UNIVERSITY HOSPITALS SCHEDULE OF MEDICAL AND PRESCRIPTION DRUG BENEFITS

Transcription

1 Plan Limits 1 Calendar Year Deductible (Does not include copayments) Coinsurance (Paid by Plan) (Amount Plan pays after deductible is met, unless otherwise specified) Calendar Year Maximum Out-of-Pocket Limit 2 Maximum Age for Eligible Children Common Medical Events Physician Services Office Visit: Primary Care (Covers office charge only. Includes OB/GYN & Pediatrics) Office Visit: Specialist (Covers office charge only) Allergy Treatment, Injections, and Extracts Office Surgery Additional Services Performed During Office Visit Physician Inpatient Services Physician Outpatient Services Anesthesiologist Diagnostic Testing (Stress test, sleep study, EKG, etc.) Laboratory and Pathology (Freestanding Facility or Physician Office) Radiology (X-rays, MRI, CT Scan, etc. - Freestanding Facility or Physician Office) Preventive Care/Wellness Services Annual Physical Exam Annual Well Woman Visit (1 per year, including Annual Pap) Breastfeeding Support and Supplies (One rental or purchase of a breast pump per pregnancy) Bone Density Screening (Ages 60+ for screening/at risk no age limit) (1 every 2 years) $650 $1,300 85% $2,250 $4,500 Eligible children are covered until the end of the month the child reaches the age of % after $25 copayment, per visit 100% after $50 copayment, per visit 1 There is no out-of-network coverage except for Urgent Care (outside of the UH Quality Care Network service area) and Emergency Care services. Emergency services and urgent care services received at an out-of-network provider will be paid at the same level of benefits as services provided by UH Quality Care Network providers. 2 Calendar Year Maximum Out-of-Pocket limit includes deductible, coinsurance and co-payments. Does not include prescription drug copayments, coinsurance and, prescription drug maximum out-of-pocket limit, amounts over Reasonable and Customary Charges, and non-covered services.

2 Common Medical Events Preventive Care/Wellness Services, cont. Contraceptives (Women) HPV Test for Females (Ages 30+) (1 every 3 years) Preventive Counseling for Alcohol or Substance Abuse, Tobacco Use & Diet Related Chronic Diseases (Based on recommended frequency and age) Preventive/Routine Screening Services (Based on recommended frequency, age and gender) Prostate Cancer Screening/PSA Test Recommended Immunizations (CDC/ACIP Age Schedule) Recommended Well Baby/ Well Child Care Routine Eye Exams Screening for Colorectal Cancer Colonoscopy (45+) 1 every 5 years; Sigmoidoscopy 1 every 5 years; Annual Fecal Occult blood testing; & related surgeon, facility & anesthesia charges. Does not include pathology or prior related office visit charges, which are payable under Major Medical. Screening Hearing Exams (Newborns and ages 4-18 annually; ages every two years) Screening Mammography Enhanced Preventive Care Diabetes Management Primary Care Visits (4 annually; 1 per quarter) Endocrinologist visit (annual) Microalbumin Test (no test limit) HbA1c Test (no test limit) Lipid Panel (no panel limit) Insulin Facility Services Inpatient Semi-Private Room & Board (Includes ICU & ancillary charges - Inpatient Private Room & Board paid at hospital's average semi-private room rate) Birthing Center Diagnostic Testing (Stress test, sleep study, EKG, etc.) Skilled Nursing Facility (Limited to 90 days per calendar year) Inpatient Rehabilitation (Limited to 60 days per calendar year) Outpatient Ambulatory Surgery Center Covered under prescription drug benefit

3 Common Medical Events Facility Services, cont. Outpatient Hospital Surgery Outpatient Laboratory & Pathology Outpatient Radiology (X-rays, MRI, CT Scan, etc.) Outpatient Observation Emergency Services Emergency Department Facility UNIVERSITY HOSPITALS Emergency Department Physicians Emergency Air & Ground Ambulance Transport (For emergent medical transport and Medically Necessary non-emergent transport) Urgent Care Behavioral Health Services (Mental Health & Substance Abuse) Inpatient Behavioral Health Room & Board (Includes ICU & ancillary charges - Inpatient Private Room & Board paid at hospital's average semi-private room rate) Partial Hospitalization, Intensive Outpatient and Ambulatory Detoxification Outpatient Behavioral Health Services Residential Hearing Aid Services Hearing Aid Evaluation Hearing Aid Test Hearing Aid (Limited to one per year every four calendar years) Cochlear Implants Other Services Acupuncture (Limited to chronic pain management, select pregnancy and cancer treatment side effects.) (Available at Connor Integrative only) Bariatric Surgery Chemotherapy Chiropractic Office Visit (20 visit maximum per calendar year) Chiropractic Other services performed during office visit Dialysis Durable Medical Equipment (Including Orthotic Appliances & Prosthetics) Home Health Care (Limited to 50 visits per calendar year, includes RN, physical therapy, occupational therapy, and speech therapy) Hospice Services Infertility Diagnosis 100% after $250 copayment Copayment will be waived if admitted/observation 100% after $40 copayment 100% after $25 copayment 100% after $50 copayment, per visit 100% after $25 copayment, per test Individual: $20 copayment per employee, per visit. Group: $10 copayment per employee, per visit. 100% after $50 copayment, per visit 100%, no deductible

4 Common Medical Events Other Services, cont. Infertility Treatment (Limited to a lifetime maximum of $10,000. Limited to MacDonald and IVF Program) Mastectomy Supplies (Includes 2 bras post mastectomy) Organ Transplants Physical Therapy and Occupational Therapy (30 visit combined maximum per calendar year; additional visits will require preauthorization) Pulmonary Rehabilitation & Cardiac Rehabilitation Radiation Therapy Speech Therapy (30 visit maximum per calendar year; additional visits will require preauthorization) Telehealth (In-Network Telehealth and UH Virtual Visit only) Covered Wigs & Hair Pieces (1 per calendar year, per treatment, during or after chemo and radiation therapy, up to a maximum of $175) All Other Covered Expenses 50% after deductible 100% after $25 copayment, per visit 100% after $25 copayment, per visit 100% after $25 copayment

5 Prescription Drugs Calendar Year Deductible Calendar Year Maximum Outof-Pocket Limit 3 (Includes prescription drug copays and coinsurance) UNIVERSITY HOSPITALS None None $2,500 $5,000 Generic Drugs Formulary Brand Non-Formulary Brand Name Drugs Name Drugs Network Retail (CVS Caremark) (30 day supply per prescription) $15 copayment* 30% coinsurance $30 minimum* $75 maximum 50% coinsurance $70 minimum* $200 maximum Network Retail (CVS Caremark) Network Mail Order (90 day supply per prescription) $30 copayment* 20% coinsurance $60 minimum* $150 maximum 50% coinsurance $150 minimum* $400 maximum Non-Network Retail Not Covered Not Covered Not Covered Insulin (CVS Caremark) $0 copayment Limitations Smoking Cessation Drugs Immunizations Infertility Drugs Diabetic Supplies (300 meter strips per Covered Member per month; additional meter strips covered as needed with prior authorization) Contraceptives Generic Drug Program Prior Authorization Covered 100% for approved dosage levels for tobacco cessation treatment for the following: Bupropion (HCL Tab SR 12HR 150 MG), Chantix, generic nicotine patches, gum, or lozenges. Covered at 100%. Shingles for Covered Members 50 years of age and older; flu and pneumonia immunization only when administered by a pharmacist. Covered at 50% up to a lifetime maximum benefit of $5,000. This coinsurance does count toward the annual maximum out-of-pocket limit. Meter strips, lancets, syringes, urine test strips and one blood glucose meter per year will be covered at one Generic copayment per Prescription. Contraceptive injectables, oral form, and patch form are covered. Contraceptive implants and devices are covered under the medical benefit. Generic Drugs will be dispensed whenever permitted by state and federal law. If the Covered Member requests a Brand Name Drug when a Generic equivalent is available, the member will be charged the generic copayment plus the difference in cost between the Brand Name Drug and the Generic Drug. See Step Therapy for information about using a generic drug first before certain brand drugs. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled. Prior authorization must be obtained by the Covered Member s physician in order for the member to receive benefit for these drugs. Drug classes with Prior Authorization may include but may not be limited to: ADHD (>19y/o), Narcolepsy, Anabolic Steroids, Pain (Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys), Testosterone Products, Acne (>35 y/o). 3 The Prescription Drug Maximum Out-of-Pocket Limit is separate from the Medical plan Maximum Out-of-Pocket Limit.

6 Limitations, cont. Quantity Limits Step Therapy Certain prescription drugs have specific quantity limits per prescription per month. Drug classes with a quantity limit include but may not be limited to: Antiemetic (nausea), Antimigraine Influenza (Tamiflu, Relenza). Certain prescriptions drugs require Step Therapy, which is a process where a Covered Member may be required to first try an alternative therapy before receiving the requested medication. The Covered Member must first try generic drugs, if available, before using certain brand drugs. Coverage Exceptions Specialty Preferred Drug Therapy Specialty Formulary Drug classes with Step Therapy include: Solodyn Drug classes with Generic Step Therapy include but may not be limited to: ARB/Combos (blood pressure), bisphosphonates, HMGs (cholesterol), Sleep agents, PPIs (acid reflux), NSAIDs, Nasal Steroids, SSRIs/SNRIs, (depression/pain), Triptans (migraine), Urinary Antispasmodics (overactive bladder), Fibrates (cholesterol), BPH (enlarged prostate), Prostaglandin Analogs (glaucoma), Acne, Asthma/COPD For certain medications will be covered at 100% by the Plan per provisions related to the Affordable Care Act (ACA). Under the ACA, a Covered Member can receive preventive services or a contraceptive products for a $0 copayment. Medications covered include preventive services medications (Aspirin, Folic Acid, Fluoride, Smoking Cessation Drugs, etc.) and contraceptive agents. In select categories of specialty medications (infertility, TNG inhibitors and growth hormones), a Covered Member must try a preferred product before having access to a non-preferred product. The Covered Member s physician can contact CVS Caremark for coverage of a non-preferred product should clinical evidence suggest that drug is medically necessary. Specialty drugs can be expensive and Covered Members can control their costs for certain specialty drugs by accessing drugs on the preferred formulary drug list. A listing of preferred drugs can be accessed on the CVS Caremark website * If the full cost of the drug is less than the minimum, the copayment will be the full cost of the drug.