Highlights of your Health Care Coverage
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1 Group Number: Effective Date: 01/01/2017 *Premera Blue Cross believes this plan is a grandfathered health plan under the Affordable Care Act. For more information, please refer to your Benefit Booklet. Any deductibles, copays, and coinsurance percentages shown are amounts for which you re responsible. Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay. MEDICAL PLAN *ACA Exempt CPI - RETIREE WITHOUT MEDICARE ALL PROVIDERS MEDICAL COST SHARE OPTIONS Individual Deductible PCY (Family embedded deductible 2X Individual) $500 PCY / $1,000 PCY Coinsurance (Member's percentage of costs after deductible based on allowable charges) Individual Out of Pocket Maximum PCY, excludes copay (No Family OOP max) $3,000 Per Person, Excludes Deductible Office Visit Cost Share Deductible, then PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION Preventive Office Visit (Unlimited) Immunizations (Unlimited) Nicotine Dependency Programs (ND) (Unlimited) Waive Deductible, Covered in Full Diabetes Health Education (DE) ($250 PCY) Waive Deductible, Covered in Full PROFESSIONAL CARE Professional Office Visit Inpatient Professional Services DIAGNOSTIC SERVICE OPTIONS Preventive Professional Diagnostic Imaging and Laboratory Services - Including Mammogram and PAP/PSA Other Professional Diagnostic Imaging Other Professional Diagnostic Laboratory/Pathology Diagnostic Mammography FACILITY CARE OPTIONS Inpatient Facility Outpatient Surgery Facility EMERGENCY CARE AND TRANSPORTATION OPTIONS Emergency Care (If applicable, waive copay if admitted to inpatient facility) Emergency Room Physician Urgent Care Facility Ambulance Transportation (Unlimited) Air Ambulance (Unlimited) 1-6F2M0X Rev #1 Q 10/14/2016 Page 1 of 3
2 Group Number: Effective Date: 01/01/2017 *Premera Blue Cross believes this plan is a grandfathered health plan under the Affordable Care Act. For more information, please refer to your Benefit Booklet. Any deductibles, copays, and coinsurance percentages shown are amounts for which you re responsible. Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay. MEDICAL PLAN *ACA Exempt CPI - RETIREE WITHOUT MEDICARE ALL PROVIDERS OTHER SERVICES Allergy/Therapeutic Injections Mental Health Inpatient Facility Care (Unlimited) Mental Health Outpatient Professional Care (Unlimited) Chemical Dependency Inpatient Facility Care (Unlimited) Chemical Dependency Outpatient Professional Care (Unlimited) Rehab Inpatient Facility (30 Days PCY) Rehab Outpatient Care, Including Physical, Occupational, Speech and Massage Therapy; Cardiac & Pulmonary Rehab.; and Chronic Pain (45 Visits PCY) Medical Supplies, Equipment, Prosthetics (Unlimited) Foot Orthotics, Orthopedic Shoes and Accessories ($300 PCY) Home Health Visits (130 visits PCY) TMJ (Temporomandibular Joint Disorders) ($1,000 PCY/$5,000 Lifetime. Covered as any other Service) Transplants (Unlimited; $7,500 travel and lodging limits) ALTERNATIVE CARE Manipulations (Spinal and other) ( 30 Visits PCY) Acupuncture (12 Visits PCY) Nutritional Therapy ( 4 Visits PCY) ANNUAL PLAN MAXIMUM Annual Plan Maximum Unlimited PCY = Per Calendar Year This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highligh is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service. 1-6F2M0X Rev #1 Q 10/14/2016 Page 2 of 3
3 Group Number: Pharmacy Benefits Tier 1 = Generic Tier 2 = Brand Name Below is a brief overview of what you can expect to pay for a generic prescription drug when using an In-Network Pharmacy. For more information on your pharmacy benefits, including Out-of-Network benefits, see your benefit booklet. To locate an In-Network Pharmacy, go to Any deductibles, copays, and coinsurance percentages shown are amounts for which you re responsible. Effective Date: 01/01/2017 PHARMACY PLAN RETAIL RX MAJOR MED (CPI) Cost Share Category Tier1/Tier2 PRESCRIPTION DRUGS Retail Cost Shares Maximum supply: 30 day or 100 unit supply, whichever is greater, unless the drug Day Supply maker s packaging limits the supply in some other way Individual Deductible PCY Family Deductible PCY Out of Network Non-participating retail pharmacies Out of Pocket Maximum Annual Benefit Maximum Drug List $500 PCY Combined with Medical Deductible $1,000 PCY Combined with Medical Deductible $3,000 PCY Combined with Medical Max OOP Unlimited Open A2 PCY = Per Calendar Year. Balance billing may apply if a provider is not contracted with Premera Blue Cross. Members are responsible for amounts in excess of the allowable charge. This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highligh is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service. 1-6F2M0X Rev #1 Q 10/14/2016 Page 3 of 3
4 . 1-7JEXDK Rev #1 GP 10/21/ :31 PM Page 4 of An Independent Licensee of the Blue Cross Blue Shield Association
5 1-7JEXDK Rev #1 GP 10/21/ :31 PM Page 5 of An Independent Licensee of the Blue Cross Blue Shield Association
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