Medical Plan (Effective ) BENEFIT IN-NETWORK (PPO) OUT-OF-NETWORK (NON-PPO)

Transcription

1 GENERAL PROVISIONS (Includes ) Deductibles (Medical and Prescription Drug) Annual Out-of-Pocket Maximum A $125 per person per calendar year deductible for medical services (maximum of 3 medical deductibles per family) AND a separate $125 per person per calendar year deductible for prescription drugs (maximum of 3 prescription drug deductibles per family). $2,500 per person per calendar year; $12,700 family aggregate. All coinsurance, deductibles and copays for in-network covered health benefits apply to the in-network out-of-pocket maximum including out-of-network emergency services for mental health, substance abuse and prescription drugs. There is no out-of-pocket maximum. Baby Yourself A benefit that offers the opportunity to have a Blue Cross & Blue Shield of Alabama registered nurse case manager to monitor a covered member s pregnancy while enrolled in this medical plan. Note: The $350 inpatient hospital copay per admission will be waived for Baby Yourself participants who enroll within the first trimester of pregnancy and continue participation until the baby is born. Individual Case Management A voluntary program to assist employees and their families in coordinating care in the event of a lengthy illness. Disease Management A voluntary program that coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease. Air Medical Services Air ambulance service to a hospital near the member s home if hospitalized while traveling more than 150 miles from home. To arrange transportation, call AirMed at PHYSICIAN SERVICES (Includes ) Office Visits & Outpatient Consultations Rendered by a Primary Care Physician (includes, Internist, Family & General Practitioner, Pediatrician, subject to the medical OB/GYN & Geriatrician, Psychiatrist, Psychologist and Master s Level Licensed Counselor) subject to the medical Office Visits & Outpatient Consultations rendered by a Specialist ER Physician Services Surgery Performed in a Physician s Office Inpatient Visits, Consultations, Surgery & Anesthesia a $40 office visit copay and the medical deductible if performed by a Primary Care Physician or a $40 office visit copay and the medical deductible if performed by a Specialist. the medical subject to the medical a $35 office visit copay and the medical services apply to the in-network out-ofpocket maximum. subject to the medical subject to the medical In and Outside Alabama: Covered at 80% of the

2 Maternity Diagnostic X-rays & Lab Exams the medical the medical However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catherizations covered at 100% of the allowance, subject to a $35 copay and the medical subject to the medical subject to the medical However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catherizations covered at 60% of the allowance, subject to a $35 copay and the medical However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catherizations covered at 80% of the allowance, subject to a $35 copay and the medical subject to the medical Nurse Practitioner/Nurse Midwife and Physician Assistant s Office Visits & Consultations a $20 office copay and the medical Services must be rendered under the supervision of a doctor. subject to the medical INPATIENT HOSPITAL FACILITY SERVICES (Includes ) Inpatient Facility Services Covered at 100% of the allowance for semi- (Including Residential private room and board, intensive care units, Treatment Facilities) general nursing services and usual hospital ancillaries, subject to a $350 per admission copay and the medical deductible (maximum of 3 inpatient per admission copays per person per calendar year); 365 days per confinement. subject to the medical In Alabama: Not covered unless in cases of medical emergency or accidental injury. allowance for semi-private room and board, intensive care units, general nursing services and usual hospital ancillaries, subject to a $350 per admission copay and the medical deductible (maximum of 3 inpatient per admission copays per person per calendar year); 365 days per confinement. Preadmission Certification Preadmission certification required for all inpatient admissions (except emergency hospital admission and maternity); notification within 48 hours for emergencies. Call for precertification. If precertification is not obtained, no benefits are available. OUTPATIENT HOSPITAL FACILITY SERVICES (Includes ) Surgery Facility $125 facility copay and the medical Diagnostic Lab, X-ray & Tests Hemodialysis, Chemo, Radiation & IV Therapy the medical However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catherizations covered at 100% of the allowance, subject to the $125 copay and the medical the medical the medical However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catherizations covered at 80% of the allowance, subject to $125 copay and the medical Covered at 80% of the allowance, subject to the medical

3 ER - Medical Emergency ER - Non-Emergency ER - Accidental Injury Intensive Outpatient Program (IOP) & Partial Hospitalization Program (PHP) Note: Preadmission Certification is required. Call Routine Preventive Services OTHER COVERED SERVICES (Includes ) Participating Chiropractor Services Nutritionist Visits $125 facility copay and the medical a $40 daily hospital copay and the medical 100% of the allowance, no deductible or copay. See AlabamaBlue.com/preventiveservices for a listing of specific covered preventive services and immunizations. In addition to the standard services, the following are also covered by this plan: One CBC and one urinalysis each year TB skin testing one each year through age 6; one between ages 7 and 18; one between ages 19 and 34 and one age 35 and older Cholesterol testing (beginning at age 19; once every 5 years) Thyroid profile (one each calendar year, beginning at age 50) Routine EKG (one each calendar year, beginning at age 50) SMA 22 lab test (or lesser automated panel test) beginning at age 19, one each calendar year Chest x-ray beginning at age 35 CA 125 blood test covered for females Routine bone density screening (one every two calendar years beginning at age 40) Pneumonia-beginning at age 65 or earlier if warranted. Malaria (when approved) Cervical cancer vaccine for females age 9 to 26 Covered at 80% of the allowance, subject to the medical deductible when services are provided by a participating in-network chiropractor. a $125 facility copay and the medical services apply to the in-network out-ofpocket maximum. $125 facility copay and the medical a $125 facility copay and the medical Covered at 80% of the allowance, subject to the medical deductible; in Alabama, not covered. Not covered. subject to the medical deductible when services are provided by an out-of-network chiropractor. Note: Limited to a maximum of 24 visits per person each calendar year. a $20 office visit copay and the medical Limited to a maximum of eight visits per person each calendar year. Note: Employee is also responsible for any charges above the allowance.

4 Routine Vision Physical Therapy Covered at 80% of the allowance subject to the medical deductible for one routine eye exam per person each calendar year. Covered at 80% of the Speech Therapy Covered at 80% of the Limited to a maximum of 20 visits per person each calendar year. Occupational Therapy Covered at 80% of the Limited to a maximum of 20 visits per person each calendar year. Durable Medical Equipment Covered at 80% of the Ambulance Services Covered at 80% of the Preferred Home Health Care Preferred Hospice Care the medical Precertification required for services rendered outside Alabama. Call the medical Precertification required for services rendered outside Alabama. Call In Alabama: No benefits are available if a nonpreferred provider is used. Precertification required. Call In Alabama: No benefits are available if a nonpreferred provider is used. Precertification required. Call

5 Pharmacy Benefits are administered by OptumRx and employees who participate in the UA Medical Plan are automatically enrolled. You will receive a separate Member ID card for pharmacy benefits. RETAIL PHARMACY Separate $125 prescription drug deductible per person per calendar year; maximum of 3 prescription drug deductibles per family. Only one prescription drug deductible will apply if an individual uses a retail pharmacy and/or the mail order program. The first prescription for a drug on the maintenance list requires a 31 day supply. Subsequent refills for 60 or 90 days can be made at a participating pharmacy. Diabetic supplies are only covered under your prescription drug program; limited to a 60 or 90 day supply at an in-network retail pharmacy or through mail order. Insulin, insulin needles & syringes purchased on the same day will require only one copay. Blood glucose strips & lancets purchased on the same day will require only one copay. Glucose monitors will always require a separate copay. IN-NETWORK (PPO) Participating Pharmacy: Prescription drugs will be covered at 100% of the allowed charge after the prescription drug deductible is met & subject to the following copays: Type of Drugs (available for maintenance & nonmaintenance drugs) day supply OUT-OF-NETWORK (NON-PPO) Non-Participating Pharmacy: Prescription drugs will be covered at 75% of the allowed charge after the prescription drug deductible is met & subject to the following copays: (available for maintenance & non- Tier 1 (Generic) $15 copay $30 copay $45 copay $15 copay $30 copay Tier 2 (Preferred Brand) $45 copay $90 copay $135 copay $45 copay $90 copay Tier 3 (Non-Preferred Brand) $55 copay $110 copay $165 copay $55 copay $110 copay Tier 3 (Non-Preferred Brand with a Generic Alternative) $65 copay $130 copay $195 copay $65 copay $130 copay Tier 4 (Specialty) $125 copay NA NA $125 copay NA Note: View more information and Drug Lists that apply to the plan at or call OptumRx at HOME DELIVERY PROGRAM Separate $125 prescription drug deductible per person per calendar year; maximum of 3 prescription drug deductibles per family. Only one prescription drug deductible will apply if an individual uses a retail pharmacy and/or the mail order program. The first prescription for a drug on the maintenance list requires a 31 day supply. Subsequent refills for 60 or 90 days can be made at a participating pharmacy. Diabetic supplies are only covered under your prescription drug program; limited to a 60 or 90 day supply at an in-network retail pharmacy or through mail order. Insulin, insulin needles & syringes purchased on the same day will require only one copay. Blood glucose strips & lancets purchased on the same day will require only one copay. Glucose monitors will always require a separate copay. Provided through OptumRx. Enroll online at optumrx.com/mycatamaranrx or call Mail Order Program: Prescription drugs will be covered at 100% of the allowed charge after the deductible & subject to the following copays: Type of Drugs (available for maintenance & non day supply Tier 1 (Generic) $10 copay $20 copay $30 copay Tier 2 (Preferred Brand) $35 copay $70 copay $105 copay Tier 3 (Non-Preferred Brand) $40 copay $80 copay $120 copay Tier 3 (Non-Preferred Brand with a Generic Alternative) $55 copay $110 copay $165 copay This is not a contract, benefit booklet or Summary Plan Description. Benefits are subject to the terms, limitations & conditions of the group contract. Check your benefit booklet for more detailed information. Group #79912 Revised