer this benefit. Pre Authorization is required by ASHN for all chiropractic care services. 6 To receive services, contact ASHN's Member Services at Representatives are available from 8:00 AM to 9:00 PM Monday Friday. Coverage is limited to a combined maximum benefit with in and out ofnetwork benefits of 30 visits per Person, per calendar year. This benefit also includes coverage of Chiropractic appliances up to a combined maximum benefit with inand out of network benefits of 1 appliance per Person per calendar year when medically necessary. For providers not in the ASHN network the Member will be responsible for payment of all charges in excess of ASHN s allowable charge in addition to any coinsurance amount. Allowable charge is the lesser of the provider s actual charge or ASHN s In Network fee schedule for the same services. After Deductible Covered at 75% of ASHN fee schedule After Deductible Covered at 50% of ASHN fee schedule ADMINISTERED BY OPTIMA HEALTH PLAN 7 EqPl250080_

99 Other Covered Services Diabetic Supplies and Equipment Includes FDA approved equipment and supplies for the treatment of diabetes and in person outpatient self management training and education including medical nutrition therapy. Insulin, syringes, and needles are covered under the Plan s Prescription Drug Benefit for the applicable Copayment or Coinsurance per 31 day supply. An annual diabetic eye exam is covered from an Optima Health Plan Provider, a participating EyeMed Provider, or a Non Plan Provider at the applicable office visit Copayment or Coinsurance amount. For more information about how to access this benefit for meters, strips and lancets, please call one of the following providers: Home Care Delivered: EdgePark Medical Supplies: You may also call or SENTARA for information on educational classes. Other Covered Services Optima Network / PHCS Network Blood glucose monitoring equipment and supplies including home glucose monitors, lancets, blood glucose test strips, and insulin pump infusion sets if prescribed by your physician: After Deductible Covered at 100% Insulin pumps: After Deductible covered at 100% Outpatient self management training and education, including medical nutritional therapy: After Deductible covered at 100% Out of Network Blood glucose monitoring equipment and supplies including home glucose monitors, lancets, blood glucose test strips, and insulin pump infusion sets if prescribed by your physician: After Deductible Covered at 50% Insulin pumps: After Deductible covered at: 50% Outpatient self management training and education, including medical nutritional therapy: After Deductible covered at: 50% Durable Medical Equipment (DME) and Supplies 7 Orthopedic Devices and Prosthetic Appliances 7 Pre Authorization is required for single items over $ Pre Authorization is required for all rental items. 6 Pre Authorization is required for repair and replacement. 6 After Deductible Covered at 75% After Deductible Covered at 50% Covered Services include durable medical equipment, orthopedic devices, prosthetic appliances other than artificial limbs, colostomy, ileostomy, and tracheostomy supplies, suction and urinary catheters, and repair/replacement. Early Intervention Services Pre Authorization is required. 6 Covered for Dependents from birth to age three who are certified as eligible by the Virginia Department of Behavioral Health and Developmental Services. Covered Services include: Medically Necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of service. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of service. ADMINISTERED BY OPTIMA HEALTH PLAN 8 EqPl250080_

100 Other Covered Services Family Planning Depo Provera Injection: Other Covered Services Optima Network / PHCS Network Covered at 100% Out of Network After Deductible Covered at 50% Lunelle Injection: Tubal Ligation: Pre authorization required Vasectomy: Covered at 100% Covered at 100% After Deductible Covered at 100% Subject to any applicable outpatient/inpatient surgery copayment/coinsurance. After Deductible Covered at 50% After Deductible Covered at 50% After Deductible Covered at 50% Subject to any applicable outpatient/inpatient surgery copayment/coinsurance. Hearing Aid Rider Pre Authorization is required. 6 Covered up to $1250 per hearing aid. Includes replacement every 36 months. Batteries are not covered. Home Health Care Skilled Services 7 Pre Authorization is required. 6 Services are covered up to a maximum combined benefit with In Network and Out of Network benefits of 100 visits per calendar year for Members who are home bound, and in the Plan s judgment require Home Health Skilled Services. 7 After Deductible Covered at 75% After Deductible Covered at 50% After Deductible Covered at 75% After Deductible Covered at 50% You will pay a separate outpatient therapy Copayment or Coinsurance amount for physical, occupational, and speech therapy visits received at home. Therapy visits received at home will count toward Your Plan s annual outpatient therapy benefit limits. You will pay a separate outpatient rehabilitation services Copayment or Coinsurance amount for cardiac, pulmonary, vascular, and vestibular rehabilitation visits received at home. Rehabilitation visits received at home will count toward Your Plan s annual outpatient rehabilitation benefit limits. Hospice Care After Deductible Covered at 75% After Deductible Covered at Pre Authorization is required. 6 50% ADMINISTERED BY OPTIMA HEALTH PLAN 9 EqPl250080_

101 Other Covered Services Vision Care and Materials 7 Optima Health contracts with EyeMed Vision Care to administer this benefit. Medical conditions related to the eye, such as glaucoma, are covered under the medical plan. Coverage includes one examination every 12 months when done by a participating EyeMed Provider. To locate a participating EyeMed provider, please call or visit Other Covered Services Optima Network / PHCS Network Spectacle Exam: $20 Copayment then covered at 100%. OR Contact Lens Exam: $40 Copayment then covered at 100%. Limited to one exam every 12 months (from the date of last exam) by a participating EyeMed Provider. Materials By a participating EyeMed Provider: Lenses (single vision, bifocal, trifocal) covered in full. Frames: Covered in full up to $100 retail Contact Lenses (in lieu of glasses) covered in full up to $95 retail. If you choose contact lenses when they are not medically indicated, you will receive an allowance of $95 toward the purchase price. (Contact lenses are deemed medically necessary following cataract surgery, to correct extreme visual acuity problems not correctable with spectacle lenses, or if you have certain conditions of anisometropia or keratoconus). If contact lenses are obtained, they are in lieu of spectacles. Out of Network For eye examinations from Out of Network providers, Members will be reimbursed up to $40 for an eye examination (once every 12 months from date of last exam). No coverage for eyeglasses/contacts out of network. Telemedicine Services Telemedicine Services means the use of interactive audio, video, or other electronic media used for the purpose of diagnosis, consultation, or treatment. Telemedicine services do not include an audio only telephone, electronic mail message, or facsimile transmission. Members are responsible for any applicable Copayment, Coinsurance, or Deductible depending on the type and place of treatment or service. Your out of pocket deductible, copayment, or coinsurance amounts will not exceed the deductible, copayment or coinsurance amount You would have paid if the same services were provided through face to face diagnosis, consultation, or treatment. ADMINISTERED BY OPTIMA HEALTH PLAN 1 EqPl250080_

102 Basic POS Outpatient Prescription Drug Rider Schedule of Benefits This schedule of benefits describes Your outpatient prescription drug coverage. All drugs must be Food and Drug Administration (FDA) approved and you must have a prescription. You will need to pay Your Copayment or Coinsurance when you fill your prescription at the pharmacy. If Your Plan has a Deductible you must meet that amount before your coverage begins. Some drugs require Pre-Authorization by Your Physician, and some quantities may be limited. Your drug coverage has specific Exclusions and Limitations, so please read the next few pages carefully. Optima Health s Pharmacy and Therapeutics Committee places covered drugs into the following Tiers. You will pay Your Copayment or Coinsurance depending on which Tier Your Drug is in. This Plan has a closed formulary and covers a specific list of drugs and medications. Drugs not included on the Plan s formulary will be excluded from coverage. Selected Generic (Tier 1) includes commonly prescribed generic drugs. Other drugs may be included in Tier 1 if the Plan recognizes they show documented long-term decreases in illness. Selected Brand & Other Generic (Tier 2) includes brand-name drugs, and some generic drugs with higher costs than Tier 1 generics, that are considered by the Plan to be standard therapy. Non-Selected Brand (Tier 3) includes brand name drugs not included by the Plan on Tier 1 or Tier 2. These may include single source brand name drugs that do not have a generic equivalent or a therapeutic equivalent. Drugs on this tier may be higher in cost than equivalent drugs, or drugs determined to be no more effective than equivalent drugs on lower tiers. Specialty Drugs (Tier 4) includes those drugs classified by the Plan as Specialty Drugs. Tier 4 also includes covered compound prescription medications. Specialty Drugs have unique uses and are generally prescribed for people with complex or ongoing medical conditions. Specialty Drugs typically require special dosing, administration, and additional education and support from a health care professional. Specialty Drugs include the following: Medications that treat certain patient populations including those with rare diseases; Medications that require close medical and pharmacy management and monitoring; Medications that require special handling and/or storage; Medications derived from biotechnology and/or blood derived drugs or small molecules; and Medications that can be delivered via injection, infusion, inhalation, or oral administration. Specialty Drugs are only available through Proprium Pharmacy at or (toll free). Specialty Drugs will be delivered to Your home address from Our Specialty mail order pharmacy. If You have a question or need to find out if Your drug is considered a Specialty Drug please call Member Services at the number on Your Optima Health ID Card. You can also log onto optimahealth.com for a list of Specialty Drugs. A compound prescription medication is used to meet the needs of a specific individual and must have at least one ingredient requiring a physician s authorization by State or Federal Law. Compound prescriptions can usually be filled at Your local pharmacy. Your Copayment, Coinsurance, and Deductible amounts for each Tier are listed on the following page. Your Maximum Out-of-Pocket Amount is also listed. If You need help please call Member Services or log on to optimahealth.com to find out which of the following Tiers Your drug is in. ADMINISTERED BY OPTIMA HEALTH PLAN 100

103 Basic POS Outpatient Prescription Drug Rider Schedule of Benefits Deductibles and Maximum Out-of-Pocket Limit Deductibles You must meet the medical Deductible listed on the Your Plan s Schedule of Benefits. Maximum Out-of-Pocket Limit Outpatient Prescription Drug Copayments or Coinsurance apply to the Plan s Maximum Medical Out-of-Pocket Limit. Ancillary charges which result from a request for a brand name outpatient prescription drug when a generic drug is available are not Covered, do not count toward the Plan s Maximum Out-of-Pocket Limit and must continue to be paid after the maximum out-of-pocket Limit has been met. Copayments and Coinsurances For a single Copayment or Coinsurance charge You may receive up to a consecutive 31-day supply of a covered drug. A Copayment is a flat dollar amount. A Coinsurance is a percent of Optima Health s Allowable Charge. Certain prescription drugs will be covered at a generic product level established by the Plan. If a generic product level has been established for a drug and You or Your prescribing Physician requests the brand-name drug or a higher costing generic, You must pay the difference between the cost of the dispensed drug and the generic product level in addition to the Copayment charge (not to exceed $150 per each 31-day supply prescription). PREFERRED NETWORK You will pay a lower Copayment if you fill your prescriptions at a Walgreens, Walmart or Sam s Club Preferred Pharmacy. Selected Generic (Tier 1) After Deductible $10 Copayment (or the plan s negotiated cost of the drug, if less) Selected Brand & Other Generic After Deductible $25 Copayment (or the plan s negotiated cost of the drug, if less) (Tier 2) Non-Selected Brand (Tier 3) After Deductible Covered at 75% (maximum $50) Non-Preferred Pharmacy (all retail other than Walgreens, Walmart or Sam s Club) Selected Generic (Tier 1) After Deductible $25 Copayment (or the plan s negotiated cost of the drug, if less) Selected Brand & Other Generic After Deductible $45 Copayment (or the plan s negotiated cost of the drug, if less) (Tier 2) Non-Selected Brand (Tier 3) After Deductible Covered at 75% (maximum $75) Specialty Drugs (Tier 4) After Deductible Covered at 75% (maximum $200) PLEASE NOTE: Prescription medications used to prevent any of the following medical conditions are not subject to the deductible including medications for Hypertension, high cholesterol, diabetes, asthma, osteoporosis, stroke, prenatal nutrient deficiency. Mail Order Pharmacy Benefit Copayments and Coinsurances Some Outpatient prescription drugs are available through the Plan s Mail Order Provider. This does not include Tier 4 Specialty Drugs. You may call OptumRx Home Delivery at to find out if a drug is available. If Your drug is available You may purchase up to a 90-day supply for the Copayment or Coinsurance amount. Selected Generic (Tier 1) After Deductible $25 Copayment (or the plan s negotiated cost of the drug, if less) Selected Brand & Other Generic After Deductible $60 Copayment (or the plan s negotiated cost of the drug, if less) (Tier 2) Non-Selected Brand (Tier 3) After Deductible Covered at 75% (maximum $125) Specialty Drugs (Tier 4) No 90 day mail order benefits are available for Tier 4 Specialty Drugs Non-formulary requests. You have the right to request a non-formulary prescription drug if You believe that You need a prescription drug that is not on the Plan s list of covered drugs (formulary), or You have been receiving a specific non-formulary prescription drug for at least six months previous to the development or revision of the formulary and Your prescribing physician has determined that the formulary drug is inappropriate for Your condition or that changing drug therapy presents a significant health risk to You. Your physician must complete a medical necessity form and deliver it to the Optima Health pharmacy authorization department. After reasonable investigation and consultation with the prescribing physician, Optima Health will make a determination. Optima Health will act on such requests within one business day of receipt of the request. You will be responsible for all applicable Copayments, Coinsurance, or Deductibles depending upon which Tier a drug is placed in by the Plan. ADMINISTERED BY OPTIMA HEALTH PLAN 101

104 Notes The Covered Services herein are subject to the terms and conditions set forth in the Plan Document. Words that are capitalized are defined terms listed in the Definitions section of the Plan Document. Optima Health has an internal claims appeal process and an external review process. Please look in Your Plan Document for details about how to file a complaint or an appeal. Under certain circumstances Your coverage can be terminated. However, Your Coverage can only be rescinded for fraud or intentional misrepresentation of material fact. Please look in Your Plan Document in the section on When Your Coverage Will End. For Optima Health plans that require that You choose a primary care provider (PCP), You have the right to choose any PCP who participates in our network and who is available to accept new patients. For children, You may choose a pediatrician as the PCP. 1. You or Your means the Subscriber and each family member who is a Covered Person under the Plan. 2. Copayment and Coinsurance are out of pocket amounts You pay directly to a Provider for a Covered Service. A Copayment is a flat dollar amount. A Coinsurance is a percent of Optima Health s Allowable Charge (AC) for the Covered Service You receive. Allowable Charge is the amount Optima Health determines should be paid to a Provider for a Covered Service. When You use In Network benefits from Plan Providers Allowable Charge is the Provider s contracted rate with Optima Health or the Provider s actual charge for the service, whichever is less. Plan Providers accept this amount as payment in full. Medically Necessary Covered Services provided by a Non Plan Provider during an Emergency at a Plan Facility, or during an authorized Admission to a Plan Facility, will be Covered under In Network benefits. All other Covered Services received from Non Plan Providers will be Covered under Your Out of Network benefits. When You use Out of Network benefits from Non Plan Providers the Allowable Charge may be a negotiated rate; or if there is no negotiated rate the Allowable Charge is Optima Health s In Network contracted rate for the same service performed by the same type of Provider or the Provider s actual charge for the service, whichever is less. Non Plan Providers may not accept this amount as payment in full. If You use a Non Plan Provider who charges more than Optima Health s allowable amount the Provider may balance bill You for the difference. You will have to pay the difference to the Provider in addition to Your Copayment or Coinsurance amount. Charges from Non Plan Providers will be higher than the Plan s Allowable Charge so You will usually pay more out of pocket when You use Out of Network benefits. 3. Deductible means the dollar amount You must pay out of pocket each calendar year for Covered Services before the Plan begins to pay for Your benefits. If You have individual coverage You must satisfy the individual member Deductible before Coverage begins. If You have family coverage You must satisfy the family coverage Deductible. Your Plan has a non embedded individual deductible. Non embedded means if one covered family member meets the individual member deductible his or her benefits will not begin until the entire family deductible is satisfied. Once the total family coverage deductible is met benefits are available for all covered family members. A Plan may have separate individual and family Deductibles for In Network Covered Services and for Out of Network Services. Deductibles will not be reimbursed under the Plan. The Deductible does not apply to Preventive Care Visits and Screenings, Preventive Drugs, or Preventive Vision Services and You are required to pay Your office visit Copayment or Coinsurance only. Amounts applied to Your In Network Deductible will apply toward Your Plan s In Network Maximum Out of Pocket Limit. Amounts applied to Your Out of Network Deductible will apply toward Your Out of Network Maximum Limit. Should the Federal Government adjust the deductible for high deductible health plans as defined by the Internal Revenue Service, the deductible amount in the Policy will be adjusted accordingly. 4. Maximum Out of Pocket Limit for In Network Benefits means the total dollar amount You pay out of pocket for most In Network Covered Services during a calendar year. Your Plan has a separate out of pocket limit for Covered Services You receive under the Plan s Out of Network Benefits. Copayments and Coinsurance amounts that You pay for most In Network Covered Services will count toward Your In Network Maximum Out of Pocket Limit. Amounts applied to Your In Network Deductible will apply to Your In Network Maximum Out of Pocket Limit. Copayments or Coinsurance for Outpatient Prescription Drug Coverage will count toward Your In Network Maximum Out of Pocket Limit. If a service does not count toward Your Maximum Out of Pocket Limit You must continue to pay Your Copayments, Coinsurance and any other charges for these services after Your Maximum Out of Pocket Limit has been met. Copayments, Coinsurances, or any other charges for the following will not count toward Your In Network Maximum Out of Pocket Limit: 1. Amounts You pay for services not covered under Your Plan; 2. Amounts You pay for Out of Network Benefits; 3. Amounts You pay for Vision care; ADMINISTERED BY OPTIMA HEALTH PLAN 9 EqPl250080_

105 4. Amounts You pay for any benefits covered under a plan rider; 5. Amounts You pay for Reduction Mammoplasty benefits, except for procedures associated with reconstructive breast surgery following mastectomy; 6. Ancillary charges which result from Your request for a brand name outpatient prescription drug when a generic drug is available. Ancillary charges are not Covered Services; 7. Amounts You pay for any services after a benefit limit has been reached; 8. Amounts You pay as a penalty for failure to comply with the Plan s Pre authorization procedures; 9. Amounts applied to Your Out of Network Deductible. 5. Maximum Out of Pocket Limit for Out of Network Benefits means the total dollar amount You will pay during a calendar year for most Out of Network Covered Services. Your Plan has a separate Out of Pocket limit for Covered Services You receive under the Plan s In Network Benefits. Copayments and Coinsurance amounts that You pay for most Out of Network Covered Services will count toward Your Out of Network Maximum Out of Pocket Limit. Amounts applied to Your Out of Network Deductible will apply to Your Out of Network Maximum Out of Pocket Limit. If a service does not count toward Your Maximum Out of Pocket Limit You must continue to pay Your Copayments or Coinsurance for these services after Your Maximum Out of Pocket Limit has been met. Copayments, Coinsurances, or any other charges for the following will not count toward Your Out of Network Maximum Out of Pocket Limit: 1. Amounts You pay for services not covered under Your Plan; 2. Amounts You pay for In Network Benefits; 3. Amounts You pay for Vision care; 4. Amounts You pay for any benefits covered under a plan rider; 5. Amounts You pay for Reduction Mammoplasty benefits, except for procedures associated with reconstructive breast surgery following mastectomy; 6. Ancillary charges which result from Your request for a brand name outpatient prescription drug when a generic drug is available. Ancillary charges are not Covered Services; 7. Amounts You pay for any services after a benefit limit has been reached; 8. Amounts You pay as a penalty for failure to comply with the Plan s Pre authorization procedures; 9. Amounts applied to Your In Network Deductible; 10. Amounts that exceed the Plan s Allowable Charge for a Covered Service 6. This benefit requires Pre Authorization before You receive services. Your benefits for Covered Services may be reduced or denied if You do not comply with the Plan's Pre Authorization requirements. The Plan may also apply a penalty of up to $500 to any benefits paid for Covered Services if You do not comply with the Plan s Pre Authorization requirements. 7. Coverage for this benefit or service is limited by a dollar amount and/or visit or day limits as stated. Maximum amounts are combined maximums of both In Network and Out Of Network Covered Services unless otherwise stated. The Plan will not cover any additional services after the limits have been reached. You will be responsible for payment for all services after a benefit limit has been reached. Amounts You pay for any services after a benefit limit has been reached are excluded from Coverage and will not count toward Your Maximum Out of Pocket Maximum Limit. 8. Coverage for obstetrical services as an inpatient in a general hospital or obstetrical services by a physician shall provide such benefits with durational limits, deductibles, coinsurance factors, and Copayments that are no less favorable than for physical illness generally. If the Plan charges a Global Copayment for prenatal, delivery, and postpartum services You are entitled to a refund from the Delivering Obstetrician if the total amount of the Global Copayment for prenatal, delivery, and postpartum services is more than the total Copayments You would have paid on a per visit or per procedure basis. 9. All Emergency, Urgent Care, Ambulance, and Emergency Mental/Behavioral Health Services may be subject to Retrospective Review to determine the Plan s responsibility for payment. If the Plan determines that the condition treated was not an Emergency Service, the Plan will have no responsibility for the cost of the treatment and You will be solely responsible for payment. Members who receive Emergency Services from Non Plan Providers may be responsible for charges in excess of what would have been paid had the Emergency Services been received from Plan Providers. In no event will the Plan be responsible for payment for services from Non Plan Providers where the service would not have been covered had the member received care from a Plan Provider. 10. Preventive Care includes recommended preventive care services under the Patient Protection and Affordable Care Act (PPACA) listed below. You may be responsible for an office visit copayment or coinsurance when you receive preventive care out of network. Some services may be administered under Your prescription drug benefit under the Plan. ADMINISTERED BY OPTIMA HEALTH PLAN 10 EqPl250080_

106 1. Evidence based items or services that have in effect a rating of A or B in the recommendations of the U.S. Preventive Services Task Force as of September 23, 2010, with respect to the individual involved; 2. Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. For purposes of this subdivision, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention; 3. With respect to infants, children, and adolescents, evidence informed preventive care and screenings in the Recommendations for Preventive Pediatric Health by the American Academy of Pediatrics and the Recommended Uniform Screening Panels by the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children; and 4. With respect to women, evidence informed preventive care and screenings recommended in comprehensive guidelines supported by the Health Resources and Services Administration. Services include well woman visits, screening for gestational diabetes, human papillomavirus, testing (HPV), counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus (HIV), FDA approved contraception methods, sterilization procedures, and patient education and counseling for women, breastfeeding support, supplies, and counseling, screening and counseling for interpersonal and domestic violence. 11. You do not need prior authorization from Optima Health or from any other person (including a Primary Care Provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre approved treatment plan, or procedures for making referrals. Look in Your Plan Document in the Utilization Management section for more information on pre authorization. ADMINISTERED BY OPTIMA HEALTH PLAN 11 EqPl250080_

107 105 Pharmacy Information

108 106

109 Dear Member, Thank you for choosing Optima Health! To help ensure that you are paying the lowest possible price for your medicines, make sure you show your member ID card EVERYTIME you fill a prescription! WE WANT TO HELP YOU MAKE THE BEST OF YOUR PHARMACY DOLLARS In order to maximize your pharmacy benefit, be sure to present your Optima Health member ID card whenever you have a prescription filled. This is important whether the prescription is for a brand or a generic drug because the cost of many drugs can be less than your Copayment. Some pharmacies advertise a $4 drug list; however that may not be the lowest price for you. For some drugs the actual cost of the drug with your Optima Health member ID card may be less than the advertised $4 generic program. Here are a few examples where your cost may be less than $4: Examples of Savings with Generics 30-day supply Drug Quantity What You Pay Pharmacy $4 Program Sample Tier 1 Copayment Amoxicillin 500mg capsules 30 $2.51 $4.00 $15.00 Atenolol 50mg tablets 30 $1.40 $4.00 $15.00 Fluoxetine 20mg capsules 30 $2.23 $4.00 $15.00 Hydrochlorothiazide (HCTZ) 25 mg tablets 30 $1.30 $4.00 $15.00 Ibuprofen 800 mg tablets 30 $2.35 $4.00 $15.00 Lisinopril 20 mg tablets 30 $2.23 $4.00 $15.00 Metformin 500 mg tablets 60 $2.47 $4.00 $15.00 The drugs and prices listed above are examples only. Prices are subject to change and prices may vary between pharmacies. Optima Health offers an online tool that can help you determine what your cost will be for any of your prescription drugs. Simply sign in to optimahealth.com and select Pharmacy Resources from the MyOptima menu. Then select the Price and Save button and follow the directions to find out your cost for a specific drug. 5/

110 OptumRx home delivery Frequently asked questions Why should I use OptumRx for my prescriptions? Home delivery from OptumRx is a convenient and cost-effective way for you to order up to a 90-day supply of maintenance or long-term medication for delivery to your home, office or location of your choosing. You will minimize trips to the pharmacy and save money on your prescriptions. What is a maintenance medicine? A maintenance medicine is taken on a regular basis for long-term conditions such as arthritis, diabetes, high blood pressure, ulcers and many others. You can save money on these medicines by filling a 90-day supply and using your OptumRx home delivery pharmacy benefit. How do I use home delivery? 1. Have your doctor write your prescription for the number of days your plan allows for home delivery (for example, 90 days). Note: If you need your medicine right away, ask your doctor to write two prescriptions. Fill the first one at your local drug store. Mail the second one to OptumRx. 2. Fill out an order form. This form includes a confidential patient profile section for you and any family members. Write the member identification number, patient name and patient date of birth on the back of each prescription. 3. Mail the form with the prescription(s) and co-payment to: OptumRx, PO Box 2975 Shawnee Mission, KS We will ship orders to the address entered on the form. 5. Check your order upon receipt. Make sure you review your order within 21 days of receipt. Contact us immediately to report any issues. Member service representatives and clinical pharmacists are available to discuss any questions at our toll-free number that is located on the back of your prescription ID card. How do I refill a prescription I have already received through OptumRx? Do one of the following: Visit our website: optimahealth.com/members. Call OptumRx toll-free: Send in the refill slip that came with your previous order. Be sure to include your co-payment. Mail it to OptumRx. 108

111 OptumRx home delivery Frequently asked questions How do I fill a new prescription? Fill out an order form. Write the member ID number, patient name and patient date of birth on the back of each prescription. Mail the form to OptumRx. Include the prescription(s) and payment information. How can my doctor order a prescription for me? Doctors may call our toll-free number to prescribe your medication(s). Doctors may fax prescriptions to In addition to prescription information, your doctor must provide member ID number, patient name and patient date of birth. Note: To be legally valid, the fax must originate from the physician s office. All state laws apply. Timing and shipping When will I receive my order? You should receive your order within 14 days from the time OptumRx receives your prescription. Once received, a prescription typically takes one to two days to be processed and mailed if no additional information is required. Please allow a few extra days for your first order. If you have questions or do not receive your order within 14 days, please check the website at optimahealth.com/members or contact us at What situations may cause a delay in prescription processing? Situations that may create a delay include an incomplete or unreadable prescription, manufacturer backorders and medications that require prior authorization. We will notify you if there will be a delay with your prescription shipment. Your prescriptions ship in separate packages if necessary. Note: Orders received without payment may cause processing delays and extended delivery times. Am I charged for shipping? No, shipping is free. However, OptumRx also offers expedited shipping for an extra charge. How can I check on the status of my prescription order? Visit optimahealth.com/members or call us at Plan members who create an account on optimahealth.com/members will receive notification when a prescription is shipped. If I pay for rush shipping, when will it arrive? Rush shipping reduces the time in transit only. The actual prescription processing time does not change and can vary due to quality checks we perform or exceptions that may arise. Possible exceptions include needing additional information from your doctor, prior authorizations or drug interactions. These steps promote the health and safety of plan members and provide the highest level of quality when processing your prescriptions. OptumRx optumrx.com 109

112 Why am I receiving overnight shipping when I did not request it? We ship certain medications overnight at our expense due to special handling requirements. This may apply to prescriptions for controlled substances or medications that are temperature sensitive. What happens if I don t receive my order? If you do not receive your order within 14 days, please contact us toll-free. We will reship your order to you as it is our priority to ensure you have the medication you need. Prescription refills How do I know whether I have refills remaining on my prescription? The number of refills allowed is noted at the bottom of your medication label, on your refill form and can also be found on the optimahealth.com/members website. How soon can I order a prescription refill? For most prescriptions, you may reorder when you have approximately 3 weeks of your prescription left. Your medication label includes a target date for refilling the prescription. When ordering refills from OptumRx using the automated phone system, you will receive a message if your prescription is too soon to refill. You will be given the date when refills will be available. If you place a refill order after the expiration of your prescription, or if no refills are remaining, we will contact your physician for a new prescription. This may cause a slight delay. I have a prescription on file at a retail pharmacy; can I order refills from OptumRx? Yes, however a new prescription from your doctor is recommended. Medication coverage and cost What drugs are covered? Your plan decides which medications are covered through OptumRx. To verify coverage please go to optimahealth.com/members, or call our toll-free number. How much will my medicine cost me? The easiest way to determine the cost of your prescription is to log in to optimahealth.com/members. How can I pay for my home delivery prescriptions? Checks, money orders or major credit cards can be used to cover your co-payments. Credit cards are preferred to allow for variations in the prices of drugs and are required when placing an order through our website. For your convenience, your credit card number will be maintained on a secured site for future orders. 110

113 Miscellaneous How do I obtain additional order forms? You can print order forms at optimahealth.com/members. You also receive a reorder form, refill form and pre-addressed envelope with each prescription mailed to you. Can I speak with a pharmacist if I use OptumRx home delivery? Yes, pharmacists are available to answer questions regarding your medication at Can I fax my prescription that I received from my doctor? No. Legally, OptumRx is only allowed to accept faxed prescriptions from your doctor s office. Is my information kept private? Yes. We ask you for some personal information and we keep this information completely private. We use this information to help make sure you get the best care possible. Why did I receive less than a 90-day supply of my prescription? The most common reason is that your doctor may have only written the prescription for 30 days or a prepackaged medication may not be packaged as a 30-, 60- or 90-day supply. Remember to ask your doctor to write a prescription for up to a 90-day supply, with up to three refills, if your doctor determines it s appropriate. What is a controlled medicine? A controlled medicine, such as a narcotic, has stricter guidelines and may be handled differently than non-controlled medicines, such as a medication for diabetes. We adhere to federal and state laws in the dispensing of all medicines. State law may require a copy of a state-issued ID, such as a driver s license, for controlled medications to be dispensed. Call OptumRx home delivery toll-free: or visit: optimahealth.com/members optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum company a leading provider of integrated health services. Learn more at optum.com. All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners Optum, Inc. All rights reserved. ORX224877_

114 Fill your prescriptions with home delivery. How it works. 1 Order up to a three-month supply of your maintenance medications ones you take regularly by mail, phone or online. 2 OptumRx fills your order, mails it to you and lets you know when to expect your delivery. 3 Your medication arrives within 7 to 10 days of placing the order. OptumRx will notify you if there will be a delay in your order. Four easy ways to enroll: Online. Log in to the website on the back of your member ID card. Phone. Call the toll-free number on the back of your member ID card. Mail. Complete the attached order form and mail it to OptumRx, P.O. Box 2975, Mission, KS eprescribe. Or your doctor can send an electronic prescription to OptumRx. Manage your medication home delivery on the go. Order and track your prescriptions online or with our app. The benefits of home delivery. Your medication is delivered right to your mailbox, saving you a trip to the pharmacy. Your maintenance medication could cost less. Pay nothing for standard shipping. Phone, text 1 and reminders help you remember every dose and every refill. 1 OptumRx provides this service at no additional cost. Standard message and data rates charged by your carrier may apply. OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum company a leading provider of integrated health services. Learn more at optum.com. All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners Optum, Inc. All rights reserved. ORX9542_

115 1 NEW PRESCRIPTION MAIL-IN ORDER FORM Member and physician information please use black or blue ink. One form per member. Member ID Number (Additional coverage, if applicable) Secondary Member ID Number Last Name First Name MI Delivery Address Apt. # City State ZIP Phone Number with Area Code Date of Birth (mm/dd/yyyy) Physician Name Gender M F Physician Phone Number with Area Code Health history Medication Allergies: Aspirin Erythromycin Quinolones Others: None known Cephalosporins NSAIDs Sulfa Amoxil/Ampicillin Codeine Penicillin Tetracyclines Health Conditions: Asthma Glaucoma High cholesterol Others: None known Cancer Heart condition Osteoporosis Arthritis Diabetes High blood pressure Thyroid Disease Over-the-counter/herbal medications taken regularly: Payment and shipping information do not send cash Standard delivery is included at no charge. New prescriptions should arrive within about 10 business days from the date the completed order is received. Completed refill orders should arrive within about 7 business days. OptumRx will contact you if there will be an extended delay in delivering your medications. You may log on to optumrx.com to see if drug pricing information is available before enclosing payment. Once shipped, medications may not be returned for a refund or adjustment. Ship overnight. Add $12.50 to New Credit Card Number order amount (subject to change). Check enclosed. All checks must be signed and made payable to: OptumRx. Charge to my credit card on file. Charge to my NEW credit card. Expiration Date (Month/Year) Visa, MasterCard, AMEX and Discover are accepted. Signature: Date: For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such expenses related to prescription orders. By supplying my credit card number, I authorize OptumRx to maintain my credit card on file as payment method for any future charges. To modify payment selection, contact customer service at any time. Mail this completed order form with your new prescription(s) to OptumRx, P.O. Box 2975, Mission, KS DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM ORX5633_ NRX

116 114

117 115 Health

118 116

119 Optima POS Plan Behavioral Health and Substance Abuse Benefit Behavioral healthcare and substance abuse services are included as part of the healthcare coverage. How to receive services Behavioral healthcare and substance abuse services may be accessed in the following ways: In-Network coverage: Call to be directed to a participating behavioral health provider. It is not necessary to go through the Primary Care Physician (PCP); or Contact a participating behavioral health provider directly to arrange for an initial authorization. If hospitalization is required, the behavioral health provider will arrange for admission to the appropriate In-Network facility. Pre-Authorization must be obtained prior to receiving inpatient services. Out-of-Network coverage: Contact the provider of choice to arrange for treatment. The provider is responsible for obtaining pre-authorization of inpatient or outpatient treatment prior to rendering services; however, the member is responsible for initiating the process and for confirming that the process has been completed. Pre-Authorization Penalty Failure to pre-authorize inpatient services may result in the member s responsibility to pay a $500 penalty. Emergency Services If currently in treatment, contact the attending behavioral health provider. If not currently receiving care, call and arrangements will be made for the member to be seen by a behavioral health professional. In order to ensure a prompt response to any clinical emergency, a 24-hour crisis hotline is available after normal business hours, weekends, and holidays. Please call 911 or go directly to an emergency department facility if any covered member is engaged in behaviors that pose an immediate danger to themselves or to the life of another. Exclusions Non-medical ancillary services are not covered. These may include, but are not limited to, vocational rehabilitation services, employment counseling, health education, and expressive therapies. Residential Treatment is not covered by the Plan. A complete list of exclusions can be found in the. Additional Information Current members with questions regarding benefits should call Member Services at the number on the back of their member ID card. If you are considering enrolling for the first time and have questions, please consult with the group s Benefits Administrator. A Telecommunications Device for the Deaf (TDD) can be accessed by dialing

120 118

121 119 Other Health Insurance Information

122 120

123

124 122

125 Vision Care and Materials Rider EyeMed Vision Services administers this benefit for vision care services and materials. Each covered person is eligible to receive a routine eye examination, refraction, as well as, lenses and frames, or contact lenses once every 12 months (from the date of last exam). In-Network: Spectacle Exam - $20 copayment Contact Lens Exam - $40 copayment Lenses (single vision, bifocal, trifocal) covered in full Frames covered in full up to $100 retail Contact Lenses (in lieu of spectacles) covered in full up to $95 retail For eye examinations from Out-of-Network providers, members will be reimbursed $40 for an eye examination only. Copayments or Coinsurance for covered services under this rider are not applied toward any Plan out-of-pocket maximum and must continue to be paid after the maximum is met. Refer to the Discount Schedule on the next page for savings on lens treatment options. After your primary eyewear benefit is exhausted, you are eligible to purchase glasses and contacts in unlimited quantities at the discounted prices listed on the next page (cannot be combined with any other promotion). To receive covered services Select a participating EyeMed Vision Services network provider from the Plan's provider directory or by calling EyeMed at Automated location information is available 24 hours a day. Customer service representatives are available Monday through Friday 9 a.m. - 9 p.m., and Saturday 9 a.m. - 5 p.m. Visit or call the participating provider and identify yourself as a member by providing your Member ID information. The provider will verify eligibility, your Plan's covered services, and any applicable Copayment or Coinsurance. Payment is due when you receive services. If the vision provider determines that you need additional medical care, you should contact your Plan physician. Additional information Current members with questions regarding benefits should call Member Services at the number on the back of their member ID card. 123

126 Preventive Vision Discount Fee Schedule A Defined Materials Discount Vision Care Services Member Cost Complete Pair of Glasses Purchased*: Frame, lenses, and lens options must be purchased in the same transaction to receive full discount. Standard Plastic Lenses: Single Vision $ 50 Bifocal $ 70 Trifocal $105 Frames: Any frame available at provider location 40 percent discount off retail price Lens Options: UV Coating $15 Tint (solid and gradient) $15 Standard Scratch-Resistance $15 Standard Polycarbonate $40 Standard Progressive (add-on to bifocal) $65 Standard Anti-Reflective Coating $45 Other Add-ons and Services 20 percent discount Contact Lens Materials: (Discount applied to materials only) Disposable Conventional Laser Vision Correction: Lasik or PRK No discount on disposable 15 percent discount off retail price 15 percent discount off retail price or 5 percent discount off promotional price *Items purchased separately will be discounted 20 percent off the retail price. These discounts apply for all Optima Health members and do not, in any way, affect your premium, nor are they covered benefits under your health plan. These discounts cannot be used in conjunction with any other discount, rider, or benefit; and you will be responsible for applicable taxes. Optima Health is the trade name of Optima Health Plan, Optima Health Insurance Company, and Sentara Health Plans, Inc. Optima Health Plan underwrites HMO and Point of Services products. Optima Health Insurance Company underwrites Preferred Provider Organization products. Self-funded health benefit plans are administered by Sentara Health Plans, Inc. 124

127 Hearing Aid Rider Pre-Authorization for all covered services is required. Covered services include the following up to the annual maximum benefit amount of $1,250 and as specified on the Plan s Schedule of Benefits: Hearing aid(s); Audiometric specialist office visit(s) for fitting, including molds, and dispensing; Repair, replacement, or refurbishment of the hearing aid(s) up to the annual maximum benefit amount. Replacement of the hearing aid(s) may be received every thirty-six (36) months from the date of acquisition. Hearing aid providers are reimbursed using the Plan's established fee schedule. If the member elects to get a hearing aid which exceeds the benefit maximum, the member will be responsible for the difference between the Plan s maximum allowable amount, or fee schedule, and the cost of the hearing aid. Exclusions and Limitations: Batteries and supplies are not covered. The member will be responsible for the cost of all services once the maximum benefit as specified in the Schedule of Benefits is met. Once the benefit maximum is met, the Plan will not cover repair or refurbishment. Replacement of the hearing aid is covered only as specified in the Schedule of Benefits. Benefit Maximum: Copayments, Coinsurance, or additional payments beyond the $1,250 benefit maximum for hearing aid services are not applied toward the Plan's maximum out-of-pocket amount. Applicable Copayments and Coinsurance must continue to be paid after the benefit maximum is met. Please refer to Plan documents for any applicable Copayments, Coinsurance, or benefit maximums. 125

128 Chiropractic Care Optima Health contracts with American Specialty Health Group (ASH) to administer this benefit. Coverage will begin after the plan s Deductible has been met (if applicable). Copayments or Coinsurance for chiropractic care services will apply toward the Plan's maximum out-of-pocket. Pre-Authorization is required by ASH for all chiropractic care services. Benefits and cost Covered services include examination, re-examination, manipulation, conjunctive therapy, radiology, chiropractic appliances (up to a maximum benefit of one (1) appliance per person per benefit year), and laboratory tests related to the delivery of chiropractic services when medically necessary. Coverage is limited to a combined maximum benefit (with in- and out-of-network benefits) of 30 visits per benefit year. How to receive services Questions regarding providers, or to select a participating provider, contact ASH via the Web at optimahealth.com (choose Search Tools, then select Find a Doctor), or call ASH at , (Monday-Friday, 8:00 a.m. to 9:00 p.m. ET). Contact the participating chiropractic provider of choice to schedule an appointment. No physician referral is required. The chiropractic provider is responsible for obtaining authorization from ASH prior to providing care (except for an initial examination and emergency services). Out-of-Network coverage When using a provider not in the ASH network, have the provider call ASH at , (Monday-Friday, 10 a.m. to 9 p.m. ET) to request an authorization packet. The provider must receive authorization from ASH in order for the member to receive covered services (except for an initial exam and emergency services). Please note that when using a provider not in the ASH network, you may be required to submit claims directly to ASH for reimbursement. A claim form is available on optimahealth.com. Additionally, all claim forms and clinical treatment forms should be submitted to and received by ASH within 180 days from the first date of service. Submitted forms received later than 180 days from the date of service will not be approved for reimbursement unless extraordinary circumstances exist and are demonstrated upon appeal. Payment is due when services are rendered. The member will be responsible for payment of all charges in excess of ASH s allowable charge* in addition to any Coinsurance amount listed on the Summary of Benefits. Any maximum benefit shown on the Summary of Benefits will be a combined maximum benefit for In- and Out-of-Network coverage. *allowable charge is the lesser of the provider s actual charge or ASH s In-Network fee schedule for the same services Exclusions and limitations Any services or treatments not authorized by ASH, except for an initial examination and emergency services; Services for examinations and/or treatments from participating chiropractors for conditions other than those related to Neuro-musculoskeletal disorders; Hypnotherapy, behavior training, sleep therapy, and weight programs; Thermograph; Services, lab tests, X-rays, and other treatments not documented as clinically necessary as appropriate, or classified as experimental or investigational and/or as being in the research stage; Services and/or treatments that are not documented as medically necessary services; Magnetic resonance imaging, CT scans, bone scans, nuclear radiology, and any type of diagnostic radiology other than covered plain film studies; Transportation costs including local ambulance charges; Education programs, non-medical self-care or self-help, or any self-help physical exercise training or any related diagnostic testing; 126

129 Services or treatments for pre-employment physicals or vocational rehabilitation; Any services or treatments caused by, or arising out of, the course of employment or covered under a final judgment, compromise, or settlement as a result of injuries caused by a third party; Air conditioners, air purifiers, therapeutic mattresses, supplies, or any other similar devices or appliances; all chiropractic appliances or durable medical equipment, except as described in this Rider; Prescription drugs or medications including a non-legend proprietary medicine or medication not requiring a prescription order; Services provided by a non-participating ASH chiropractor outside the service area, except for emergency services; Hospitalization, anesthesia, manipulation under anesthesia, and other related services; All auxiliary aids and services, including but not limited to, interpreters, transcription services, written materials, telecommunications devices, telephone handset amplifiers, television decoders, and telephones compatible with hearing aids; Adjunctive therapy not associated with spinal, muscle, or joint manipulation; Vitamins, minerals, or other similar products. Additional information Current members with questions regarding benefits should call Member Services at the number on the back of their member ID card. If considering enrolling for the first time and have questions, please consult with the group s Benefit Administrator. A Telecommunications Device for the Deaf (TDD) can be accessed by dialing

130 Alternative Medicine Discount Program Each covered individual is offered a discount on acupuncture, chiropractic, and massage therapy services administered by American Specialty Health Group (ASH). Participating providers extend up to a 25 percent discount off their usual and customary charges. How to receive services Select a participating complementary healthcare provider from the Plan s website at optimahealth.com. Schedule an appointment with a participating provider. A physician referral is not necessary. The participating provider will develop, if necessary, a treatment plan for the member. There are no visit limitations. A change from a participating provider is permitted at any time. In order to receive the complementary discount, present your member ID card to the participating provider at the time of service. The member is responsible for payment of services at each visit. There are no claim forms to file. If chiropractic care is covered under the Plan s medical benefit, the member may find it beneficial to use this discount program after the annual Plan limit has been met, or for services not covered under that benefit. Additional Information For more information regarding this discount program, or to nominate a provider not yet in the network, please call ASH s Member Services at or refer to the Plan s website at optimahealth.com. ASH s Member Service representatives are available from 8 a.m. to 9 p.m. (Monday-Friday). Current members with questions regarding benefits should call Member Services at the number on the ID card. If you are considering enrolling for the first time and have questions, please consult with your group s Benefit Administrator. A Telecommunications Device for the Deaf (TDD) can be accessed by dialing

131 Diabetic Equipment and Supplies Coverage includes benefits for FDA approved equipment; supplies; and in-person outpatient selfmanagement training and education; including medical nutrition therapy, treatment of insulindependent diabetes, gestational diabetes, insulin-using diabetes, and non-insulin-using diabetes if prescribed by a healthcare professional legally authorized to prescribe such items under law. Equipment and supplies shall not be considered durable medical equipment. This benefit is not subject to any policy or calendar-year dollar or durational benefit limitations or maximums for benefits or services. The Member will be responsible for any applicable Copayment, Coinsurance, or Deductible as specified on the Face Sheet or Schedule of Benefits depending upon the type of service received. Diabetic equipment and supplies are covered when received from Plan providers only. To qualify for Coverage under this section, diabetes in-person self-management training and education shall be provided by a certified, registered, or licensed healthcare professional. Members may call SENTARA for information on educational classes. Members may call one of the following providers to arrange for prescribed supplies to be delivered to their home: Home Care Delivered at EdgePark Medical Supplies at

132 130

133 131 Additional

134 132

135 The EPIC Hearing Service Plan (HSP) gives you access to the largest hearing care provider network in the country, and substantial savings on top tier manufacturer brand hearing devices. Prices for brand name products, and services, starting as low as $495 Group: Optima Health Reference Code: OptimaHealth 2015 HEARING SERVICE PLAN EPIC HSP Toll Free Contact EPIC for a referral to a participating provider. Coverage for hearing exams & devices Referrals to the largest national network of Audiologists and ENT physicians Fixed pricing reduced 30-60% below MSRP Access to all name brand hearing aids and technology Money-back trial periods Follow-up care On call customer service support Extended warranties & complimentary batteries Call EPIC today to start the process to better hearing Welcome The EPIC Hearing Service Plan is the nation s first specialty care plan devoted to the vital sense of hearing. EPIC is dedicated to delivering the highest quality of care at the best value to our members. Provider Network The EPIC network is comprised of professional Audiologists and ENT physicians and represents the largest network of its kind in the nation with provider locations in all 50 states. Hearing Aids The EPIC Hearing Service Plan gives you access to all name brand hearing aid technology by the top tier hearing aid manufacturers at reduced prices, 30%-60% below MSRP; maximizing your value and savings. How it Works Contact an EPIC hearing counselor today. The hearing counselor can answer any questions you may have about the plan and coordinate your referral to a nearby participating provider. If the provider recommends you obtain hearing aids, an EPIC counselor will contact you to coordinate your coverage and payment. You will receive a 45 day trial period with a complimentary extended 3 year product warranty and one year supply of batteries*. 133 HEAR BETTER epichearing.com *Excludes Basic Level Products LIVE FULLY v3.2015

136 ListenHear LiveWell Welcome to the Listen Hear, Live Well Hearing Health Wellness Program Here s How it Works: Members go to and register with your name and address. Complete the 4 fun, educational hearing health activities. Receive your reward coupon for additional savings off of your purchase. Listen Hear, Live Well reward coupon savings are applied per each hearing device that is purchased--maximizing your value! Plus, these reward savings are applied on top of the 30% - 60% savings off of MSRP that is already available on an open selection of major brand hearing aids through the EPIC Hearing Service Plans. Simply complete the online wellness program on your desktop or mobile device and contact the EPIC Hearing Service Plan toll free at to redeem your reward, and start the process to better hearing! Save Premium Devices: $200 off Advanced Devices: $100 off Standard Devices: $50 off LISTENHEARLIVEWELL.COM 134 LISTENHEAR@EPICHEARING.COM

137 Hear Better Live Well EPIC Hearing Service Plan PERKS The EPIC Hearing Service Plan (HSP) gives you access to the largest hearing care provider network in the country and substantial savings on top tier manufacturer brand devices and related professional services. HEARING SERVICE PLAN Group: Optima Health Coverage: Savings of 30% - 60% off MSRP on name brand hearing aids and related professional services. Effective: 1/1/2016 Contact EPIC for a referral: hear@epichearing.com EPICSAV2016 LEVEL OF HEARING AID TECHNOLOGY DEGREE OF HEARING LOSS TYPICAL MSRP EPIC PRICING BASIC Mild to Moderate $1,400-$1,600 $495 STANDARD ADVANCED PREMIUM Moderate Moderate to Severe Moderate to Severe $1,601-$2,300 $2,301-$3,000 $3,001-$4,000 Savings on hearing exams and hearing aid devices Access to the largest nationwide network of Audiologists and ENT physicians Pricing 30% - 60% below MSRP on name brand products Money-back Trial Periods Extended warranties & batteries with purchase Call EPIC today to start the process to better hearing hear@epichearing.com $849-$1,499 $1,500-$2,099 $2,100-$2, Welcome The EPIC Hearing Service Plan is the nation s first specialty care plan devoted to the vital sense of hearing. EPIC is dedicated to delivering the highest quality of care at the best value to our members. Provider Network The EPIC network is comprised of professional Audiologists and ENT physicians and represents the largest accredited network of its kind in the nation, with provider locations in all 50 states. Hearing Aids The EPIC Hearing Service Plan gives you access to all name brand hearing aid technology by the top tier hearing aid manufacturers at reduced prices, 30%-60% below MSRP; maximizing your value and savings. Note: the following top tier manufacturer brands are available through EPIC: Phonak, Unitron, Lyric, GN Resound, Starkey, Siemens, Oticon, and Widex. How it Works Contact an EPIC hearing counselor today. The hearing counselor can answer any questions you may have about the plan and coordinate your referral to a nearby participating provider. If the provider recommends you obtain hearing aids, an EPIC counselor will contact you to coordinate your coverage and payment. You will receive a 45 day trial period with a complimentary extended 3 year product warranty and one year supply of batteries*. *Excludes Basic Level Products EPICHSPIDV415

138 136

139 24/7/365 on-demand access to affordable, quality healthcare. Anytime, Anywhere. MDLIVE offers 24/7/365 on-demand access to a national network of boardcertified doctors and pediatricians that can diagnose, recommend treatment, and prescribe medication. Get the care you need, when you need it. MDLIVE App Now Available Doctor visits are easier than ever with the new MDLIVE Mobile App! When should I use MDLIVE? What can be treated? If you re considering the ER or urgent care for a non-emergency medical issue Your primary care physician is not available At home, traveling or at work 24/7/365, even holidays! Allergies Asthma Bronchitis Cold and Flu Ear Ache Joint Aches and Pain Respiratory Infection Sinus Problems Pediatric Care related to: Cold & Flu Constipation Ear Ache Fever Nausea & Vomiting Pink Eye And More! And More! Who are our providers? Are my children eligible? Our providers practice primary care, pediatrics, family and emergency medicine, and have incorporated MDLIVE into their practice to provide convenient access to quality care. Yes. MDLIVE has local pediatricians on-call 24/7/365. However, a parent or guardian must be present during registration and any consultations involving minors. How much does it cost? Your cost is listed on your Summary of Benefits Register now! Call us at or visit us at optimahealth.com & click on "Access MDLIVE" Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. VB

140 ll Options For Care Do You Want to Save Time and Money? Knowing where to go when you are sick or injured can keep money in your pocket and save you valuable time. In an emergency situation, you should always go to your nearest provider. However, you have several options in a non-emergency health situation, since care in a hospital Emergency Department is expensive. Be sure your health situation is an emergency before you go to a hospital Emergency Department for care. Situations such as ear pain, throat pain, colds/ flu, and rashes are often best treated by calling your doctor. For non-emergency illness or injury: For a complete list of doctors in the Optima Health network, visit optimahealth. com. Step 1 Call your doctor s office first. If your doctor is available after hours, follow the instructions provided. If your doctor s office is closed, and your doctor is unavailable by phone, call the Care Coordination Program/After Hours Nurse Advice Line at This free call is your link to a licensed nurse who can assist you in determining your immediate next steps for care. If it is determined that you seek care somewhere other than your doctor s office when it re-opens, then consider steps 2 and 3. Step 2 Consider calling Sentara MDLIVE prior to visiting an Urgent Care Center or the Emergency Department for non-emergent matters if your primary care physician is not available. When you need to connect with a physician, call From there, you can choose to connect to a physician via phone right away, or you can request an online video visit. Make sure to request that information from your MDLIVE visit is shared with your Primary Care Physician or doctor. Step 3 Urgent Care Centers may meet your needs and are usually a less expensive and faster option for treatment than a hospital Emergency Department. These facilities are usually open on evenings, weekends, and holidays when your doctor s office may be closed. Be sure to request that information from your visit is shared with your Primary Care Physician or doctor. Step 4 Hospital Emergency Departments are the most expensive and often take longer than other treatment options in non-life-threatening situations. If you choose to go to an Emergency Department, knowing which hospitals participate with Optima Health can save you money. Be sure to request that information from your visit is shared with your Primary Care Physician or doctor. 138 optimahealth.com v

141 Optima Health TREATMENT COST CALCULATOR Better Information Better Decisions Better Health View estimates on over 300 procedures and services in your area, based on your specific benefit plan information. Shop and compare out-ofpocket costs for a specific procedure at a specific doctor or medical facility. Compare your options, plan for future expenses, and make the best decisions for both your health and your wallet. MyOptima Sign In Step One Sign in at optimahealth.com/members then select Treatment Cost Calculator from your MyOptima menu on the left side of your screen. x-ray GO Step Two Search or browse for a procedure or condition. The Treatment Cost Calculator avatar Gina is displayed at the top of each page and provides important tips to help you navigate the tool and understand technical healthcare information. Your likely out-of-pocket cost is: $ 45 Step Three View the general Market Estimate based on average costs for innetwork providers in your area, and learn how your benefits apply. Find Providers $ $$$ $$ Step Four Find local physicians/facility providers. Step Five Select providers to compare. View maps, get directions, call for appointments, and print or estimates. optimahealth.com/members v

142 The AccordantCare TM Program Your Personal Health Care Support A free health program from Optima Health OPT_2013 We know your time is important and it can be hard to take care of your health when you are busy. You, your family, and your doctors want you to have the best health possible. We re here to give you even more tools to help you make good health decisions and stay well. That is why we are working with Accordant Health Services to offer you the AccordantCare Program. Get started today! A team of nurses is waiting to talk with you and answer your questions by phone or , 24-hours a day, seven days a week. With the AccordantCare Program you will receive monthly newsletters filled with the latest news about treatments and medicines, tips for managing stress, and other useful information. You will also have access to Accordant.com, where you can watch webinars, disease specific videos, and brochures. The AccordantCare Program can: Provide tips on how to stay well. We can give you easy tips to manage your health and your busy life. Help you find ways to save money. Like to save money? We can help you to live well and still get the care you need...while cutting costs. The AccordantCare Program is designed for members with: Epilepsy Disorders Rheumatoid Arthritis (RA) Multiple Sclerosis (MS) Crohn's Disease Parkinson's Disease (PD) Systemic Lupus Erythematosus (SLE or Lupus) Myasthenia Gravis (MG) Sickle Cell Disease (SCD) Cystic Fibrosis (CF) Hemophilia Scleroderma Polymyositis Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) Amyotrophic Lateral Sclerosis (ALS) Dermatomyositis Gaucher Disease Help you find real ways to put your doctor's advice to work in your busy life. Learn how to make the most out of every visit with your doctor. Help you connect to resources near your home. The support you need may be just around the corner. We can help you find it. For more information about the AccordantCare Program call us at: Monday through Friday,8 am to 9 pm EST Or go online 140

143 SQCN The Sentara Quality Care Network The Sentara Quality Care Network (SQCN) is a community-wide network of healthcare providers who voluntarily work together to improve health care. SQCN is dedicated to the following: improving the quality of health care improving access to care and the overall patient experience reducing or controlling the costs of care (costs incurred by patients, payers and providers) The Value of SQCN The goals of SQCN range from improving wellness and preventing disease to providing professional care coordination for patients with chronic disease or other complex medical conditions. SQCN aims to ensure that patients receive the right care, at the right place, at the right time. Today, SQCN has more than 2,200 providers in the Hampton Roads region and more than 600 providers in the Blue Ridge region, as well as affiliations with Sentara Healthcare hospitals and Children s Hospital of The King s Daughters. Becoming More Accountable for Care Even in today s world of electronic messaging and electronic health records, there are gaps in communication and, at times, gaps in care. SQCN works to identify solutions and to invest in the staff and technology that will improve the way that patients experience health care, both within a practice and between practices. Here are some examples of how SQCN works to become accountable for care: Helping to make sure that patients receive eligible cancer screenings within the timeframes set by national guidelines Educating providers on the most effective as well as cost-efficient prescription medications Creating a collaboration of SQCN pediatricians, local schools and athletic associations to educate parents on the importance of adolescent health evaluations in the pediatrician s office. These evaluations can include what is required for sports physicals, but also include immunizations, depression screening and preventive counseling. Ensuring patients with chronic diseases see their primary care provider as frequently as needed Providing resources to help patients to understand their medical condition and to engage in the management of their disease Developing standards for diabetic patients including patient education and lab result monitoring, as well as developing individual care plans to stabilize and improve diabetic patient health Providing nurse care managers to coach, educate and follow-up with patients after a hospital stay or emergency room visit A Clinically Integrated Network sentaraqualitycarenetwork.com 141

144 Your Employee Member Benefit Your employer is generously supporting the Sentara Quality Care Network by offering you a reduced co-pay when you choose a SQCN healthcare provider. Take a look at your insurance card, or your health plan fee structure, for the discounted amount. The reduced co-pay applies to you, the member, as well as your covered family members. How to Choose a SQCN provider If your Primary Care Provider (PCP) is already a SQCN provider, then you already receive the service benefits of the network. If you are not sure, or would like to find a SQCN provider, you can call SQCN Member Services at or search for SQCN providers on the Optima Health website. To change your primary care provider, or learn more about your health plan, call Optima Health at or or visit Find a SQCN Provider Online: Visit and click on the Find Doctors, Drugs, and Facilities tab. Choose Doctors. Then in the Doctor Search menu, customize your search for Clinically Integrated Network (CIN) / Sentara Quality Care Network (SQCN). Call: SQCN Member Services Monday Friday, 8:30 a.m. 5:00 p.m