Mid-Market and Large Group Plans Optima Health Benefit Changes
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- Donald Lester
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1 Mid-Market and Large Group Plans Optima Health Benefit Changes The following changes will be effective January 1, 2018 All Plans In compliance with a new Virginia state law, prescriptions for up to a 12-month supply of hormonal contraceptives are covered when dispensed or furnished at one time by an in-network provider or pharmacy. Members are responsible for the applicable Copayment or Coinsurance. Mail Order Tier 3 Maximum Copayment per prescription per 90 day supply decreased from $750 to $300. Discontinued plans Vantage 10/20 Vantage 15/35 Vantage POSA 10/20 Vantage POSA 15/35 Design Vantage 1500/30% Design Vantage POSA 1500/30% Design Vantage Rx After Ded 3000/10% Design Vantage Rx After Ded 3000/30% Design Vantage Rx After Ded 4000/0% Design Vantage POSA Rx After Ded 3000/10% Design Vantage POSA Rx After Ded 3000/30% Design Vantage POSA Rx After Ded 4000/0% POS 10/20 POS 15/35 POS 500/15/20% POS 1500/20/20% Design POS 1500/30% Design POS Rx After Ded 3000/10% Design POS Rx After Ded 3000/30% Design POS Rx After Ded 4000/0% Plus 10/10% Plus 15/20% Design Plus 1500/30% Design Plus Rx After Ded 3000/10% Design Plus Rx After Ded 3000/30% Design Plus Rx After Ded 4000/0%
2 New plans Vantage 2000/50%: in-network Deductible $2,000/$4,000; in-network maximum out-of-pocket testing supplies and education, and preventive vision covered at 100%. Vantage POSA 2000/50%: in-network Deductible $2,000/$4,000; in-network maximum out-of-pocket testing supplies and education, and preventive vision covered at 100%; out-of-network Deductible $5,000/$10,000; out-of-network maximum out-of-pocket $8,000/$16,000; 30% AD primary out-of-network Coinsurance. Equity Vantage 4000/40%: in-network Deductible $4,000/$8,000; in-network maximum out-of-pocket $6,550/$13,100; 40% AD primary in-network Coinsurance; PCP $25 AD, Specialist $50 AD, Behavioral Health Outpatient $25 AD ; 50% AD primary out-of-network Coinsurance. Equity Vantage POSA 4000/40%: in-network Deductible $4,000/$8,000; in-network maximum out-ofpocket $6,550/$13,100; 40% AD primary in-network Coinsurance; PCP $25 AD, Specialist $50 AD, Behavioral Health Outpatient $25 AD ; out-of-network Deductible $6,000/$12,000, out-of-network maximum out-of-pocket $10,000/$20,000; 50% AD primary out-of-network Coinsurance. POS 2000/50%: in-network Deductible $2,000/$4,000; in-network maximum out-of-pocket testing supplies and education, and preventive vision covered at 100%; out-of-network Deductible $4,000/$8,000, out-of-network maximum out-of-pocket $13,200/$26,400, 50% AD primary out-of-network Coinsurance. Equity POS 4000/40%: in-network Deductible $4,000/$8,000; in-network maximum out-of-pocket $6,550/$13,100; 40% AD primary in-network Coinsurance, preventive care; PCP $25 AD, Specialist $50 AD, Behavioral Health Outpatient $25 AD ; urgent care center $50 AD ; out-of-network Deductible $5,500/$10,500, out-of-network maximum out-of-pocket $13,100/$26,200, 50% AD primary out-ofnetwork Coinsurance. Plus 2000/50%: in-network Deductible $2,000/$4,000; in-network maximum out-of-pocket testing supplies and education, and preventive vision covered at 100%; chiropractic care 20% AD /30% AD out-of-network; 50% AD primary out-of-network Coinsurance; out-of-network Deductible $4,000/$8,000, out-of-network maximum out-of-pocket $13,200/$26,400. Equity Plus 4000/40%: in-network Deductible $4,000/$8,000; in-network maximum out-of-pocket $6,550/$13,100; 40% AD primary in-network Coinsurance; PCP $25 AD, Specialist $50 AD, Behavioral Health Outpatient $25 AD ; urgent care center $50 AD ; 50% AD primary out-of-network Coinsurance.
3 Out-of-Network Deductible Changes Plan 2017 Out-of-Network Deductible 2018 Out-of-Network Deductible POS 10/25 $300/$900 $400/$1200 POS 4000/30/20% $6,600/$13,200 $8,000/$16,000 POS 4000/30/30% $6,600/$13,200 $8,000/$16,000 POS 5000/30/20% $7,500/$15,000 $10,000/$20,000 POS 5000/30/30% $7,500/$15,000 $10,000/$20,000 Design POS 3000/10% $4,000/$8,000 $5,000/$10,000 Design POS 3000/20% $4,000/$8,000 $5,000/$10,000 Design POS 3000/30% $4,000/$8,000 $5,000/$10,000 Design POS Rx After Ded 4000/20% $5,500/$10,500 $5,500/$11,000 Design POS Rx After Ded 4000/30% $5,500/$10,500 $5,500/$11,000 Design Plus 3000/10% $4,000/$8,000 $5,000/$10,000 Design Plus 3000/20% $4,500/$9,000 $5,000/$10,000 Design Plus 3000/30% $4,500/$9,000 $5,000/$10,000 Design Plus Rx After Ded 4000/20% $5,500/$10,500 $5,500/$11,000 Design Plus Rx After Ded 4000/30% $5,500/$10,500 $5,500/$11,000 Equity Plus 2700/10% $3,000/$6,000 $3,500/$7,000
4 Vantage and Vantage POSA In-Network Maximum Out-of-Pocket () Changes Plan 2017 In-Network 2018 In-Network Vantage 20/20% $3,000/$6,000 $4,000/$8,000 Vantage 25/30% $3,000/$6,000 $4,500/$9,000 Vantage 30/30% $4,000/$8,000 $4,500/$9,000 Vantage 500/20/20% $3,500/$7,000 $4,500/$9,000 Vantage 1000/20/20% $3,500/$7,000 $5,500/$11,000 Vantage 1000/30/30% $5,000/$10,000 $4,500/$9,000 Vantage 1500/25/30% $6,850/$13,700 $5,000/$10,000 Vantage 5000/30/20% $6,850/$13,700 $7,350/$14,700 Vantage 5000/30/30% $6,850/$13,700 $7,350/$14,700 Vantage 5000/30/75 $6,850/$13,700 $7,350/$14,700 Vantage 5000/20% $6,850/$13,700 $7,350/$14,700 Vantage 6000/20% $6,850/$13,700 $7,350/$14,700 Vantage POSA 20/20% $3,000/6,000 $4,000/$8,000 Vantage POSA 25/30% $3,000/$6,000 $4,500/$9,000 Vantage POSA 30/30% $4,000/$8,000 $4,500/$9,000 Vantage POSA 500/20/20% $3,500/$7,000 $4,500/$9,000 Vantage POSA 1000/20/20% $3,500/$7,000 $5,500/$11,000 Vantage POSA 1000/30/30% $5,000/$10,000 $4,500/$9,000 Vantage POSA 1500/25/30% $6,850/$13,700 $5,000/$10,000 Vantage POSA 5000/30/20% $6,850/$13,700 $7,350/$14,700 Vantage POSA 5000/30/30% $6,850/$13,700 $7,350/$14,700 Vantage POSA 5000/30/75 $6,850/$13,700 $7,350/$14,700 Vantage POSA 5000/20% $6,850/$13,700 $7,350/$14,700 Vantage POSA 6000/20% $6,850/$13,700 $7,350/$14,700 Design Vantage 1500/30% $6,850/$13,700 $7,350/$14,700 Design Vantage POSA 1500/30% $6,850/$13,700 $7,350/$14,700 Design Vantage Rx After Ded 5000/0% $6,850/$13,700 $7,350/$14,700 Design Vantage POSA Rx After Ded 5000/0% $6,850/$13,700 $7,350/$14,700
5 POS Maximum Out-of-Pocket () Changes 2017 In-Network Plan 2018 In-Network 2017 Out-of- Network 2018 Out-of- Network POS 1000/25/30% $3,000/$6,000 $4,500/$9,000 $4,000/$8,000 $9,000/$18,000 POS 2000/25/30% $4,000/$8,000 $5,500/$11,000 $8,000/$16,000 $11,000/$22,000 POS 4000/30/20% $6,500/$13,000 $6,600/$13,200 $9,500/$19,000 $13,200/$26,400 POS 4000/30/30% $6,500/$13,000 $6,600/$13,200 $9,500/$19,000 $13,200/$26,400 POS 5000/30/20% $6,850/$13,700 $7,350/$14,700 $11,000/$22,000 $14,700/$29,400 POS 5000/30/30% $6,850/$13,700 $7,350/$14,700 $11,000/$22,000 $14,700/$29,400 POS 5000/20% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 POS 6000/20% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 Design POS 3000/0% $3,000/$6,000 $5,000/$10,000 $8,000/$16,000 $10,000/$20,000 Design POS 4000/0% $4,000/$8,000 $6,000/$12,000 $9,000/$18,000 $10,000/$20,000 Design POS 5000/0% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 Design POS Rx After Ded 5000/0% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 Equity POS 4000/0% $6,550/$13,100 No change $10,100/$20,200 $13,100/$26,200 Equity POS 4000/20% $6,550/$13,100 No change $10,100/$20,200 $13,100/$26,200 Equity POS 4000/30% $6,550/$13,100 No change $10,100/$20,200 $13,100/$26,200 Equity POS 5000/0% $6,550/$13,100 No change $10,100/$20,200 $13,100/$26,200 Design Plus Rx After Ded 5000/0% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 Plus Maximum Out-of-Pocket () Changes 2017 In-Network Plan 2018 In-Network 2017 Out-of- Network 2018 Out-of- Network Plus 1000/30/30% $4,500/$9,000 No change $8,500/$17,000 $9,000/$18,000 Plus 4000/30/20% $6,500/$13,000 $6,600/$13,200 $13,000/$26,000 $13,200/$26,400 Plus 4000/30/30% $6,500/$13,000 $6,600/$13,200 $13,000/$26,000 $13,200/$26,400 Plus 5000/30/20% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 Plus 5000/30/30% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 Plus 5000/20% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 Plus 6000/20% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 Design Plus 3000/0% $3,000/$6,000 $5,000/$10,000 $8,000/$16,000 $10,000/$20,000 Design Plus 4000/0% $4,000/$8,000 $6,000/$12,000 $9,000/$18,000 $10,000/$20,000 Design Plus 5000/0% $6,850/$13,700 $7,350/$14,700 $13,700/$26,400 $14,700/$29,400 Equity Plus 4000/0% $4,000/$8,000 No change $10,100/$20,200 $13,100/$26,200 Equity Plus 4000/20% $4,000/$8,000 No change $10,100/$20,200 $13,100/$26,200 Equity Plus 4000/30% $4,000/$8,000 No change $10,100/$20,200 $13,100/$26,200 Equity Plus 5000/0% $6,550/$12,000 No change $10,100/$20,200 $13,100/$26,200
6 Other Plan Changes Vantage 5000/20%: Outpatient Behavioral Health $0 Copayment for first 4 visits (previously $30 Copayment). Vantage POSA 5000/20%: Outpatient Behavioral Health $0 Copayment for first 4 visits (previously $30 Copayment). Equity Vantage 3000/0%: Emergency Department benefit covered at 100% AD (previously 10% AD ); Pre- Authorized Injectables and Infused Medications covered at 100% AD (previously 20% AD ). Equity Vantage POSA 3000/0%: Emergency Department benefit covered at 100% AD (previously 10% AD ); Pre-Authorized Injectables and Infused Medications covered at 100% AD (previously 20% AD ). POS 10/25: Out-of-Network Coinsurance 40% AD (previously 25% AD ) POS 20/20%: Out-of-Network Coinsurance 40% AD (previously 30% AD ) POS 500/20/20%: Out-of-Network Coinsurance 40% AD (previously 30% AD ) POS 5000/20%: Outpatient Behavioral Health $0 Copayment for first 4 visits (previously $30 Copayment) Plus 1000/20/30%: Diabetic Treatment pump infusion sets and supplies 30% AD (previously 20% AD ) Plus 1000/30/30%: Diabetic Treatment pump infusion sets and supplies 30% AD (previously 20% AD ) Plus 2000/20/30%: Diabetic Treatment pump infusion sets and supplies 30% AD (previously 20% AD ) Plus 2500/30/30%: Diabetic Treatment pump infusion sets and supplies 30% AD (previously 20% AD ) Plus 5000/20%: Outpatient Behavioral Health $0 Copayment for first 4 visits (previously $30 Copayment) Equity Plus 4000/40%: Outpatient Behavioral Health $25 AD (previously 40% AD )
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