You don't have to meet deductibles for specific services.

Transcription

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services BlueCross and BlueShield of Nebraska : BlueFreedom Opt 42 Rx Opt 6 Coverage Period: 1/1/ /31/2018 Coverage for: Individual/Family Plan Type: PPO 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, 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 or call to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? Individual/Family In-Network: $3,000/$6,000 Out-of-Network: $6,000/$12,000 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, they have to meet their own individual deductible until the overall family deductible amount has been met. Are there services covered before you meet your deductible? Yes, preventive care, prescription drugs, and provider office services. This?plan?covers some items and services even if you haven t yet met the annual?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? Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? In-Network: $6,000/$12,000 Out-of-Network: $12,000/$24,000 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. What is not included in the out-of-pocket limit? Premium,?balance billed?charges, penalties, denial for failure to obtain Even though you pay these expenses, they don t count toward the?out-of-pocket limit. certification and services this?plan?doesn t cover. Yes. See Will you pay less if you use a or network provider? call for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay 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 (a balance bill). 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. Do you need a referral to see No. a specialist? You can see the specialist you choose without a referral. 1 of 9

2 BlueFreedom Opt 42 Rx Opt 6 i. Point Coverage Period: 1/1/ /31/2018 All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if a deductible applies. Common Medical Event Services You May Need Primary care visit to treat an injury or illness Limitations, Exceptions, & Other Important Information $30 copay/visit Some office services may be subject to deductible and/or coinsurance. $50 copay/visit Some office services may be subject to deductible and/or coinsurance. Preventive care/screening/ immunization No charge for federally mandated services.. For immunizations for children up to age 7, the deductible is waived. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood work) None Imaging (CT/PET scans, MRIs) Prior certification may be required. Failure to obtain prior certification when required will result in denial of the claim. If you visit a health care provider's office Specialist visit or clinic If you have a test What You Will Pay In-Network Out-of-Network (You will pay the least) (You will pay the most) For all prescription drugs, out-of-pocket costs shown are per 30-day supply. If allowed by your prescription, up to a 90-day supply may be obtained at one time (except for specialty drugs) by paying 3 copay amounts. Certain prescription drugs may require prior certification. Failure to obtain prior certification will result in denial of the claim. Mail order benefits are not available out-of-network. If you need drugs to treat your illness or condition Generic drugs $15/prescription, deductible waived $15/prescription, deductible waived plus 25% penalty None Preferred brand drugs $45/prescription, deductible waived $45/prescription, deductible waived plus 25% penalty None $80/prescription, deductible waived $80/prescription, deductible waived plus 25% penalty None More information about prescription drug Non-preferred brand drugs coverage is available at Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield Association. 2 of 9

3 Common Medical Event Services You May Need Coverage Period: 1/1/ /31/2018 Limitations, Exceptions, & Other Important Information $150/prescription, deductible waived Retail and mail order: 30-day supply maximum. Designated pharmacy may apply. None Physician/surgeon fees None Emergency room care $150 copay/visit Same cost shares as in-network provider Copay waived if admitted. Same cost shares as in-network provider Limitations may apply to air ambulance. $75 copay/visit Copay applies to urgent care facilities. Some urgent care services may be subject to the deductible and coinsurance. Prior certification required. Failure to obtain prior certification will result in denial of the claim. Physician/surgeon fee None Outpatient services Office Visit: $30 copay/visit Other Outpatient Services: Some office services may be subject to deductible and coinsurance. Inpatient services Prior certification required. Failure to obtain prior certification will result in denial of the claim. Copay may apply for visit to determine pregnancy. Cost sharing does not apply to certain preventive services. Depending on the type of services, copay, deductible and coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC. Childbirth/delivery professional services See pregnancy office visits limit. Specialty drugs If you have outpatient Facility fee (e.g., ambulatory surgery center) surgery If you need immediate Emergency medical medical attention transportation Urgent care If you have a hospital Facility fee (e.g., hospital room) stay If you need mental health, behavioral health, or substance abuse services BlueFreedom Opt 42 Rx Opt 6 What You Will Pay In-Network Out-of-Network (You will pay the least) (You will pay the most) Office visits If you are pregnant Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield Association. 3 of 9

4 Common Medical Event Services You May Need Childbirth/delivery facility services If you need help recovering or have other special health needs BlueFreedom Opt 42 Rx Opt 6 What You Will Pay In-Network Out-of-Network (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information See pregnancy office visits limit. Home health aide: 60 days per calendar year. Skilled nursing in the home: Limited to 8 hours per day. Prior certification required. Respiratory care: 60 days per calendar year. Rehabilitation services Outpatient therapy: Manipulations: Other services: Outpatient therapy: Manipulations: Other services: Outpatient physical, occupational, speech, physiotherapy: Combined 60 session limit per calendar year. Manipulations and adjustments: Combined 30 session limit per calendar year. Outpatient cardiac rehabilitation: Combined 18 session limit per diagnosis. Outpatient pulmonary rehabilitation: Combined 18 session limit per diagnosis for certain diagnoses and criteria. Prior certification required. Inpatient physical rehabilitation: Prior certification required. Failure to obtain prior certification will result in denial of the claim. Habilitation services See the Rehabilitation services and If you have a hospital stay sections. Educational services are not covered. In the home: See the Home health care section. Skilled nursing care: Limited to 60 days per calendar year. Prior certification required. Failure to obtain prior certification will result in denial of the claim. Rental or purchase, whichever is least costly. Prior certification may be required. Failure to obtain prior certification when required will result in denial of the claim. Home health care Skilled nursing care Durable medical equipment Coverage Period: 1/1/ /31/2018 Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield Association. 4 of 9

5 Common Medical Event Services You May Need Hospice services If your child needs dental or eye care BlueFreedom Opt 42 Rx Opt 6 What You Will Pay In-Network Out-of-Network (You will pay the least) (You will pay the most) Coverage Period: 1/1/ /31/2018 Limitations, Exceptions, & Other Important Information Prior certification required. Children's eye exam Visual acuity tests are covered under the preventive services benefit. No coverage for eye exams. Children's glasses Lenses: Frames: Contacts: Lenses: Frames: Contacts: No coverage for glasses. Children's dental check-up No coverage for dental check-up. 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 Bariatric surgery Cosmetic surgery Dental care (adults) Dental care (children) Glasses (children) Hearing aids Infertility treatment Long-term care Private-duty nursing Routine eye care (adults) Routine eye care (children) Routine foot care Weight loss programs 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 US Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield Association. 5 of 9

6 BlueFreedom Opt 42 Rx Opt 6 Coverage Period: 1/1/ /31/2018 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: Blue Cross and Blue Shield of Nebraska at or visit for group health coverage subject to ERISA, the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or for non-federal governmental group health plans, the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or or your employer s human resources department. 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: Blue Cross and Blue Shield of Nebraska at or visit the Nebraska Department of Insurance at or for group health coverage subject to ERISA, the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or your employer s human resources or employee benefits department. Does this plan provide Minimum Essential Coverage? Yes. If you don't have Minimum Essential Coverage for a month under this plan or under other coverage, 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. Language Access Services: To see examples of how this plan might cover costs for a sample medical situation, see the next page. Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield Association. 6 of 9

7 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 Managing Joe s type 2 Diabetes Mia s Simple Fracture (9 months of in-network pre-natal care and a hospital delivery) (a year of routine in-network care of a well-controlled condition) (in-network emergency room visit and follow up care) The plan s overall deductible Specialist copay Hospital (facility) coinsurance Other coinsurance $3,000 $50 30% 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 In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Peg would pay is $12,800 $3,200 $200 $2,500 $60 $5,960 The plan s overall deductible Specialist copay Hospital (facility) coinsurance Other coinsurance $3,000 $50 30% 30% 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 In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Joe would pay is $7,400 $200 $2,600 $0 $200 $3,000 The plan s overall deductible Specialist copay Hospital (facility) coinsurance Other coinsurance $3,000 $50 30% 30% 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 In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Mia would pay is $1,900 $1,700 $100 $0 $0 $1,800 The plan would be responsible for the other costs of the EXAMPLE covered services. 7 of 9

8

9

10 Schedule of Benefits Summary Option 42 Payment for Services In-network Out-of-network Covered Services are reimbursed based on the Allowable Charge. Blue Cross and Blue Shield of Nebraska In-network s have agreed to accept the benefit payment as payment in full, not including Deductible, Coinsurance and/or Copayment amounts and any charges for non-covered services, which are the Covered Person s responsibility. That means that In-network providers, under the terms of their contract with Blue Cross and Blue Shield, can t bill for amounts over the Contracted Amount. Out-of-network s can bill for amounts over the Out-of-network Allowance. In-Network provider: The provider network is shown on your ID card. For help in locating In-Network providers, visit Deductible (the amount the Covered Person pays each Calendar Year for Covered Services before the Coinsurance is payable) Individual $3,000 $6,000 Family (Embedded*) $6,000 $12,000 Coinsurance (the percentage amount the Covered Person must pay for most Covered Services after the Deductible has been met) Covered Person Pays 30% 50% Out-of-pocket Limit (includes the Deductible, Coinsurance and Copayment amounts) Individual $6,000 $12,000 Family (Embedded*) $12,000 $24,000 Once the annual Out-of-pocket Limit is reached, most Covered Services are payable by the plan at 100% for the rest of the Calendar Year. In-network and Out-of-network Deductible and Out-of-pocket Limits are separate and do not cross accumulate. All other limits (days, visits, sessions, dollar amounts, etc.) do cross accumulate between In-network and Out-of-network, unless noted differently. *Embedded If you have single coverage, you only need to satisfy the individual Deductible and Out-of-pocket Limit amounts. If you have family coverage, no one family member contributes more than the individual amount. Family members may combine their covered expenses to satisfy the required family Deductible and Out-of-pocket amounts revised 1/ /2018 BlueFreedom Option 42

11 Covered Services Illness or Injury In-network Out-of-network Physician Office Primary Care Physician Office $30 Copay Services Specialist Physician Office $50 Copay Services Other Covered Services and supplies provided in the Physician s Office (with or without an office visit billed) Telehealth Services (by a designated provider) Applicable office visit Copay $10 Copay Not Covered Primary Care Physician is a physician who has a majority of his or her practice in internal or general medicine, obstetrics/gynecology, general pediatrics or family practice. A physician assistant is covered in the same manner as a Primary Care Physician. Specialist Physician is a physician who is not a Primary Care Physician. Office Visit Benefits for Primary Care and Specialist Physician Office Visit include office visits (including the initial visit to diagnose pregnancy) and consultations. Other Covered Services not part of the Physician Office Benefit (Refer to the appropriate category for benefit information) include: Advanced Diagnostic Imaging (CT, MRI, MRA, MRS, PET & SPECT scans and other Nuclear Medicine); Pregnancy Services; Preventive Services; Radiation Therapy & Chemotherapy; Surgery & Anesthesia; Therapy & Manipulations; Durable Medical Equipment; Sleep Studies; Biofeedback; Psychological Evaluations, Assessments, and Testing. Convenient Care/Retail Clinics (Quick Care) Same as a Primary Care Physician Same as a Primary Care Physician Urgent Care Facility Services (a single copay applies to each urgent care visit) $75 Copay Emergency Care Services (services received in a Hospital emergency room setting) Facility $150 Copay In-network level of benefits Professional Services Plan Pays 100% In-network level of benefits (Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis) Outpatient Hospital or Facility Services Services such as surgery, laboratory and radiology, cardiac and pulmonary rehabilitation, observation stays, and other services provided on an outpatient basis Inpatient Hospital or Facility Services Services for room and board, diagnostic testing, rehabilitation and other ancillary services provided on an inpatient basis revised 1/ /2018 BlueFreedom Option 42

12 Preventive services Preventive Services Affordable Care Act (ACA) required preventive services (may be subject to limits that include, but are not limited to, age, gender, and frequency) ACA required covered preventive services (outside of limits) In-network Plan Pays 100% Plan Pays 100% Out-of-network Other covered preventive services not required by ACA, such as: laboratory tests, as specified by Us, including urinalysis and completed blood count; Prostate cancer screenings (PSA); and hearing exam; all other laboratory tests; Plan Pays 100% Same as illness Same as illness Radiology; cardiac stress test; EKG, pulmonary function and other screening services. Immunizations Pediatric (up to age 7) Plan Pays 100% Coinsurance Age 7 and older Plan Pays 100% Related to an illness Same as any other illness Same as any other illness Mental Illness and/or Substance Dependence and Abuse covered services In-network Out-of-network Inpatient Services Outpatient Services Office Services Telehealth Services (by a $30 Copay $10 Copay Not Covered designated provider) All Other Outpatient Items & Services Emergency Care Services (services received in a Hospital emergency room setting) Facility $150 Copay In-network level of benefits Professional Services (Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis) Plan Pays 100% In-network level of benefits revised 1/ /2018 BlueFreedom Option 42

13 Other Covered Services Illness or Injury Advanced Diagnostic Imaging (CT, MRI, MRA, MRS, PET & SPECT scans and other Nuclear Medicine) In-network Out-of-network Ambulance (to the nearest facility for appropriate care) Ground Ambulance In-network level of benefits Air Ambulance (In-network level of benefits if due to an emergency) Drugs Administered in an Outpatient Setting (such as home, physician office and other outpatient settings) Not Covered Not Covered (NOTE: Some prescription drugs and covered services administered in an outpatient setting, other than a hospital emergency room, are only payable under the Prescription Drug category. A list of these drugs and covered services is available on the website or by contacting the Member Services Department.) Durable Medical Equipment and Supplies (including Prosthetics) (rental or purchase, whichever is least costly; rental shall not exceed the cost of purchasing) Home Health Care Skilled Nursing Care (limited to 8 hours per day) Home Health Aide (limited to 60 days per Calendar Year) Respiratory Care (limited to 60 days per Calendar Year) Hospice Services Independent Laboratory Diagnostic Plan Pays 100% In-network level of benefits Preventive Same as Preventive Services Innetwork level of benefits Oral Surgery and Dentistry Services such as incision and drainage of abscesses and excision of tumors and cysts. Same as Preventive Services Innetwork level of benefits Dental treatment when due to an accidental injury to naturally healthy teeth (treatment related to accidents must be provided within 12 months of the date of injury). Organ and Tissue Transplantation Ostomy Supplies revised 1/ /2018 BlueFreedom Option 42

14 Other Covered Services Illness or Injury Physician Professional Services Inpatient and Outpatient services, such as, surgery, surgical assistant, anesthesia, inpatient hospital visits and other non-surgical services Pregnancy, Maternity and Newborn Care Pregnancy and maternity (Payment for prenatal and postnatal care is included in the payment for the delivery) In-network Out-of-network Newborn care NOTE: Newborns are covered at birth, subject to the plan s enrollment provisions. Radiation Therapy and Chemotherapy Radiology (x-ray) Services and other Diagnostic Test Rehabilitation Services Inpatient Facility Rehabilitation Services Cardiac rehabilitation (limited to 18 sessions per diagnosis) Pulmonary Rehabilitation (Chronic lung disease is limited to 18 sessions per diagnosis, not to exceed 18 sessions per Calendar Year. Lung, heart-lung transplants and lung volume are limited to 18 sessions following referral and prior to surgery plus 18 sessions within six months of discharge from hospital following surgery) Renal Dialysis Skilled Nursing Facility (limited to 60 days per Calendar Year) Temporomandibular and Craniomandibular Joint Disorder revised 1/ /2018 BlueFreedom Option 42

15 Other Covered Services Illness or Injury In-network Out-of-network Therapy & Manipulations Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 60 sessions per Calendar Year for both rehabilitative and habilitative services) Chiropractic or osteopathic manipulative treatments or adjustments (combined limit to 30 sessions per Calendar Year) *NOTE: session limits are not applicable to mental illness and/or substance dependence and abuse Vision Exams Diagnostic (to diagnose an illness) See Physician Office Services See Physician Office Services Preventive (routine exam including refraction) Not Covered Not Covered All Other Covered Services Please note: This Schedule of Benefits Summary is intended to provide you with a brief overview of your benefits. It is not a contract and should not be regarded as one. For more complete information about your plan, including benefits, exclusions and contract limitations, please refer to the master group contract. In the event there are discrepancies between this document and the contract, the terms and conditions of the contract will govern revised 1/ /2018 BlueFreedom Option 42

16 Prescription Drugs Retail and Mail order per 30-day supply In-network Rx Option 6 Out-of-network Generic drugs $15 Copay In-network level of benefits + 25% Formulary Brand Name Drugs $45 Copay In-network level of benefits + 25% Non-formulary Brand Name Drugs $80 Copay In-network level of benefits + 25% NOTE: A 90-day supply is available at an Extended Supply Network pharmacy subject to 3 copays. Specialty drugs (specialty drugs must be purchased through a designated specialty pharmacy after two fills) $150 Copay Not Covered Please note: This Schedule of Benefits Summary is intended to provide you with a brief overview of your benefits. It is not a contract and should not be regarded as one. For more complete information about your plan, including benefits, exclusions and contract limitations, please refer to the master group contract. In the event there are discrepancies between this document and the contract, the terms and conditions of the contract will govern revised 1/ /2018 BlueFreedom RX Option 6