Archdiocese of Philadelphia. Benefits Program

Transcription

1 Archdiocese of Philadelphia Benefits Program For Priests As of July 2018

2 Table of Contents About Your Benefits 1 If You Are Retired Or Disabled. 1. Keystone Health Plan East HMO 2 Choosing Your PCP. 2 Covered Services. 2 In An Emergency. 2 Away From Home Care Program. 3 Pre-Certification Requirements 3 Prescription Drug Benefits. 3.. Personal Choice PPOs 4 Follow These Tips For Maximum Benefits 4 A Step-By-Step Guide To Personal Choice. 5 Personal Choice Covers Medically Necessary Care. 6 Finding In-Network Providers. 6 Benefits For In-Network Care 6 Benefits For Out-of-Network Care. 7 In An Emergency. 8. Summary Of Medical Plans 10 How Using In-Network Providers Can Save You Money. 12 Telemedicine Opion (MDLIVE). 12 Pre-Certification Requirements 13 Filing Medical Claims. 14 Special Situations. 15 Prescription Drug Benefits 16 Consider Mail-Order For Your Maintenance Medications Dental Benefits 18 Vision Benefits 19 Hearing Care Discount 20 Important 20

3 About Your Benefits This brochure describes the health care benefits provided to priests of the Archdiocese of Philadelphia. These benefits include: Medical You have a choice among three medical plans. The Keystone Health Plan East HMO (Core) is available to you at no cost. However, you have the option to buy-up and enroll in the Personal Choice PPO Base Plan or the Personal Choice PPO Plus Plan. Each Medical Plan includes prescription drug coverage. If You Are Retired Or Disabled If you are eligible for Medicare, you are covered by a Medicare Supplement Plan. This Plan reimburses all or part of eligible medical expenses that are not covered by Medicare. If you are retired or disabled and NOT eligible for Medicare, you are covered by one of the Medical Plans. Dental The Dental Plan pays all or part of your costs for dental services. When you use dentists who have a fee agreement with United Concordia, you save money because your share of the cost is based on the negotiated rate. Vision The Vision Plan covers periodic eye exams and pays a portion of the cost for eyeglasses or contact lenses. As with the Dental Plan, you will save money if you use participating providers. 1

4 Keystone Health Plan East HMO (Core) The Keystone Health Plan East HMO (Core) is available to you at no cost. This plan offers a wide range of prepaid services that are coordinated through a specific doctor or group of doctors, hospitals, and medical facilities that have an agreement with the HMO. All referrals will be to providers affiliated with the HMO. All providers are chosen carefully and periodically reviewed to ensure that you receive quality care. The Keystone Health Plan East HMO provides quality health care with minimal out-ofpocket costs. To receive benefits, you must see your primary care physician (PCP) for all services or referrals. A referral is not required in certain emergency situations. If you seek services on your own, without receiving a referral from your PCP, the cost of services will not be covered by the Plan (except for true emergency care). Choosing Your PCP When you join the Keystone Health Plan East HMO, you must choose a primary care physician (PCP) to provide or coordinate all of your health care. You may change your PCP simply by calling Member Services. Covered Services When your PCP provides or refers your care, most services are covered in full after a flat copayment amount. See the side-by-side comparison chart on pages 10 and 11 for details. Additional information about the Keystone Health Plan East HMO is available by calling Member Services or on their website at In An Emergency A prudent person definition is used to determine medical emergencies that is, situations when a reasonable person would seek immediate treatment. Some examples of medical emergencies are: apparent heart attack, severe bleeding, loss of consciousness, and severe or multiple injuries. Whenever possible, call your PCP before you receive any care. If your PCP pre-authorizes an emergency room visit, you are guaranteed the Plan benefits. However, a serious accident or sudden acute illness may require emergency care from the nearest available source before you can contact your PCP. Use of emergency facilities is covered for all medical emergencies in or out of the network. 2

5 To receive benefits, you must report the services to your PCP within 24 hours of the time emergency services are received. Unless the situation requires immediate attention, you may be able to avoid the emergency room by calling your PCP. Each PCP, or the physician covering for your PCP, can be reached 24 hours a day. Of course, in an emergency, get the treatment you need at the nearest facility and then call your PCP. Away From Home Care Program If you will be out of the area for at least 90 days, you can apply for a guest membership in a participating plan in your travel area through the Away From Home Care Program. For details, call Keystone Member Services at the number shown on your ID card. Pre-Certification Requirements Your PCP or the hospital generally will handle any pre-certification for you. If you are out of the service area and need urgent care, be sure to contact Member Services or your PCP. Read your HMO member handbook for details. Prescription Drug Benefits When you elect Medical coverage, you automatically receive prescription drug coverage. See page 16 for details. 3

6 Personal Choice PPOs You have the option to buy-up and enroll in the Personal Choice PPO Base plan or the Personal Choice PPO Plus plan. The Personal Choice plans are preferred provider organizations or PPO plans, which simply means that there are two levels of benefits, based on whether you use certain preferred providers carefully chosen by Independence Blue Cross. You have the freedom to use the doctors and hospitals of your choice, but your benefits are greater when you choose providers in the network. When you receive care from out-of-network providers, you are responsible for your share of the cost, plus any amount above the Plan allowance. With the Personal Choice plans, you do not need to choose a primary care physician, and you do not need any referrals. A higher level of benefits is paid whenever you use in-network providers. The Personal Choice network includes more than 55,000 doctors and specialists, as well as the region s premier medical facilities. And, because the PPO plans are provided through Independence Blue Cross, you have access to the BlueCard PPO, the nationwide network of Blue Cross and Blue Shield PPO providers and facilities across the United States. So, you may receive the higher benefit level at home and when you travel. Benefits for prescription drugs are provided through Independence Blue Cross (IBC)/ FutureScripts. You have the freedom to use the doctors and hospitals of your choice. When you use network providers, the Plan pays a larger share of your expenses. Follow These Tips For Maximum Benefits To receive the highest benefits from the PPO plans, follow these simple rules: Choose In-Network Providers Make sure you use providers who are in the Personal Choice Network or who participate in the BlueCard PPO program (see Finding In-Network Providers ). Show Your ID Card Your identification card shows a PPO in a suitcase logo that is recognized by participating Blue Cross/Blue Shield PPO doctors across the country, assuring you in-network benefits. Get Authorization When Necessary Certain care, such as hospital admissions, must be precertified (see pages 10 11). 4 Use The FutureScripts Mail-Order Service When you use the mail-order service to fill prescriptions for ongoing or chronic conditions, you may save money (see page 17).

7 When In Doubt If you are not positive that your treatment will be paid at the in-network level, don t hesitate to ask your provider or call Member Services. Personal Choice Member Services representatives can provide information and other services you may need to make the most of your benefits. The Member Services number, shown on your Personal Choice ID card, is The chart on pages 10 and 11 shows how the medical plans cover typical medical services. A Step-By-Step Guide To Personal Choice You decide whether to use in-network or out-of-network providers each time you need care. Step 1 In-Network Or Out-of-Network? Each time you need medical care, you choose... In-Network In-Network means you use doctors and hospitals that participate in the Personal Choice network (or the BlueCard PPO program). Out-of-Network Out-of-Network means you use doctors and hospitals that DO NOT participate in the Personal Choice network (or the BlueCard PPO program). Step 2 Receiving Benefits Low out-of-pocket costs There s no deductible; you pay a copay for office and specialist visits. Doctor takes care of pre-certification for you (if you are out of the Personal Choice area, you must call for precertification of hospital stays and certain other services). No (or few) claim forms. Higher out-of-pocket costs You pay a deductible and a percentage of the Plan allowance (20% or 30%), plus you may be billed for amounts above the Plan allowance. You must call for pre-certification of hospital stays and certain other services. Claim forms required. 5

8 Personal Choice Covers Medically Necessary Care Personal Choice covers most medical services and supplies. However, some services, such as experimental care or hearing aids, are not covered. To be covered by Personal Choice, the expense must be incurred while you are covered under Personal Choice, and the services or supplies must be medically necessary and appropriate. Medically necessary means that any confinement, operation, treatment, or service is ordered by a doctor for the diagnosis or treatment of an illness or injury, and is consistent with currently accepted medical practices and considered a valid course of treatment. Independence Blue Cross medical professionals determine if services are medically necessary. Finding In-Network Providers To find a provider in the area covered by the Personal Choice network, go to the Independence Blue Cross website at or call ASK-BLUE ( ). The customer service representatives can give you information about specific providers, or they can connect you to Member Services for a Provider Directory. Nationwide, more than 750,000 doctors and 5,500 hospitals participate in the BlueCard PPO program so you should be able to receive in-network benefits when you are traveling. If you are outside the Personal Choice network service area, call BlueCard Access at BLUE ( ), and you will be given information about BlueCard PPO providers in any state. Benefits For In-Network Care Most in-network care is covered at 100%. You pay a copay for some services, such as office visits with your primary care physician (PCP). A copay also applies to other services, such as specialist visits, physical therapy, or respiratory therapy. If you are away from home, call BLUE for information about the nearest participating BlueCard PPO doctors and hospitals (remember to call for pre-certification, if necessary). Show your ID card when you visit the doctor or hospital, and the provider will verify your membership and coverage information. After you receive medical attention, your claim is electronically routed to Personal Choice for processing. You will not need to file a claim, but you will be required to pay your usual share of the expense (copayment or deductible). The chart beginning on page 10 shows the Plan s benefits for typical medical services. 6

9 Benefits For Out-of-Network Care Once you meet your calendar-year deductible, the PPO plans cover 70% or 80% of the Plan allowance for most eligible expenses, and you pay the remaining 20% or 30%. The share you pay is called your coinsurance. There are two types of out-of-network providers participating and non-participating: Participating Providers have a written agreement with Pennsylvania Blue Shield to accept the usual, customary, and reasonable (UCR) amount as payment in full. If you use a participating provider, you are responsible for your coinsurance. Non-Participating Providers do not have an agreement with Pennsylvania Blue Shield or any other Blue Cross and/or Blue Shield Plan. The Plan s payments to non-participating providers are based on the Personal Choice Plan allowance. You are responsible for your coinsurance plus the difference between the provider s charge and the Personal Choice allowance. The BlueCard PPO program gives you access to network providers throughout the country. Deductible Each year, before Personal Choice pays benefits for any out-of-network care, you must pay a portion of your covered expenses. This amount is called your deductible. If you meet part or all of the deductible during the last three months of any calendar year, that amount will carry over toward the deductible for the next calendar year. For example, assume that you incur $50 in eligible medical expenses in November and that amount is used toward the deductible for that year. That $50 will be used toward your deductible for the next year as well. Out-of-Pocket Limit Protects You If your share of out-of-network expenses reaches a certain amount each year, called the maximum out-of-pocket limit, the Plan will pay 100% of your eligible medical expenses for the rest of that year. The following amounts are not counted toward the out-of-pocket limit: Prescription drug expenses; Charges that exceed the Plan allowance for eligible expenses; or Any charges you incur because you do not call for pre-certification (see pages 10 11). 7

10 In An Emergency A medical emergency is generally defined as a sickness or injury of such a nature that failure to get immediate treatment could put a person s life in danger or cause serious harm to bodily functions. Some examples of medical emergencies include apparent heart attack, severe bleeding, loss of consciousness, and severe or multiple injuries. If you need immediate emergency medical care, get the care you need right away. Personal Choice will always pay 100% for a true emergency. There is a copayment for treatment in a hospital. Call For Certification If you are admitted to the hospital in the Personal Choice network, the hospital staff will call for you. If you are admitted to a hospital as the result of a medical emergency, you must notify Personal Choice if: You are outside of the Personal Choice network area, or You use out-of-network providers (in or out of the Personal Choice area). To avoid a penalty, you must call within two business days of the admission (see Pre-Certification Requirements beginning on page 12). Personal Choice pays 100% for necessary emergency care after a copay. 8

11 Changing Your Doctor If your doctor does not participate in Personal Choice, you may want to switch to a Personal Choice network physician to avoid substantial out-of-pocket expenses. If you decide to change your doctor, here are a few questions to ask the doctor (or office administrator): What is your style of working with patients? Will you participate fully in my treatment? Will you clearly explain my condition, options, risks? Tell me honestly the chances of success and probability of pain? How long will I have to wait for an appointment for sick care? For well care? What are your office hours? Weekend hours? Whom do I call in an emergency, and who provides back-up coverage? Are you available for non-emergency telephone consultations? Will you help me obtain medical or hospital records and send me the test results? 9

12 Summary of Medical Plans Using Doctors/ Hospitals Keystone Health Plan East HMO (Core) Benefits paid only if you use HMO providers Personal Choice PPO Base Personal Choice PPO Plus In-Network Out-of-Network In-Network Out-of-Network Higher-level benefits Lower-level benefits Higher-level benefits Lower-level benefits Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Calendar-Year Deductible Calendar-Year Out-of-Pocket Maximum* None None $500 per person None $250 per person $1,500 per person $1,500 per person $3,000 per person $1,000 per person $2,000 per person Inpatient Hospital Care** 100% after $100 copay per day; 5-copay maximum per admission*** 100% after $150 copay per day; 5-copay maximum per admission*** 70% after deductible up to 70 days 1 100% 80% after deductible up to 70 days 1 Outpatient Surgery** 100% after $50 copay 100% after $75 copay 70% after deductible 100% 80% after deductible Emergency Room 100% after $100 (copay not waived if admitted) 100% after $100 copay (copay not waived if admitted) 100% after $100 copay (copay not waived if admitted) 100% after $50 copay (copay waived if admitted) 100% after $50 copay (copay waived if admitted) Doctor s Office Visits 100% after $10 copay for PCP; $20 copay for specialist 100% after $15 copay for primary care services; $30 copay for specialist 70% after deductible 100% after $15 copay for primary care services; $15 copay for specialist 80% after deductible Routine Preventive Care Telemedicine (MDLIVE) Outpatient Laboratory/ Pathology 100% 100% 70%, no deductible 100% 80%, no deductible 100% per call 100% per call N/A 100% per call N/A 100% 100% 70% after deductible 100% 80% after deductible Outpatient X-ray/ Radiology** (includes MRI/MRA, CT/CTA, PET scans) 100% after $20 copay for routine/diagnostic; $40 copay for MRI/MRA, CT/ CTA scan, or PET scan 100% after $30 copay for routine/ diagnostic; $60 copay for MRI/ MRA, CT/ CTA scan, or PET scan 70% after deductible 100% 80% after deductible Home Health Care** 100% 100% 70% after deductible 100% 80% after deductible Outpatient Private Duty Nursing** 90%, up to 360 hours per calendar year 85% up to 360 hours per year 70% after deductible, up to 360 hours per year 100% 80% after deductible *Includes medical copays, deductibles, and coinsurance. ** Pre-certification may be required; failure to pre-certify may result in a significant reduction in benefits and/or penalties may apply (Personal Choice Members: If you receive care outside the network service area, you must call for pre-certification, even if you use a BlueCard provider). Combined in-network/out-of-network. ***Copay waived if you are readmitted within 10 days of discharge. 1 Inpatient hospital day limit combined for all out-of-network inpatient medical, mental health, serious mental illness, substance abuse and detoxification services. Note: This summary provides a brief overview of each Plan s benefits. See the carrier booklets for details and exclusions. 10

13 Keystone Health Plan East HMO (Core) Personal Choice PPO Base Personal Choice PPO Plus In-Network Out-of-Network In-Network Out-of-Network Skilled Nursing Facility Care** 100% after $50 copay per day, 5-copay maximum per admission***; up to 120 days per year 100% after $75 copay per day, 5-copay maximum per admission***; up to 120 days per year 70% after deductible, up to 120 days per year 100% 80% after deductible Outpatient Physical, Occupational, or Speech Therapy 100% after $20 copay per visit; visit limits vary based on type of therapy service 1 100% after $30 copay per visit; visit limits vary based on type of therapy service 1 70% after deductible, visit limits vary based on type of therapy service 100% after $15 copay per visit; visit limits vary based on type of therapy service 80% after deductible; visit limits vary based on type of therapy service Cardiac Rehabilitation Therapy 100% after $20 copay, up to 36 visits per year 100% after $30 copay, up to 36 visits per year 70% after deductible, up to 36 visits per year 100% after $15 copay, up to 36 visits per year 80% after deductible, up to 36 visits per year Durable Medical and Prosthetics** 70% 50% 50% after deductible 100% 80% after deductible Spinal Manipulation 100% after $20 copay, up to 20 visits per year 100% after $30 copay, up to 20 visits per year 70% after deductible, up to 20 visits per year 100% after $15 copay 80% after deductible Mental Health Care** (Different outpatient benefit limits may apply for Serious Mental Illness and HMO benefits may vary by state) Inpatient: 100% after $100 copay per day (5-copay maximum per admission***) 1 Outpatient: 100% after $20 copay Inpatient: 100% after $150 copay per day (5-copay maximum per admission***) 1 Outpatient: 100% after $30 copay Inpatient: 70% after deductible 1 Outpatient: 70% after deductible Inpatient: 100% Outpatient: 100% after $15 copay Inpatient: 80% after deductible, up to 70 days 1 Outpatient: 80% after deductible Substance Abuse Care** (HMO benefits may vary by state) Inpatient: 100% after $100 copay per day (5-copay maximum per admission***) 1 Outpatient: 100% after $20 copay Inpatient: 100% after $150 copay per day (5-copay maximum per admission***) 1 Outpatient: 100% after $30 copay Inpatient: 70% after deductible 1 Outpatient: 70% after deductible Inpatient: 100% Outpatient: 100% after $15 copay Inpatient: 80% after deductible, up to 70 days 1 Outpatient: 80% after deductible Prescription Drugs See chart on page 17. See chart on page 17. See chart on page 17. See chart on page 17. See chart on page 17. For More Information ASK-BLUE ( ) or ASK-BLUE ( ) or ASK-BLUE ( ) or *Includes medical copays, deductibles, and coinsurance. ** Pre-certification may be required; failure to pre-certify may result in a significant reduction in benefits and/or penalties may apply (Personal Choice Members: If you receive care outside the network service area, you must call for pre-certification, even if you use a BlueCard provider). Combined in-network/out-of-network. ***Copay waived if you are readmitted within 10 days of discharge. 1 Inpatient hospital day limit combined for all out-of-network inpatient medical, mental health, serious mental illness, substance abuse and detoxification services. Note: This summary provides a brief overview of each Plan s benefits. See the carrier booklets for details and exclusions. 11

14 How Using In-Network Providers Can Save You Money When you use Personal Choice Network providers, you don t pay a deductible, and Personal Choice pays a larger share of your expenses. This example shows the potential out-of-pocket difference for someone enrolled in Personal Choice PPO Plus plan. Note: Some services may need to be approved in advance (see Pre-certification Requirements). In-Network Out-of-Network Deductible None $250 You will meet the deductible when you pay the first $250 of your eligible expenses each year. Routine Preventive Care You pay $0 You pay the full cost for each visit until you meet your deductible. Once you meet your deductible, you would pay 20% of the Plan allowance. For example, if the Plan allowance is $45 per visit, you would pay $9.* Doctor s Office Visit You pay $15 per PCP visit, $15 per Specialist visit You pay the full cost for each visit until you meet your deductible. Once you meet your deductible, you would pay 20% of the Plan allowance. For example, if the Plan allowance is $45 per visit, you would pay $9.* Hospital Admission You pay $0 You pay 20% of the Plan allowance, until you reach the out-of-pocket limit of $2,000 a year.* Example 5 Office Visits: $250 You pay $75 ($15 times 5 visits) You pay $250 (deductible) Hospital Stay: $10,000 You pay $0 You pay $2,000 (20% coinsurance, up to the $2,000 out-of-pocket maximum)* Total: $10,250 You pay $75 You pay $2,250 Difference You pay $2,175 more if you use out-of-network providers. *Important For out-of-network care, you may be billed for the difference between the Plan allowance and the provider s actual charge. This amount would be in addition to your 20% coinsurance. Telemedicine Option (MDLIVE) When it s not possible to visit your doctor s office, retail clinic, or urgent care center, you have the option to consult a physician via secure video on your smartphone or other device. These physicians can diagnose medical conditions, provide short-term treatment plans, and prescribe necessary medications for non-emergency medical conditions, such as allergies, asthma, cold/flu, ear infections, nausea, respiratory infections, or sinus problems. If you are enrolled for medical coverage, you pay nothing for each call. How to Activate your MDLIVE Account Save time by activating your account today, so you will be ready to speak with a doctor when you need one. Go to mdlive.com/ibx and click Activate Now. Enter the information requested. Note: Include the three letters before your member ID (e.g. ABC ). When the Sign-Up Completed page appears, click Access your account. MDLIVE will send a welcome . Verify your address by clicking Verify . IBC offers the telemedicine service through MDLIVE, a national vendor that connects you to licensed and board certified PCPs via a HIPAA-secure video, telephone, or mobile app. You can find more information online at mdlive.com/ibx or by calling Member Services at ASK.BLUE ( ). 12

15 Pre-Certification Requirements The pre-certification review program is designed to ensure that all the services you receive are medically necessary, appropriate, and cost-effective. When you use providers in the Personal Choice network, your doctor or the hospital will handle the pre-certification process for you. If you are outside of the Personal Choice network service area, YOU must call for pre-certification even if you use a provider or facility that participates in the BlueCard PPO program. You or your doctor must call Personal Choice for pre-certification in order to receive full benefits for the following services: ALL non-emergency hospital admissions; Ambulance services for non-emergency use; MRI, CT scan, or PET scan; Durable medical equipment (all rentals and all purchases of $500 or more must be pre-certified); Home Health Care; Hospice care (inpatient only); Mental health or substance abuse treatment (inpatient/partial hospitalization programs/ intensive outpatient programs); Outpatient private duty nursing services; Prosthetics; Skilled Nursing Facility; Surgery including these outpatient surgical and diagnostic procedures: Bunionectomy; Cataract surgery;* Laparoscopic cholecystectomy; Hemorrhoidectomy; Knee surgery/diagnostic arthoscopy; Ligation and stripping of varicose veins; Obesity surgery; Submucous resection (nasal surgery); or Tonsillectomy and/or adenoidectomy; Infusion therapy; Transplants. * Note: Pre-certification is not required for these services if you use a BlueCard PPO provider. Call ASK-BLUE ( ) to pre-certify the services shown on this page. If you use Personal Choice network providers, the provider will call for you. You must call if you use BlueCard PPO or out-of-network providers. 13

16 Call For Maximum Benefits The pre-certification procedures are mandatory for all admissions outside the Personal Choice network service area and for the services listed on the previous page. If you use providers who are not in the Personal Choice network (even providers through the BlueCard Access program), or if you use out-of-network providers, you must call for pre-certification. If you don t make the required call, Plan benefits will be reduced or not paid at all. Call ASK-BLUE ( ) for pre-certification of care received from providers/facilities who do not participate in the Personal Choice network. If you do not call when required: Benefits for eligible inpatient charges will be reduced by $1,000; and Benefits for other outpatient services will be reduced by 20%. How Pre-Certification Works The pre-certification staff includes nurses, doctors, and other medical professionals who compare the information about your condition with nationally accepted medical standards. The Personal Choice representative will also talk with your doctor, hospital, or other service provider. During a hospital stay, a Patient Care Management nurse will stay in touch with you and your doctor. If your hospital stay needs to be extended, the representative and your doctor will discuss the length of the stay and more days may be approved. If long-term care is required, the representative will continue to monitor your treatment and may suggest alternatives, such as Home Health Care. Pre-certification is not a determination of eligibility nor a guarantee of benefits. Filing Medical Claims When you use Personal Choice Network or participating BlueCard PPO doctors and hospitals, you usually do not have to file a claim. When you use doctors or hospitals who are not in the Personal Choice Network or the BlueCard PPO program, you may have to pay the full charges and then file a claim for reimbursement. Claim forms, available from Member Services, or from the Archdiocesan Human Resources Office, contain step-by-step instructions. You must submit all claim forms within 12 months after you receive services or supplies. Claims submitted after 12 months will not be considered for payment. If you would like another opinion about whether a recommended surgery is necessary, they will help you obtain a second surgical opinion. If a hospital stay is necessary, Personal Choice Patient Care Management will approve a length of stay that is covered by the Plan. 14

17 When you submit a claim, be sure to include an itemized bill the original, not a copy and proof of payment (if you have already paid for the services). The itemized bill must show: The name and address of the service provider (such as the doctor or hospital); Your full name; The date of the services; A description of the services performed on each date; The amount charged for each service or item; The diagnosis or nature of the illness or injury; and The doctor s certification for durable medical equipment, the nurse s license number and hours worked for private duty nursing services, or the total mileage (round trip) for ambulance services. Make sure you complete the full claim form and that you sign and date it (keep a copy of the form and the itemized bill for your records). Mail the form to the address on the claim form. After the claim is processed, you will receive an Explanation of Benefits (EOB) form that will tell you: The actual charges and the allowance for that service; The total benefits payable; and The deductible and coinsurance amount you owe (if any). If you are eligible for Medicare, your medical plan will provide your primary coverage while you are working. That means your medical plan pays benefits before Medicare. Expenses not covered by your medical plan may be submitted to Medicare. Since you are eligible for Medicare, some providers may assume that claims should automatically be submitted to Medicare. You may need to remind them to submit claims to your medical plan first. When you actually retire, Medicare and the Medicare Supplement Plan will provide your coverage. Medicare will become primary and pay benefits before the Medicare Supplement Plan. If you chose to opt out of Social Security and Medicare, your medical coverage will be provided through your medical plan while you are actively working and after you retire. Note that a penalty may apply if you choose to join Social Security and/or Medicare at a later date. If You Are Retired Or Disabled Your medical coverage depends on whether or not you are eligible for Medicare: If you are eligible for Medicare, you are covered by a Medicare Supplement Plan. This Plan reimburses all or part of eligible medical expenses that are not covered by Medicare. If you are retired or disabled and NOT eligible for Medicare, you are covered by your Archdiocese of Philadelphia medical plan. Special Situations If You Are Between Age 65 And Age 75 And Not Yet Retired If you are between age 65 and age 75 and you are not retired, you may be eligible for Medicare. Special provisions may apply when you reach age 65 or retire, or if you become disabled. 15

18 Prescription Drug Benefits Prescription drug coverage is included in medical coverage. If you are enrolled in Personal Choice PPO Plus, your copays are based on whether your prescription is a generic or brand-name drug. The HMO and Personal Choice PPO Base medical plans use a preferred drug list (called a formulary). The Plan s benefits and your copays vary based on three categories of drugs: generic drugs on the preferred drug list, brand-name drugs on the preferred drug list, and brand-name drugs not on the preferred drug list. Generic drugs are chemically equal to the brandname version and are equal in their effectiveness. Brand-name drugs on the preferred drug list are selected for their safety, effectiveness, and affordability. If you are enrolled in the HMO or Personal Choice PPO Base, you may still receive brand-name drugs that are not on the preferred drug list, but you will pay the highest copay. Brand-Name or Generic? A generic drug is essentially a copy of a brand-name drug. The only significant difference between brand-name drugs and generic drugs is price. Generic drugs can cost up to 90% less than the brand-name versions. 16

19 Consider Mail-Order For Your Maintenance Medications If you use the mail-order program through FutureScripts, you will save time because the medicine is delivered to your door. You will also save money because you can receive up to a 90-day supply for less than three copays at a retail pharmacy. Prescription Drugs at a Glance Prescription Drug Category Keystone Health Plan East HMO Generic on Preferred Drug List lowest copay Personal Choice PPO Base Personal Choice PPO Plus Generic Pharmacy** (up to 30-day supply) $10* copay $10* copay $10* copay Mail-Order (up to 90-day supply) $20* copay $20* copay $10* copay Brand-Name Formulary Brand-Name Pharmacy** (up to 30-day supply) $25* copay $30* copay $15* copay Mail-Order (up to 90-day supply) $50* copay $60* copay $15* copay Non-Formulary Pharmacy** (up to 30-day supply) $50* copay $50* copay N/A Mail-Order (up to 90-day supply) $100* copay $100* copay N/A *You pay the actual cost of the medication if that cost is less than the copay. **The above pharmacy copays apply for each covered prescription purchased from FutureScripts network pharmacies. Covered prescription drugs purchased at a non-participating retail pharmacy will be reimbursed at a percentage of the drug s retail cost for the amount dispersed, as shown below: -- The Keystone Health Plan East HMO and Personal Choice PPO Base plans will pay 30% and you are responsible for the remaining 70%. -- The Personal Choice PPO Plus plan will pay 75% and you are responsible for the remaining 25%. Please Note: It is the member s responsibility to submit for reimbursement when using an out-of-network pharmacy. 17

20 Dental Benefits The Dental Plan pays all or part of your costs for dental services. When you use dentists in the United Concordia network (called participating providers ), you save money because your share of the cost is based on the negotiated rate. And, the office will usually file the claim form for you. If you use non-participating providers, you pay your share of the expense plus any amount over the Maximum Allowable Charge (MAC) determined by United Concordia. Since the negotiated rate is usually less than the doctor s charge, you will pay more when you use non-participating providers. Claim forms are available from the Archdiocesan Office for Insurance Services. This chart summarizes how the Dental Plan covers typical expenses. Dental Plan Chart Benefit Maximum and Deductible Calendar-Year Benefit Maximum $1,500 each calendar year (per person) Calendar-Year Deductible None Diagnostic/Preventive Service Exams 100% X-rays 100% Cleanings 100% Palliative Treatment 100% Basic Services Basic Restorative 100% Endodontics 100% Simple Extractions 100% Complex Oral Surgery 100% General Anesthesia 100% Major Services Inlays, Onlays, Crowns 80% Non-Surgical and Surgical 80% Periodontics Prosthetics 80% Repairs 80% Orthodontics Not Covered To find a participating dentist, call or visit the United Concordia website at 18

21 Vision Benefits Vision benefits are included in all medical plans; the specific benefits depend upon the medical plan in which you are enrolled. Both vision plans are administered by Davis Vision. You receive the greatest benefit when you use Davis Vision providers. However, you may always use non-participating providers and still receive a reimbursement for some out-of-pocket expenses. When you make your appointment, make sure you visit a Davis provider. The Davis participating provider network consists of independent opticians, optometrists, and ophthalmologists. You will have access to more than 12,000 participating providers locally and more than 14,000 nationally. This chart is a summary of how the Vision Plans cover typical expenses. Deductible Eye Exam Participating Provider Summary of Vision Benefits Vision Plan with Keystone Health Plan East (HMO) None Not covered in Vision Plan. However, eye exams are covered through the HMO medical benefits for a $20 copay at participating providers only (every two years). Vision Plan with Personal Choice PPO Plans None $0 copay (paid in full including contact exam/fitting) Non-Participating Provider* Not covered Up to $35 reimbursement Eyeglasses (lenses and frames) Participating Provider Paid in full for standard lenses; for specialty lenses, you pay a discounted price less an allowance Paid in full for standard lenses; for specialty lenses, you pay a discounted price less an allowance Frames: You receive $10 reimbursement for choice from providers own frame collection or choice of Davis Collection of Frames. Davis frames: $0 copay for fashion selection; $16 copay for designer selection; $35 copay for designer selection Frames: You receive $60 reimbursement for choice from providers own frame collection or choice of Davis Collection of Frames. Davis frames: $0 copay for fashion or designer selection; $20 copay for designer selection Non-Participating Provider* Up to $35 reimbursement for frames and lenses Up to $75 reimbursement for frames and lenses Contact Lenses (in lieu of eyeglasses) Frequency Plan pays up to $35 for lenses (standard, specialty, and disposable lenses, evaluation, and fitting) Once every two calendar years *You are responsible for balance over allowance from non-participating provider. Plan pays up to $75 for lenses (standard, specialty, and disposable lenses, evaluation, and fitting) Once per calendar year To find a Davis network eye doctor, call or visit the IBC website at and select Vision Provider under Find A Doctor. 19

22 Hearing Care Discount You may receive free hearing exams and discounts on hearing aids if you use a Tru-Tone Hearing Aid Center. The following chart shows key facts about covered services. Hearing Benefits At Tru-Tone Hearing Aid Centers You Pay Hearing Screening, Comprehensive $0 Audiometry, or Acoustic Immittance Test Battery Analog Hearing Aid One Ear Your cost will not exceed In the Ear (ITE) $795 Behind the Ear (BTE) $845 In the Canal (ITC) $895 Completely in the Canal (CIC) $1,295 Micro Canal $1,095 Earmolds $35 Digital Hearing Aids Both Ears You receive a 30% discount of usual and customary cost House calls available; loaner hearing aids provided when a repair is necessary. Note: Benefits are paid only if you use a Tru-Tone Hearing Aid Center. To find the Tru-Tone Hearing Aid Center nearest you, call Important In an effort to keep the language as clear and non-technical, yet correct, as possible, the benefits described in this brochure are only summaries of the major Plan provisions. More detailed information is available from the Plan documents and insurance contracts. In case of any conflict, the official legal documents or contracts will govern over this brochure. 20

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24 For Priests 07/2018