SCHEDULE OF MEDICAL AND PHARMACY BENEFITS

Transcription

1 SCHEDULE OF MEDICAL AND PHARMACY BENEFITS The following benefits are per Participant per calendar year. These benefits are subject to change. Please refer to subsequent Amendments, Summary of Material Modifications, and current Schedule of Benefits Summary. These are distributed annually prior to Open Enrollment and/or Benefits Renewal period. ALL ESSENTIAL HEALTH BENEFITS BASIC LEVEL SCHEDULE OF MEDICAL BENEFITS 8/1/2014 7/31/2015 Per Participant per calendar year Unlimited HMO PPO Non-Network $650 Individual $850 $2,250 Deductible 1 Family Unit Payment Level (unless otherwise stated) $1,300 90% $1,700 80% $5,400 70% Medical Maximum Out-of-Pocket 2 Individual Family Unit $2,000 $4,000 $3,000 $6,000 $4,500 $9,000 Pharmacy (Rx) Maximum Out-of-Pocket 2 $3,000 individual / $6,000 family ENHANCED LEVEL (active participation in the Your Healthy Rewards Program is required) 3 HMO PPO Non-Network $520 Individual $680 $1,800 Deductible 1 Family Unit Payment Level (unless otherwise stated) $1,040 90% $1,360 80% $4,320 70% Medical Maximum Out-of-Pocket 2 Individual Family Unit $1,600 $3,200 $2,400 $4,800 $3,600 $7,200 Pharmacy (Rx) Maximum Out-of-Pocket 2 $3,000 individual / $6,000 family 1 Deductible is the amount of Covered Expenses that must be paid by the Participant or Dependent before Plan payments begin. 2 Maximum Out-of-Pocket is the total Amount of Covered Expenses that must be paid by the Participant or Dependent. 3 Whether a participant is subject to the Basic or Enhanced Deductibles and Out-of-Pocket Maximums is based upon active participation in the Healthy Rewards Wellness Program. Dependent children are always subject to the Enhanced Level. Out-of-Pocket Maximum o o o Copays, coinsurance, and deductibles apply to the Out-of-Pocket Maximum. In-network tiers (HMO, PPO) cross-apply to meet in-network out-of-pocket maximum. The Out-of-Pocket Maximums do not apply to or include: 1) Expenses that are excluded by the terms of the Benefit Document; 2) Non-Network expenses that exceed Usual, Customary and Reasonable; 3) Expenses that become the Covered Person s responsibility for failure to comply with the requirements of the Utilization Management Program. Annual Deductible does not apply. 1

2 1. Physician Services PCP Office Visit Basic Level PCP Office Visit Enhanced Level Specialist Office Visit Inpatient Visits 2. Hospital Inpatient Treatment Outpatient Treatment $25 Co-pay+ $10 Co-pay+ + $25 Co-pay+ $10 Co-pay+ + Covered Expenses for Inpatient room and board are limited: (1) at a Network Hospital, to the Network negotiated rates and, (2) at a Non-Network Hospital, to the Semi-Private Room Charge or the Usual, Customary and Reasonable charge for an Intensive Care Unit. Excess charges for a private room accommodation will be covered when Medically Necessary or when a semi-private room is not available. Eligible Expense for a private room will be 90% of the Hospital s lowest private room rate. 3. Emergency Services - Outpatient $200 Co-pay then 90% no Deductible $200 Co-pay then 80% no Deductible $200 Co-pay then 80% no Deductible The emergency room Co-pay is waived for a true Medical Emergency or if the patient is admitted to the Hospital directly from the emergency room. Emergency Room Services, such as a physician visit, lab work, x-rays, pathology, radiology, anesthesiology are subject to co-insurance and not part of the $200 facility Co-pay. Eligible expenses for services performed by a non-network physician or provider are limited to the Usual, Customary and Reasonable rates (UCR). Any charges above the UCR rates will be the covered Person s responsibility. 4. Ambulance 80% no Deductible 80% no Deductible 80% no Deductible 5. Ambulatory Surgical Center Pre-certification is required for: cartilage transplant knee; lumbar spine surgery; nasal septoplasty; rhinoplasty; sinus endoscopy; sleep apnea surgery LAUP/UPPP, Nasal and Uvulopalatoplasty. See Section 2 for complete list of precertification of medical and surgical procedures. 6. Allergy Services Injections/Serum/Inhalers Testing 7. Anesthesia 8. Birth Control Includes: contraceptive devices, IUDs, diaphragms, implants and Depo Provera. Oral contraceptives and other injections will be covered under the Prescription coverage. 9. Birthing Center 10. Cardiac Rehabilitation 11. Chemotherapy - See section 5.01(7) for benefit information. 12. Chiropractic Care 90% no Deductible 80% no Deductible 70% no Deductible Limited to $750 maximum benefit per calendar year. Includes diagnostic charges and osteopathic manipulations. 13. Dental Care Includes: coverage for accidental injury to sound natural teeth, including replacement of such teeth and any related x-rays; reduction of fractures of facial bones; surgical removal of impacted teeth; cutting procedures in the oral cavity other than for extractions or repair of the teeth, dentures and gums; and removal of malignant tumors. 2

3 14. Dermatology Services 15. Diabetic Benefits Value-Based Not Covered Participant must be enrolled in the diabetic disease management program. Benefits include the following: Up to 4 physician office visits per year for diabetic-related care Hemoglobin A1C test (up to 4 per year) Lipid profile test (up to 2 per year) Micro albumin test (1 per year) Annual flu shot Pneumonia vaccine (once then every 5 years if ordered by a physician, up to age 65) Diabetes education (up to 10 sessions in one year, up to 4 hours in each of 2 subsequent years) Podiatric visits as referred by MD/DO/NP, up to once every 6 months Annual dilated eye exam (1 per year) Insulin or oral diabetic medications Lipid controlling agents Blood pressure control agents Diabetic test strips 16. Diagnostic X ray and Lab- Outpatient In office with office visit co-pay In facility or independent lab* Pre-Certification is required for MRA of the head and/or neck, MRI of the brain, MRI of spine, PET Scans, Coronary CT Angiography, Coronary MRA, Cardiac MRI. *MRI/CT, EMG/NRV and PET scans are covered at 100% if services are performed by a One Call Medical network provider. Call to schedule services with a One Call Medical provider. 17. Dialysis Outpatient See section 5.02(13) for benefit requirements and information 18. Durable Medical Equipment Pre-certification is required for the following: TENS Units; Bone Growth Stimulators; Neuromuscular Stimulators; Functional Electrical Stimulator Bikes; Custom and Power Wheelchairs; Limb Prosthetics; Wound Vacs; Electric Scooters; Cardio/External Defibrillator; Cochlear Implant; Cooling Devices; CPAP/BiPAP; and Myoelectric Prosthetics. 19. Glaucoma, Cataract Surgery and Lenses (one set) 20. Home Health Care Pre-certification is required. 1 visit equals 4 hours. Includes: part-time home health aid services, physical therapy, occupational therapy, respiratory therapy, speech therapy, medical supplies, and lab charges if deemed Medically Necessary. HMO and PPO Network limited to a 100 visit maximum per calendar year and Non-Network is limited to a 60 visit maximum per calendar year. 21. Home Infusion Services Pre-certification is required. 22. Hospice Care Inpatient and Outpatient Family Bereavement Counseling Pre-certification is required for inpatient and outpatient hospice care. Bereavement counseling is limited to counseling provided within 3 months of the patient s death. Respite care is not covered. 3

4 23. Impregnation and Infertility Not Covered* Treatment See Note below Limited to a lifetime maximum benefit of $20,000. Charges do not apply to the Maximum Out-of-Pocket expenses and benefits will not be covered if Out-of-Pocket Maximum is met. Does not include charges for drugs. Non-Network services are covered only if services are not available in-network* (covered at 70% after deductible). 24. Medical and Surgical Supplies Includes: 2 surgical stockings per calendar year and 2 post mastectomy bras per calendar year. 25. Patient Education Ostomy education only 26. Podiatry Office Visit Other Services Foot Orthotics $500 annual maximumno Deductible & Co-pay $500 annual maximumno Deductible & Co-pay $500 annual maximumno Deductible & Co-pay Includes: surgical procedures or injections involving the bones, nerves, muscles or tendons of the foot or ankle; cutting or removal of corns, calluses or toenails if done in connection with an underlying medical condition such as diabetes or peripheral vascular disease. All services/products must be deemed medically necessary by a licensed Podiatrist. Palliative services are not covered. 27. Pregnancy Expenses Office visit co-pay applies to the initial visit only. Routine nursery care is covered under the mother s coverage. For Dependent daughters, well baby charges are covered under the mother s coverage while mother and baby are confined in the hospital and sick baby charges are not covered. 28. Preventive Care - Well Child Care* (0-18 years of age) Exam Immunizations Vision Screening Hearing Screening for Newborns Autism Screening (children months) 29. Preventive Care Well Adult Care* for complete list visit Routine Physical Exam Prostate Exam must be over age 50, unless Medically Necessary Routine Immunizations Colorectal Cancer screening for adults over 50 Screening of adults for obesity, depression, alcohol misuse, high blood pressure, Type-2 Diabetes (adults with high blood pressure), HIV (adults at higher risk) Mammograms must be over age 40, unless Medically Necessary High-Risk Mammogram and MRI for high risk patients annually beginning at age 30.* Pap Smears FDA-approved contraceptive methods and sterilization procedures and counseling o Oral Contraceptives see Summary of Prescription Drug Benefits o Implantable Devices & Vaginal Ring: The following quantity limits apply: Sub-dermal Rod 1 per year IUD 1 per year Vaginal Ring 1 per month / 12 per year o Diaphragms and Cervical Cap: Limited to 1 per year o Injectibles: Limited to 4 injections per year o Transdermal Patch: Weekly Transdermal Patch is covered. * Please see Plan Document, section 5.02 (34) Preventive Care for more specific coverage information and criteria 4

5 30. Private Duty Nursing Limited to $10,000 per Calendar Year (non-transplant-related) and $10,000 in benefits when related to a covered transplant. 31. Prosthetics, Orthotics, Supplies and Surgical Dressings Does not include orthotic shoes and foot devices or orthopedic shoes. (See Podiatry) $25 Co-pay then $25 Co-pay then 32. Psychiatric Expenses 33. Second Surgical Opinions 34. Skilled Nursing Facility Eligible Expenses for room and board are limited to the facility s Semi-Private Room Charge. Coverage is limited to 100 days per Calendar Year. 35. Smoking Cessation Not Covered 36. Substance Abuse Benefits $25 Co-pay then 100% no Deductible $25 Co-pay then 100% no Deductible 37. Surgery Pre-certification is required. See Section 2 for Pre-certification, Pre-Admission Testing, Pre-Surgical Approval and Second Surgical Opinion requirements and general information. 38. Therapy Occupational Therapy Physical Therapy Radiation Therapy Respiration Therapy Speech Therapy Pre-certification is required. Occupational therapy has a maximum benefit of 90 days combined with physical therapy. Speech therapy is limited to 90 days per calendar year. 39. Transplants Pre-certification and Case Management is required. Transportation, lodging and meal expenses are limited to $150 per day up to a maximum of $10,000 per transplant. 40. Urgent Care Facilities $25 Co-pay $25 Co-pay 41. Vision Services Medical, Accident or Injury only Office Visit Outpatient not in office 42. Weight Control / Obesity Covered only if Participant is diagnosed with endogenous obesity including but not limited to metabolic factors and or due to hypothalamic lesions. To be eligible for surgery Participant must be twice their ideal weight, demonstrate inability to control weight through diet over a minimum of 1 year period documented through Physician s notes and must suffer from a documented separate condition which is aggravated by obesity. PRE-CERTIFICATION IS REQUIRED FOR BARIATRIC SURGERY. SCHEDULE OF PRESCRIPTION DRUG BENEFITS Covered Prescription Drug CO-PAYS PER PRESCRIPTION OR REFILL PARTICIPATING PHARMACY OPTION MAIL ORDER OPTION GENERIC 1 $15 $30 FORMULARY NAME BRANDS $35 $70 NON-FORMULARY NAME BRANDS $50 $100 5

6 THE INFORMATION BELOW IS ONLY A SUMMARY See Plan Document, Prescription Drug Plan Section 4 for Plan Information, Covered Expenses and Exclusions Prescription Drugs must be Medically Necessary and not Experimental or Investigational in order to be Covered under this Plan. Retail Pharmacy Fill Program Up to a 30-day supply. Plan Participants can receive up to a 30-day supply of medication, plus refills, as prescribed by a Physician, when they present their Plan identification card at Participating Retail Pharmacies. Prescriptions will be filled according to the Generics Preferred Program, described below. Co-pays are charged at the time of purchase. Mandatory Mail Order Program for Maintenance Medications 90-day supply All prescriptions for maintenance medications are required to be ordered through the mail order program. There is a limit of two (2) retail fills on maintenance medications; the third fill will be denied at the retail pharmacy and must be ordered through mail order. Maintenance medications are those prescriptions that are taken on an ongoing, regular basis (over a long period of time); such as medications for diabetes, high blood pressure, birth control, etc. Short-term medications, usually prescribed for less than 60 days, should be filled through a retail pharmacy. Generics Preferred Program - Prescriptions will always be filled with a Generic drug when available, unless the written prescription is marked with Dispense as Written or Do not Substitute by the physician. If a brand name drug is requested by the patient when the physician allows a substitution, the patient will be charged the applicable co-pay plus the difference in cost between the generic and the brand name drug. Specialty Drug Program - Prescriptions for Specialty Drugs will be processed and managed through a contracted Specialty Drug vendor. A list of covered and excluded drugs is provided in the Plan Document, Section 4. Women s Preventive Care Women will have access to all FDA-approved contraceptive methods These do not include abortifacient drugs. Oral Contraceptives- all Generic and Preferred Brand prescription drugs will be covered at 100%. Cost-sharing co-pays will continue to apply to Non-Preferred Brand prescription drugs. See Plan Document, Section 4.06, Contraceptives, for a complete list of covered products. Smoking Cessation Program No co-pay and the following prescription drugs and over-the-counter (OTC) products are covered at 100%. Rx script is required. Prescription drugs covered Limit of 168 day supply in one year. Mail Order Only. Typical length of therapy (may vary by individual): Chantix - initial duration of 12 weeks with an additional 12 weeks recommended Zyban/bupropion - initial duration of 7-12 weeks - if successful, consider ongoing therapy Nicotrol Inhaler - initial duration 12 weeks with weaning over the next 6-12 weeks Nicotrol nasal spray - initial duration 8 weeks then taper over the next 4-6 weeks OTC Products Covered Need RX Script from doctor Limit of 168 day supply in one year. Typical length of therapy (may vary by individual) - each smoking cessation product varies with respect to its usual length of therapy. The patches (all OTC) vary in strengths depending on the manufacturer and commonly have 3 strengths to slowly build up the nicotine levels. Coverage: Nicotine gum (OTC) - 12 weeks Nicotine patches (OTC) weeks 6