2019 Summary of Benefits

Transcription

1 2019 Summary of Benefits BlueCross Total SM (PPO) Jan. 1, 2019 Dec. 31, TTY 711 Seven Days a Week, 8 a.m. to 8 p.m. (Oct. 1, 2018, to Mar. 31, 2019) Monday-Friday, 8 a.m. to 8 p.m. (All other times) H8003_SB2019_M 12095m-2018

2 2019 Summary of Benefits BlueCross Total SM (PPO) H8003, Plans 001, 002, and 003 This is a summary of the health and drug services covered by : January 1, 2019 December 31, This plan, BlueCross Total, is offered by BlueCross BlueShield of South Carolina. BlueCross BlueShield of South Carolina is a Medicare Advantage PPO plan with a Medicare contract. Enrollment in BlueCross BlueShield of South Carolina depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage by calling Customer Service at (TTY users should call 711). The Evidence of Coverage is available online at To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in South Carolina: Upstate (001) -Midlands/Coastal (002) Lowcountry (003) Anderson, Cherokee, Greenville, Oconee, Pickens, Spartanburg and York Aiken, Calhoun, Fairfield, Florence, Horry, Kershaw, Lexington, Orangeburg, Richland, Saluda and Sumter Beaufort, Berkeley, Charleston, Dorchester and Georgetown BlueCross Total has a network of doctors, hospitals, pharmacies, and other providers, as well as access to out-of-network providers. As a member of our plan, you do not need a referral from a Primary Care Provider in order to see a Specialist or to obtain a service. However, you are required to obtain prior authorization from our plan for some services. For more information, call us at (TTY users should call 711), or visit us at We are available for phone calls 8 a.m. to 8 p.m., Eastern Time, Monday through Friday. From October 1, 2018, through March 31, 2019, we are available 8 a.m. to 8 p.m., Eastern Time, seven days a week. Calls to this number are answered by a licensed insurance agent. Customer Service has free language interpreter services available for non-english speakers. This information is available in other formats, including Braille, large print or audio. To get this information in other formats, please call Customer Service. H8003_SB2019_M 1

3 Premiums and Benefits Monthly Plan Premium Upstate (001) - Midlands/Coastal (002) Lowcountry (003) Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage You pay $19 You must continue to pay your Medicare Part B premium. You pay $25 You must continue to pay your Medicare Part B premium. You pay $25 You must continue to pay your Medicare Part B premium. No deductible In-network: You pay no more than $6,700 annually. In-network and Out-of-network: You pay no more than $10,000 combined. Includes copays and other costs for medical services for the year. In-network: You pay $400 per day for days 1 4 (You pay nothing per day for days 5-90). Outpatient Hospital Coverage This benefit will begin on day 1 each time you are admitted to a specific facility type. You pay your cost share per admission. In-network: You pay $0 - $325 per visit. You pay nothing if polyp is found and removed during colonoscopy) Doctor Visits Primary Care Providers In-network: You pay $10 per visit. Specialists (No referral is required) Preventive Care Out-of-network: You pay $30 per visit. In-network: You pay $40 per visit. In-network: You pay nothing. Out-of-network: You pay nothing. Other preventive services are available. There are some covered services that have a cost, refer to the EOC for complete details. 2

4 Premiums and Benefits Emergency Care You pay $90 per visit. Emergency care is covered worldwide; refer to the EOC for complete details. Urgently Needed Services You pay $45 per visit. Diagnostic Services/Labs/Imaging Prior authorization may be required for these services. Diagnostic tests and In-network: You pay $0 - $275 per service. You pay nothing for procedures EKG and diagnostic colorectal screening. Lab services You pay $10 per lab service. Diagnostic In-network: You pay $0 - $150 per service. You pay nothing for radiology service mammogram and ultrasounds. (e.g., MRI and CT scan) Outpatient x-rays You pay $10 per x-ray. Hearing Services Medicare-covered hearing You pay $50. exam Routine hearing exam In-network: $0 Out-of-network: 50% Hearing aids In-network: You pay $699 - $999 using TruHearing network for up to 2 hearing aids per year (one per ear, each year). Out-of-network: Not covered Dental Services Preventive dental Comprehensive dental 2 preventive dental visits per year. 3 restorative service visits per year, 1 extraction visit per year and 1 crown per year. In-Network you pay $0. Out-of-Network you pay 50%. Vision Services Diabetic eye exam You pay $0. Glaucoma screening You pay $0. Medicare-covered eye exam You pay $50. Routine eye exam Not covered Eyeglasses (frames and Our plan pays up to $100. lenses) and contacts Eyeglasses or contact lenses after cataract surgery Vision eyewear allowance: Any licensed eyewear provider may provide services. You pay the provider for services, submit an itemized billing statement showing proof of payment to our plan, and you will be reimbursed. You are responsible for any amount over the eyewear coverage limit. You pay $0 copay for Medicare-covered eyewear related to cataract surgery. 3

5 Premiums and Benefits Mental Health Services Inpatient visit In-network: You pay $415 per day, days 1-4, $0 per day, days Outpatient group therapy/individual therapy In-network: You pay $40 per visit. Skilled Nursing Facility In-network: You pay nothing per day for days You pay $172 per day for days 21 through 100. Our plan covers up to 100 days in a SNF. Physical Therapy In-network: You pay $40 per visit. Ambulance Transportation Medicare Part B Drugs Other Information and Benefits Ambulatory Surgical Center Services Chiropractic Care (Medicarecovered) Dialysis You pay $275 per one-way trip for ground ambulance. You pay 20% of the cost of air ambulance. Prior authorization may be required for non-emergency transportation. Not covered You pay 20% of the cost of chemotherapy drugs. You pay 20% of the cost for other Part B drugs. In-network: You pay $0 - $325 per visit. In-network: You pay $20 per visit. Out-of-network: You pay $40 per visit. You pay 20% of the cost. 4

6 Premiums and Benefits Foot Care (podiatry services) Medicare-covered foot exams and treatment In-network: You pay $50 per visit. Routine foot care Not covered Home Health Care In-network: You pay nothing. Meal Program Medical Equipment/Supplies Durable Medical Equipment (e.g., wheelchairs, oxygen) You pay nothing for meal program after inpatient hospital and/or Skilled Nursing Facility (SNF)/rehabilitation stay for 5 days (2 meals per day) for up to 4 times per year. You must use the Mom s Meals Nourish Care program. In-network: You pay 20% of the cost. Out-of-network: You pay 30% of the cost. Prosthetics (e.g., braces, artificial limbs) In-network: You pay 20% of the cost. Out-of-network: You pay 30% of the cost. Diabetic supplies In-network: You pay nothing (preferred vendor One Touch/preferred pharmacy). In-network: You pay 20% of the cost (non-preferred vendor/non-preferred pharmacy). Occupational Therapy In-network: You pay $40 per visit. Outpatient Substance Abuse In-network: Individual and group therapy visits You pay $40. Out-of-network: Individual and group therapy visits You pay $55. Physical Exam - Annual In-network: You pay nothing for one physical exam per year. Out-of-network: You pay 20% of the cost for one physical exam per year. 5

7 Premiums and Benefits Speech and Language Therapy Visitor Travel Wellness Programs (e.g., fitness) In-network: You pay $40 per visit. The Visitor/Travel Program includes BlueCross Medicare Advantage PPO network coverage of all Part A, Part B, and supplemental benefits offered by our plan outside your service area in 37 states and 1 territory listed as follows: Alabama, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Missouri, Montana, North Carolina, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin and West Virginia. For some of the states listed, Medicare Advantage PPO networks are only available in portions of the state. You pay nothing for basic membership to a Silver&Fit participating fitness center. Outpatient Prescription Drugs Preferred Retail Rx 30-day supply Non-Preferred Retail Rx 30-day supply Preferred Mail Order 90-day supply Deductible You pay $70 deductible on Tiers 3, 4, and 5. Tier 1: Preferred Generic You pay $3 You pay $8 You pay $0 (Mail order and/or preferred retail) Tier 2: Generic You pay $15 You pay $20 You pay $37.50 Tier 3: Preferred Brand You pay $37 You pay $47 You pay $92.50 Tier 4: Non-Preferred Drug You pay 45% You pay 50% You pay 45% Tier 5: Specialty You pay 31% You pay 31% You pay 31% Cost-Sharing may change depending on the pharmacy you choose (preferred or non-preferred, mail order, Long Term Care (LTC) or home infusion, and 30 or 90-day supply) and when you enter another of the four phases of the Part D benefit. For more information on the additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online at 7

8 Additional Gap Coverage: Our plan offers some drug coverage in the Coverage Gap Stage. The Coverage Gap Stage begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25% of the plan s cost for covered brand name drugs and 37% of the plan s cost for covered generic drugs until your cost total $5,100, which is the end of the coverage gap. Under this plan, you may pay even less for Tier 1 preferred generic drugs during the Coverage Gap Stage as follows: At a pharmacy with preferred cost-sharing, you pay a $3 copayment for a 30-day supply of Tier 1 preferred generic drugs, or no more than 37% of the cost, whichever is less, and the plan pays the rest. At a pharmacy with standard cost-sharing, you pay an $8 copayment for a 30-day supply for Tier 1 preferred generic drugs, or no more than 37% of the cost, whichever is less, and the plan pays the rest. Catastrophic Coverage: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,100, you pay the greater of: 5% of the cost, or $3.40 copay for generic (including brand drugs treated as generic) and $8.50 copay for all other drugs. For coverage and cost of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ). TTY users should call You can call these numbers for free, 24 hours a day, 7 days a week. You must continue to pay your Part B premium. This information is not a complete description of benefits. Call Customer Service at (TTY users should call 711) for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, copayments or coinsurance may change on January 1 of each year. Out-of-network/non-contracted providers are under no obligation to treat BlueCross Total members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Customer Service number, , or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 8

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