Employer Health Plan PRODUCT GUIDE

Transcription

1 Employer Health Plan PRODUCT GUIDE 2018 PLANS EMPLOYERS WITH 1-50 EMPLOYEES

2 WE RE HERE TO HELP Our team is here to help you find the right health plans for your needs. Reach us at one of the following locations. Or visit azblue.com for more details on our products and services. PHOENIX (602) (800) ext FAX (602) TUCSON (520) (800) FAX (866) FLAGSTAFF (928) (800) FAX (866) PLANS 2

3 2018 PLAN CHOICES THAT MOVE HEALTH FORWARD What s new for 2018? Network options for higher net savings Choice of networks and health plans with multiple deductible options that give employees and employers control over the type of coverage they need and how much they spend on healthcare services. Network choice provides access to quality care and is a key money-saver for employers and employees alike. Choosing a smaller network helps lower employees premiums Staying in-network lowers costs for medical services Knowing limits on out of network services, like emergencies, helps control costs PLAN OPTIONS NETWORKS PROVIDER AFFILIATIONS PPO Plans A wide selection of primary care providers (PCPs) and specialists No requirement to have a PCP or get referrals before seeing a specialist Access to healthcare out-of-state with the BlueCard network when traveling or vacationing Out-of-network care covered, but at a higher cost Statewide (Statewide) (Maricopa County) Statewide Banner Health and HonorHealth HMO Plans Primary care provider (PCP) required PCP coordinates care with other in-network providers PCP referrals required for specialist visits (some exceptions apply) * Out-of-network services not covered except in emergencies and rare situations when pre-authorized by BCBSAZ Statewide (Statewide) PimaConnect (Pima County) Statewide Tucson Medical Center *Referrals not required for OB/GYN, chiropractic and certain other in-network provider visits 2018 PLANS 3

4 A PLAN FOR ALL NEEDS AND BUDGETS Health plan options in 2018: This popular product is a top choice for those who want comprehensive coverage. There are ten PPO and six HMO plan options that offer copays for many common services. Portfolio (HSA-qualified plan) When paired with a Health Savings Account (HSA) from HealthEquity *, this high-deductible PPO plan gives employees the flexibility to choose how their healthcare dollars are spent and offers potential tax savings. This plan is a popular choice for those who: Expect infrequent provider visits, have minimal need for prescription drugs and want lower monthly premiums. Expect frequent provider visits, have increased need for prescription drugs and want the additional tax advantages from their HSA. There are five PPO and three HMO plan options to choose from. Employers benefit from HealthEquity s HSA integration in several ways: Easy Hassle-free account set up, management and eligibility data sharing Streamlined One bill captures BCBSAZ monthly premiums and HealthEquity s HSA group administration fees Both plans offer coverage for most common healthcare needs, such as: Doctor visits Prescriptions Urgent care and ER visits Surgeries Routine pediatric vision care Pediatric dental care from in-network providers Preventive care at $0 out-of-pocket cost from in-network providers Convenient 24-hour customer service for employers integrating HSAs, HRAs and FSAs *Services from HealthEquity, an independent company. HealthEquity is contracted with BCBSAZ to administer financial services and is not affiliated in any way with BCBSAZ. This is only a brief summary of the benefit plans and is designed to help compare features of different plans. All plans are subject to the exclusions and limitations listed on page 10 of this summary. More detailed information about benefits, cost share, exclusions and limitations is in the benefit plan booklets and plan Summary of Benefits and Coverage (SBC), which are available on request. If the terms of this summary differ from the terms of the benefit plan booklets, the terms of the booklets control and apply PLANS 4

5 PPO Set costs for the most common healthcare needs, such as doctor visits and prescriptions, when employees use in-network providers. Calendar-year Deductible 500 $500/member and $1,000/family 1000 $1,000/member and $2,000/family 2000 $2,000/member and $4,000/family 3000 $3,000/member and $6,000/family 4000 $4,000/member and $8,000/family 5000 $5,000/member and $10,000/family 6000 $6,000/member and $12,000/family 2500/70 $2,500/member and $5,000/family 4500/70 $4,500/member and $9,000/family 5000/100 $5,000/member and $10,000/family Metal Level Platinum Gold Silver Silver Silver Silver Bronze Silver Silver Silver Provider Networks Available Coinsurance 10% 20% 20% 20% 20% 20% 20% 30% 30% 0% Out-of-Pocket Limit $2,000/member and $4,000/family $5,000/member and $10,000/family $6,250/member and $12,500/family $6,250/member and $12,500/family $6,500/member and $13,000/family $6,500/member and $13,000/family $7,350/member and $14,700/family $6,500/member and $13,000/family $7,000/member and $14,000/family $6,500/member and $13,000/family Primary Care Provider $15 copay $20 copay $40 copay $40 copay $40 copay $40 copay $40 copay $40 copay $40 copay $40 copay PCP Selection Required No No No No No No No No No No Specialist $30 copay $45 copay $85 copay $85 copay $85 copay $85 copay $85 copay $85 copay $85 copay $85 copay Referral Required to Visit Specialist No No No No No No No No No No Urgent Care Visit $60 copay $60 copay $85 copay $85 copay $85 copay $85 copay $85 copay $85 copay $85 copay $85 copay Preventive Services No charge No charge No charge No charge No charge No charge No charge No charge No charge No charge Prescription Formulary Drugs: * Rx Deductible for Tiers 2 and 3 None None $250/member $300/member $350/member $400/member $650/member None None None Tier 1 $5 copay $15 copay $35 copay $35 copay $35 copay $35 copay $40 copay $35 copay $35 copay $35 copay Tier 2 $20 copay $50 copay $90 copay after Tier 3 $40 copay $100 copay $180 copay after Surgery (Inpatient/ Oupatient) $80 copay after $180 copay after $80 copay after $180 copay after $80 copay after $180 copay after $100 copay after $200 copay after $90 copay $90 copay $80 copay $200 copay $200 copay $180 copay 10% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 30% after deductible 30% after deductible No charge after deductible Emergency Room Visit 10% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible $550 copay $600 copay No charge after deductible Ambulance Pediatric Dental 10% coinsurance, 30% coinsurance, 30% coinsurance, No charge Cost share amounts are for covered services by providers in your plan s network. Services by out-of-network providers are subject to higher cost share amounts. *Only formulary drugs are covered unless a formulary exception is approved. Members in plans with a copay drug benefit who pick a brand medication when a generic is available will pay the difference in cost plus the copay and any applicable deductible. All plans are subject to the exclusions and limitations on page PLANS 5

6 HMO Set costs for the most common healthcare needs, such as doctor visits and prescriptions, when employees use in-network providers. Calendar-year Deductible 1500 $1,500/member and $3,000/family 2500 $2,500/member and $5,000/family 3500 $3,500/member and $7,000/family 4500 $4,500/member and $9,000/family 5500 $5,500/member and $11,000/family 6500 $6,500/member and $13,000/family Metal Level Gold Silver Silver Silver Silver Bronze Provider Networks Available Statewide HMO, PimaConnect Statewide HMO, PimaConnect Statewide HMO, PimaConnect Statewide HMO, PimaConnect Statewide HMO, PimaConnect Statewide HMO, PimaConnect Coinsurance 20% 20% 20% 20% 20% 20% Out-of-Pocket Limit $5,500/member and $11,000/family $6,750/member and $13,500/family $6,750/member and $13,500/family $7,000/member and $14,000/family $7,000/member and $14,000/family $7,350/member and $14,700/family Primary Care Physician $35 copay $35 copay $35 copay $35 copay $35 copay $35 copay PCP Selection Required Yes Yes Yes Yes Yes Yes Specialist $70 copay $85 copay $85 copay $85 copay $85 copay $85 copay Referral Required to Visit Specialist Yes Yes Yes Yes Yes Yes Urgent Care Visit $70 copay $85 copay $85 copay $85 copay $85 copay $85 copay Preventive Services No charge No charge No charge No charge No charge No charge Prescription Formulary Drugs: * Rx Deductible for Tiers 2 and 3 None $250/member $300/member $350/member $400/member $650/member Tier 1 $25 copay $35 copay $35 copay $35 copay $35 copay $35 copay Tier 2 $70 copay $80 copay after $80 copay after $80 copay after $80 copay after $100 copay after Tier 3 $140 copay $180 copay after $180 copay after $180 copay after $180 copay after $200 copay after Surgery (Inpatient/Oupatient) 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible Emergency Room Visit 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible Ambulance Pediatric Dental No & Orthodontia: No & Orthodontia: No & Orthodontia: No & Orthodontia: No & Orthodontia: No & Orthodontia: Cost share amounts are for covered services by providers in your plan s network. Services by healthcare professionals outside your network are generally not covered except for emergencies and other special circumstances when use is preapproved. *Only formulary drugs are covered unless a formulary exception is approved. Members in plans with a copay drug benefit who pick a brand medication when a generic is available will pay the difference in cost plus the copay and any applicable deductible. All plans are subject to the exclusions and limitations on page PLANS 6

7 Portfolio PPO A low-premium plan eligible for use with a HSA from a qualified financial institution. This plan provides flexibility on how employees healthcare dollars are spent while offering potential tax savings when paired with an HSA. Many in-network preventive services are covered with no out-ofpocket cost to employees. Portfolio 2700 Portfolio 3250 Portfolio 4000 Portfolio 5500 Portfolio 6650 Calendar-year Deductible $2,700/member and $5,400/family $3,250/member and $6,500/family $4,000/member and $8,000/family $5,500/member and $11,000/family $6,650/member and $13,300/family Metal Level Silver Silver Silver Bronze Bronze Provider Networks Available Coinsurance 20% 10% 10% 20% 0% Out-of-Pocket Limit $4,250/member and $8,500/family $5,500/member and $11,000/family $5,500/member and $11,000/family $6,550/member and $13,100/family $6,650/member and $13,300/family Primary Care Physician 20% after deductible 10% after deductible 10% after deductible 20% after deductible No charge after deductible PCP Selection Required No No No No No Specialist 20% after deductible 10% after deductible 10% after deductible 20% after deductible No charge after deductible Referral Required to Visit Specialist No No No No No Urgent Care Visit 20% after deductible 10% after deductible 10% after deductible 20% after deductible No charge after deductible Preventive Services No charge No charge No charge No charge No charge Prescription Formulary 20% after deductible 10% after deductible 10% after deductible 20% after deductible No charge after deductible Drugs * Surgery (Inpatient/ Oupatient) 20% after deductible 10% after deductible 10% after deductible 20% after deductible No charge after deductible Emergency Room Visit 20% after deductible 10% after deductible 10% after deductible 20% after deductible No charge after deductible Ambulance 20% after deductible 10% after deductible 10% after deductible 20% after deductible No charge after deductible Pediatric Dental No charge after deductible; Restorative No charge after deductible; Restorative No charge after deductible; Restorative No charge after deductible; Restorative No charge after deductible; Restorative Cost share amounts are for covered services by providers in your plan s network. Services by out-of-network providers are subject to higher cost share amounts. *Only formulary drugs are covered unless a formulary exception is approved. All plans are subject to the exclusions and limitations on page PLANS 7

8 Portfolio HMO A low-premium plan eligible for use with a HSA from a qualified financial institution. This plan provides flexibility on how employees healthcare dollars are spent while offering potential tax savings when paired with an HSA. Many in-network preventive services are covered with no out-of-pocket cost to employees. Portfolio 3750 Calendar-year Deductible $3,750/member and $7,500/family $4,250/member and $8,500/family $6,650/member and $13,300/family Metal Level Silver Silver Bronze Provider Networks Available Statewide HMO, PimaConnect Statewide HMO, PimaConnect Statewide HMO, PimaConnect Coinsurance 10% 10% 0% Out-of-Pocket Limit $6,000/member and $12,000/family $6,000/member and $12,000/family $6,650/member and $13,300/family Portfolio 4250 Portfolio 6650 Primary Care Physician 10% after deductible 10% after deductible No charge after deductible PCP Selection Required Yes Yes Yes Specialist 10% after deductible 10% after deductible No charge after deductible Referral Required to Visit Specialist Yes Yes Yes Urgent Care Visit 10% after deductible 10% after deductible No charge after deductible Preventive Services No charge No charge No charge Prescription Formulary Drugs * 10% after deductible 10% after deductible No charge after deductible Surgery (Inpatient/Oupatient) 10% after deductible 10% after deductible No charge after deductible Emergency Room Visit 10% after deductible 10% after deductible No charge after deductible Ambulance 10% after deductible 10% after deductible No charge after deductible Pediatric Dental No charge after deductible; Restorative No charge after deductible; Restorative No charge after deductible; Restorative Cost share amounts are for covered services by providers in your plan s network. Services by healthcare professionals outside your network are generally not covered except for emergencies and other special circumstances when use is preapproved. *Only formulary drugs are covered unless a formulary exception is approved. All plans are subject to the exclusions and limitations on page PLANS 8

9 HELPFUL TERMS AND DEFINITIONS Allowed Amount This is the amount of reimbursement that doctors, hospitals or other healthcare providers who are in the plan s network has an agreement with the plan to accept for a covered service. Example: A doctor may normally charge $100 for a particular service. But he has an agreement with your plan to accept only $80 as reimbursement for that service. The allowed amount is $80. The allowed amount includes any amount paid by the plan, plus any amount the member pays as a cost-share, including copays and deductibles. Out-of-Pocket Costs These are expenses for medical care that aren t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance and copayments for covered services, plus all costs for services that aren t covered. These are also referred to as out-of-pocket expenses. Medications and Prescriptions BCBSAZ applies limitations to certain prescription medications obtained through the pharmacy benefit. A list of these medications and limitations is available online at azblue.com or by calling BCBSAZ. These limitations include, but are not limited to, quantity, age, gender, dosage and frequency of refill limitations. Plans are also subject to: A restricted formulary A Step Therapy Program that requires members to take the generic version of certain medications before BCBSAZ and/ or the PBM will consider coverage of the brand-name version of that medication A requirement, for plans that include a copay drug benefit, to pay the difference in cost between a brandname and generic medication plus applicable copay and deductible. BCBSAZ prescription medication limitations are subject to change at any time without prior notice Group Size Definitions 1-50: These plans are offered to employers considered small for purposes of the Affordable Care Act (ACA) -- the average number of total employees on business days during the previous calendar year is 50 or fewer. These plans are also available to an employer considered large for purposes of the ACA, but considered small for purposes of Arizona law (on a typical business day, 50 or fewer employees are eligible for health benefit plan coverage). Balance Bill This is the difference between the BCBSAZ allowed amount and a noncontracted provider s billed charge. Any time, except emergencies, a member sees a noncontracted provider, the member is responsible for the balance bill. Any amounts paid for balance bills do not count toward any deductible, coinsurance or out-of-pocket limit. Emergency Services For emergency services, members will pay their in-network cost share, even if services are received from out-of-network providers. Precertification Some services and medications require precertification. Except for emergencies, urgent care, and maternity admissions, precertification is always required for inpatient admissions (acute care, behavioral health, long-term acute care extended active rehabilitation and skilled nursing facilities), home health services and most specialty medications. Precertification may be required for other covered services and medications PLANS 9

10 EXCLUSIONS AND LIMITATIONS PPO Excluded Services & Other Covered Services: Services our plan generally does NOT cover. (Check your policy or plan document for more information and a list of any other excluded services.) HMO Excluded Services & Other Covered Services: Services our plan generally does NOT cover. (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Adult routine vision exam Care that is not medically necessary Cosmetic surgery, cosmetic services and supplies Custodial care Dental care and orthodontic services (adult), except as stated in plan Durable medical equipment (DME) rental/repair charges that exceed DME purchase price Experimental and investigational treatments, except as stated in plan Eyewear, except as stated in plan Flat feet treatment and services Genetic and chromosomal testing, except as stated in plan Habilitation outpatient services exceeding 60 visits per calendar year Home healthcare and infusion therapy exceeding 42 visits (of up to four hours) per calendar year Homeopathic services Infertility medication and treatment Inpatient EAR and SNF treatment exceeding 90 days per calendar year Long-term care, except long-term acute care Massage therapy other than allowed under medical coverage guidelines Naturopathic services Orthodontic services (pediatric) that are not dentally necessary Out-of-network mail order, out-of-network specialty and out-of-network 90-day retail supplies of drugs Pediatric dental checkups exceeding two checkups and cleanings per calendar year Pediatric glasses or contact lenses exceeding one pair of glasses or contact lenses per calendar year Private-duty nursing, except when medically necessary or when skilled nursing not available Rehabilitation outpatient services exceeding 60 visits per calendar year Respite care Routine foot care Routine vision exam (child) exceeding one visit per calendar year Sexual dysfunction treatment and services Weight-loss programs Non-emergency care when traveling outside the U.S. Acupuncture Adult routine vision exam Care that is not medically necessary Chiropractic services exceeding 20 visits per calendar year Cosmetic surgery, cosmetic services and supplies Custodial care Dental care and orthodontic services (adult), except as stated in plan Durable medical equipment (DME) rental/repair charges that exceed DME purchase price Experimental and investigational treatments, except as stated in plan Eyewear, except as stated in plan Flat feet treatment and services Genetic and chromosomal testing, except as stated in plan Habilitation outpatient services exceeding 60 visits per calendar year Home healthcare and infusion therapy exceeding 42 visits (of up to four hours) per calendar year Homeopathic services Infertility medication and treatment Inpatient EAR and SNF treatment exceeding 90 days per calendar year Long-term care, except long-term acute care Massage therapy other than allowed under medical coverage guidelines Naturopathic services Non-emergency care when traveling outside the U.S. Orthodontic services (pediatric) that are not dentally necessary Pediatric dental checkups exceeding two checkups and cleanings per calendar year Pediatric glasses or contact lenses exceeding one pair of glasses or contact lenses per calendar year Private-duty nursing, except when medically necessary or when skilled nursing not available Rehabilitation outpatient services exceeding 60 visits per calendar year Respite care Routine foot care Routine vision exam (child) exceeding one visit per calendar year Services from providers outside the network, except in emergencies and other limited situations when use preauthorized Sexual dysfunction treatment Weight-loss programs Other covered services. (Limitations may apply to these services. This isn t a complete list. Please see our plan document.) Other covered services. (Limitations may apply to these services. This isn t a complete list. Please see our plan document.) Bariatric surgery Chiropractic care Hearing aids, up to one per ear, per calendar year Non-emergency services Bariatric surgery Chiropractic care Hearing aids, up to one per ear, per calendar year 2018 PLANS 10

11 Pediatric Dental Dental benefits for children under age 19 and covered by one of the plans described in this brochure for groups size Type I Covered Services Diagnostic and Preventive Oral exams Prophylaxis Cleanings X-rays Bitewing X-rays Periapical X-rays Full-mouth X-rays Panoramic X-rays Topical Fluoride Sealants Space Maintainers Two per year 2 in any combination of periodic, limited or comprehensive exams Two per year Any combination of X-rays billed on the same date of treatment cannot exceed the allowed amount for a full-mouth X-ray benefit Two sets per year Covered One set per five-year period One set per five-year period. Panoramic X-rays accompanied by bitewing X-rays are considered a set of full-mouth X-rays and are subject to the full-mouth X-ray limit. Two treatments per year Permanent molars with no decay or restoration only. One application per three-year period. Temporary appliances to replace prematurely lost teeth until permanent teeth erupt Type II and III Covered Services Restorative All claims subject to processing based on the least expensive available treatment (LEAT) 3 Restorative Fillings Simple and Surgical Extractions Periodontics Non-surgical Prosthodontics Bridges and Dentures Amalgam and composite resin fillings covered Covered Periodontal scaling and root planing limited to one per quadrant per two-year period. Periodontal maintenance procedures limited to four per year; prophylaxis and cleanings count towards this limit. Five-year replacement limit General Anesthesia Limited coverage per BCBSAZ dental coverage guidelines 4 Endodontics Root Canal Crowns/Inlays/Onlays Periodontics Surgical Covered Five-year replacement limit One procedure per three-year period Implants Limited coverage per BCBSAZ dental coverage guidelines 4 Type IV Covered Services Orthodontia Cosmetic orthodontia not covered. Orthodontics (dentally necessary) Limited coverage per BCBSAZ dental coverage guidelines 4 In-network services available through the BluePreferred Dental network. A listing of providers in the BluePreferred Dental network can be found at azblue.com. 1 These plans are offered to employers considered small for purposes of the Affordable Care Act (ACA). 2 All per year benefits mean per calendar year. 3 Only the allowed amount, as based on least expensive available treatment (LEAT), if applicable (and not billed charges), counts to satisfy the deductible. There may be several methods for treating a specific dental condition. All claims for restorative services such as fillings and crowns are subject to analysis for the least expensive available treatment (LEAT). Benefits for restorative procedures will be limited only to the LEAT. For these procedures, BCBSAZ will only pay benefits up to the LEAT fee. Members may elect to receive a service that is more costly than the LEAT, but the member will be responsible for cost-share based on the LEAT, and will also pay the difference between the fee for the LEAT and the more costly treatment ( LEAT balance bill ). Any payment made for this LEAT balance bill will not count toward deductible or the out-of-pocket maximum. 4 BCBSAZ dental coverage guidelines are available upon request. Not all dentally necessary services are covered benefits PLANS 11

12 PEDIATRIC DENTAL EXCLUSIONS AND LIMITATIONS Examples of services not covered This is only a partial list of services that are limited or not covered by the health plans featured in this guide. Expenses for services that exceed the benefit limit are not covered. Detailed information about benefits, exclusions and limitations is in the benefit plan booklet or rider and is available prior to enrollment upon request. Alternative dentistry Athletic mouth guards Biopsies Bleaching of any kind CT scans (e.g., cone beam) and tomographic surveys Correction of congenital malformations, except as required by Arizona state law, for newborns, adopted children and children placed for adoption Cosmetic services and any related complications Dental services and supplies not provided by a dentist, except as stated in plan Duplicate, provisional and temporary devices, appliances and services Experimental or investigational services Fixed pediatric partial dentures Genetic tests for susceptibility to oral diseases Inpatient or outpatient facility services Laboratory and pathology services Locally administered antibiotics Major restorative and prosthodontic services performed on other than a permanent tooth Maxillofacial prosthetics and any related services Medications dispensed in a dentist s office, except as stated in plan Non-dentally necessary services services that are not dentally necessary as determined by BCBSAZ. BCBSAZ may not be able to determine dental necessity until after services are rendered. Occlusal guards for the treatment of temporomandibular joint syndrome or sleep apnea Oral hygiene instruction, plaque control programs and dietary instructions Removal of appliances, fixed space maintainers or posts Repair of damaged orthodontic appliances Replacement of lost or missing appliances Sealants for teeth other than permanent molars Services resulting from failure to comply with professionally prescribed treatment Telephonic and electronic consultations, except as required by law Therapy or treatment of the temporomandibular joint, orthognathic surgery or ridge augmentation Tooth transplantation 2018 PLANS 12

13 NOTES 2018 PLANS 13

14 NOTES 2018 PLANS 14

15 NOTES 2018 PLANS 15

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