BlueChoice Plus Gold 1000 Coverage Period: 01/01/ /31/2018

Transcription

1 Summary of Benefits and Coverage:What This Plan Covers & What You Pay For Covered Services BlueChoice Plus Gold 1000 Coverage Period: 01/01/ /31/2018 Coverage for: Individual Plan Type: POS 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 general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can see the Glossary at or call to request a copy. For more information about your coverage, or to get a copy of the complete terms of coverage, please visit 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? In-Network: $1,000 individual/ $2,000 family; Out-of-Network: $2,000 individual/ $4,000 family. Yes, all In-Network preventive care services, as well as the following (non-hospital facilities only, when applicable): Primary care, Specialist, Retail health, Diagnostic testing, Generic drugs, Outpatient surgery, Urgent care, Mental Health office visit, Home health, Rehabilitation services, Hospice. Yes. Pediatric Dental: In-Network: $25 individual; Out-of-Network: $50 individual. Prescription Drug: $250 individual. There are no other specific deductibles. Medical and Prescription Drug combined: In-Network: $4,000 individual/ $8,000 family.; Out-of-Network: $8,000 individual/ $16,000 family. Premiums, balance-billed charges, and health care this plan does not cover. Generally, you must pay all the costs from provider up to the deductible amount before this plan begins to pay. If you have other family member on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meet 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 must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these 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. SBC ID: SBC MANATNDB87ARXXDBJ7CN Page 1 of 12

2 Will you pay less if you use a network provider? Do I need a referral to see a specialist? Yes. See or call for a list of provider network. No. 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. What You Will Pay Common Medical Event Services You May Need In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions & Other Important Information Primary care visit to treat an injury or illness Provider: $15 copay per visit Hospital Facility: Deductible, then $50 Provider: Deductible, then $50 Hospital Facility: Deductible, then $150 If a service is rendered at a Hospital Facility, the additional Facility charge may apply If you visit a health care provider s office or clinic Specialist visit Retail Health Clinic Provider: $30 copay per visit Hospital Facility: Deductible, then $50 $15 Provider: Deductible, then $50 Hospital Facility: Deductible, then $150 If a service is rendered at a Hospital Facility, the additional Facility charge may apply None Preventive care/screening/ immunization No Charge Deductible, then No Charge Some services may have limitations or exclusions based on your contract SBC ID: SBC MANATNDB87ARXXDBJ7CN Page 2 of 12

3 Common Medical Event If you have a test Services You May Need Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) In-Network Provider (You will pay the least) LabTest: Non-Hospital: $15 Hospital: Deductible, then $30 XRay: Non-Hospital: $30 Hospital: Deductible, then $60 Non-Hospital: $200 Hospital: Deductible, then $400 What You Will Pay Out-of-Network Provider (You will pay the most) LabTest: Non-Hospital: Deductible, then $65 copay Hospital: Deductible, then $110 XRay: Non-Hospital: Deductible, then $80 copay Hospital: Deductible, then $110 Non-Hospital: Deductible, then $250 Hospital: Deductible, then $450 Generic drugs $10 copay Paid As In-Network If you need drugs to treat your illness or condition Preferred brand drugs Deductible, then $45 copay More information about prescription drug coverage is available at Non-preferred brand drugs Preferred Specialty drugs Deductible, then $65 copay Deductible, then 50% of Allowed Benefit up to a maximum payment of $100 Paid As In-Network Paid As In-Network Not Covered Limitations, Exceptions & Other Important Information In-Network Lab Test benefits apply only to tests performed at LabCorp.; For services provided at a Hospital Facility, prior authorization is required For services provided at a Hospital Facility, prior authorization is required For all prescription drugs: Prior authorization may be required for certain drugs; No Charge for preventive drugs or contraceptives; Copay applies to up to 30-day supply; Up to 90-day supply of maintenance drugs is 2 copays; Specialty Drugs: Participating Providers: covered when purchased through the Non-preferred Specialty drugs Deductible, then 50% of Allowed Benefit up to a maximum payment of $150 Not Covered Exclusive Specialty Pharmacy Network Non-Participating Providers: Not Covered SBC ID: SBC MANATNDB87ARXXDBJ7CN Page 3 of 12

4 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse services Services You May Need Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room care Emergency medical transportation In-Network Provider (You will pay the least) Non-Hospital: $200 Hospital: Deductible, then $300 Non-Hospital: $30 copay Hospital: Deductible, then $30 Deductible, then $250 Deductible, then $30 What You Will Pay Out-of-Network Provider (You will pay the most) Non-Hospital: Deductible, then $300 Hospital: Deductible, then $400 Non-Hospital & Hospital: Paid As In-Network Paid As In-Network Urgent care $50 Paid As In-Network Facility fee (e.g., hospital room) Physician/surgeon fee Outpatient services Inpatient services Office visits Deductible, then $400 copay per admission Deductible, then $30 Office Visit: $15 copay Deductible, then $400 copay per admission No Charge Deductible, then $500 copay per admission Office Visit: Deductible, then $50 Deductible, then $500 copay per admission Limitations, Exceptions & Other Important Information For services provided at a Hospital Facility, prior authorization is required For services provided at a Hospital Facility, prior authorization is required Limited to Emergency Services or unexpected, urgently required services; Additional professional charges may apply; Copay waived if admitted Prior authorization is required for air ambulance services, except when Medically Necessary in an emergency Limited to unexpected, urgently required services Prior authorization is required None For treatment at an Outpatient Hospital Facility, additional charges may apply Prior authorization is required; Additional professional charges may apply For routine pre/postnatal office visits only. For non-routine obstetrical care or complications of pregnancy, cost sharing may apply. SBC ID: SBC MANATNDB87ARXXDBJ7CN Page 4 of 12

5 What You Will Pay Common Medical Event If you are pregnant Services You May Need Childbirth/delivery professional services Childbirth/delivery facility services In-Network Provider (You will pay the least) Deductible, then $30 Deductible, then $400 copay per admission Out-of-Network Provider (You will pay the most) Deductible, then $500 copay per admission None Limitations, Exceptions & Other Important Information Additional professional charges may apply Home health care No Charge Prior authorization is required; 90 visits/episode of care Rehabilitation services Provider: $30 copay per visit Hospital Facility: Deductible, then $50 Provider: Deductible, then $50 Hospital Facility: Deductible, then $150 If a service is rendered at a Hospital Facility, prior authorization is required, and the additional Facility charge may apply If you need help recovering or have other special health needs Habilitation services Skilled nursing care Provider: $30 copay per visit Hospital Facility: Deductible, then $50 Deductible, then $30 copay per admission Provider: Deductible, then $50 Hospital Facility: Deductible, then $150 per admission Prior authorization is required for Member age 21 and older; If a service is rendered at a Hospital Facility, the additional Facility charge may apply Prior authorization is required; 60 days/benefit period Durable medical equipment Deductible, then 25% of Allowed Benefit Deductible, then 45% of Allowed Benefit Prior authorization is required for specified services. Please see your contract. Hospice services Inpatient Care: No Charge Outpatient Care: No Charge Inpatient Care: Deductible, then $50 copay per admission Outpatient Care: Deductible, then $50 Prior authorization is required; For Participating Providers and Non-Participating Providers (combined): Limited to a maximum 180-day Hospice Eligibility Period which includes a maximum of 60 days Inpatient Hospice Services per Hospice Eligibility Period SBC ID: SBC MANATNDB87ARXXDBJ7CN Page 5 of 12

6 Common Medical Event If your child needs dental or eye care Services You May Need Children's eye exam Children's glasses In-Network Provider (You will pay the least) No Charge No Charge for glasses/lenses What You Will Pay Out-of-Network Provider (You will pay the most) Member pays expenses in excess of the Pediatric Vision Allowed Benefit of $40 Allowances available for glasses/lenses Children's dental check-up No Charge 20% of Allowed Benefit Limitations, Exceptions & Other Important Information Limited to Members up to age 19; 1 visit/benefit period Limited to Members up to age 19; 1 set of glasses/lenses per benefit period Limited to Members up to age 19; 2 visits/benefit period 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 Hearing aids Routine eye care (Adult) Bariatric surgery Infertility treatment Routine foot care Cosmetic surgery Long-term care Weight loss programs Dental care (Adult) Private-duty nursing Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Abortion, except in limited circumstances Coverage provided outside the United States. See Chiropractic care Non-emergency care when traveling outside the U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor Employee Benefits Security Administration, or call EBSA (3272); or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, or call x 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 SBC ID: SBC MANATNDB87ARXXDBJ7CN Page 6 of 12

7 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: Department of Labor Employee Benefits Security Administration, or call EBSA (3272); or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, or call x 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. SBC ID: SBC MANATNDB87ARXXDBJ7CN Page 7 of 12

8 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 a routine in-network care of a well-controlled condition) Mia's Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $1,000 Specialist Copayment $30 Hospital (facility) Copayment $400 Other Copayment $15 The plan s overall deductible $1,000 Specialist Copayment $30 Hospital (facility) Copayment $400 Other Coinsurance 25% The plan s overall deductible $1,000 Specialist Copayment $30 Hospital (facility) Copayment $250 Other Copayment $30 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 $1,000 Copayments $930 Coinsurance $0 What isn t covered Limits or exclusions $10 The total Peg would pay is $1,940 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 $1,000 Copayments $1,035 Coinsurance $308 What isn t covered Limits or exclusions $0 The total Joe would pay is $2,343 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 $1,000 Copayments $210 Coinsurance $63 What isn t covered Limits or exclusions $0 The total Mia would pay is $1,273 The plan would be responsible for the other costs of these EXAMPLE covered services. SBC ID: SBC MANATNDB87ARXXDBJ7CN Page 8 of 12

9 Notice of Nondiscrimination and Availability of Language Assistance Services o o o o If you need these services, please call To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office Civil Rights Coordinator, Corporate Office of Civil Rights Page 9 of 12

10 Foreign Language Assistance አማርኛማሳሰቢያ ይህማስታወቂያስለመድንሽፋንዎመረጃይዟል ከተወሰኑቀነገደቦችበፊትሊፈጽሟቸውየሚገቡነገሮች ሊኖሩስለሚችሉእነዚህንወሳኝቀናትሊይዝይችላል ይኽንመረጃየማግኘትእናያለምንምክፍያበቋንቋዎእገዛየማግኘትመብትአለዎት አባልከሆኑከመታወቂያካርድዎበስተጀርባላይወደተጠቀሰውየስልክቁጥርመደወልይችላሉ አባልካልሆኑደግሞወደስልክቁጥር ደውለውንእንዲጫኑእስኪነገርዎድረስንግግሩንመጠበቅአለብዎ አንድወኪልመልስሲሰጥዎ የሚፈልጉትንቋንቋ ያሳውቁ ከዚያምከተርጓሚጋርይገናኛሉ Page 10 of 12

11 हदय नदइसस चन मआपकब म कवर जक ब र मज नक रदगईह ह सकत ह कइसमम य तथयक उल खह औरआपक लएकस नयतसमयस म क भ तरक मकरन ज़रह आपक यहज नक र औरस ब धतसह यत अपन भ ष मन श कप न क अधक रह सदयक अपन पहच नपक प छ दएगएफ़ न न बरपरक लकरन च हए अयसभ ल गपरक लकरसकत हऔरजबतकदब न क लएनकह ज एतबतकस व दकत कर जबक ईएजटउतरद त उस अपन भ ष बत ए औरआपक य य क रस कन ट करदय ज एग ব ল লকনএইন শআপন র বম কভ রজস ক তথর য় ছ এরম ধপ ণত রখথ ক তপ র এব ন দত র খরম ধআপন কপদ প ন তহ তপ র বন খর চ ন জরভ ষ য়এইতথপ ওয় রএব সহ য়ত প ওয় র অ ধক রআপন রআ ছ সদস দর কত দরপ রচয়প র পছ নথ ক ন রকলকর তহ ব অ নর ন র কলক রপ তন বল পযঅ প কর তপ রন যখনক ন এ জউরদ বনতখনআপন র ন জরভ ষ রন মবল ন এব আপন কদ ভ ষ রস স য কর হ ব لام لا لا لاء لا Page 11 of 12

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