Schedule of Benefits Allegian Health Plans

Transcription

1 NOTE: This consumer choice health benefit plan does not include all state mandated health insurance benefits. The following benefit is provided at a reduced level from what is mandated: Mandated Benefit Description Benefit Description Under This Plan HMOs may charge a deductible only for services A deductible will apply to some services. performed outside the service area for services performed by a provider not in the HMO s delivery network. HMOs to provide habilitative care and Federal law allows plans to impose limits. rehabilitation services without limits. Rehabilitation and chiropractic services are limited to a total of 35 combined visits per year. Habilitative services are limited to a total of 35 HMOs to provide home healthcare services without limits. visits per year. Federal law allows plans to impose limits. Home healthcare services are limited to 60 visits per year. Your Evidence of Coverage (EOC) gives You important information about Your health care benefits. It includes information such as Preauthorization requirements. This Schedule of Benefits is issued to You with Your EOC. It summarizes Your benefits and gives their effective date. Please keep Your Schedule of Benefits with Your EOC. will notify You if any changes are needed. Coverage Information Subscriber: Policy Number: [Subscriber Name] [Policy Number] Product Name: [Allegian Choice Gold HMO] Covered Person(s): Primary: [Member #1] Dependents: [Member #2] [Member #3] Date these benefits take effect: [Member #1] [Member #2] [Member #3] [MM/DD/YYYY] [MM/DD/YYYY] [MM/DD/YYYY] 63509_AHP_SOBHMOGoldStd2017_v2 Page 1 of 9

2 The applies to all Covered Services except: Preventive care services as defined under federal law and in Your EOC Primary care provider office visit (only the office copayment is exempt from the ) Specialist office visit (only the office copayment is exempt from the ) Outpatient lab (blood work) Diagnostic imaging (x-ray) Urgent care Mental health/substance abuse outpatient services Pediatric vision services Routine eye exam (adult) Foot care Fitness benefit Prescription drugs: preventive, Tier 1, Tier 2, Tier 3 and Tier 4 The renews each Plan Year. paid for Covered Services applies to the Annual Outof-Pocket Maximum. met in the current Plan Year does not carry over to the following year. If You have a Copayment and/or Coinsurance for a particular service and a, You must first pay the. The Copayment or Coinsurance is based on the remaining balance of Our approved amount. We will make payment to the provider only after Your cost sharing has been paid. Medical : Per Plan Year (for covered individual Member): $1500 Per Plan Year (for all covered family Members): $3000 Drug : Per Plan Year (for covered individual Member): $500 Per Plan Year (for all covered family Members): $ _AHP_SOBHMOGoldStd2017_v2 Page 2 of 9

3 Annual Out-of-Pocket Maximum The Annual Out-of-Pocket Maximum is the total amount You must pay during a Plan Year for Yourself and each Covered Dependent before We will Pay benefits at 100%. The Annual Out-of-Pocket Maximum does not include premiums, balance-billed charges, claims with Non- without Our Prior Approval, fitness benefit and health care the plan does not cover. Medical Out-of-Pocket Maximum: Per Plan Year (for covered individual Member): $5000 Per Plan Year (for all covered family Members): $10000 Drug Out-of-Pocket Maximum: Per Plan Year (for covered individual Member): Per Plan Year (for all covered family Members): Integrated with medical Integrated with medical Covered Services Services provided by Non- are excluded unless for Emergency Care, Urgent Care, Emergency Ambulance or Preauthorized by Us. Office Visits Primary Care Office Visit $20 Copay per visit 100% of allowed costs Specialist Office Visit $40 Copay per visit 100% of allowed costs Routine Prenatal/Postnatal Visits Preventive Care after Physical Exams No charge 100% of allowed costs Please refer to the age and clinical Immunizations No charge 100% of allowed costs recommendation limitations as specified Screenings No charge 100% of allowed costs in the EOC 63509_AHP_SOBHMOGoldStd2017_v2 Page 3 of 9

4 Well-Baby/Child No charge 100% of allowed costs Emergency Medical & Urgent Care Emergency Room Services $200 Copay per visit after (Copay waived if admitted) 100% of allowed costs and Urgent Care Services $50 Copay per visit 100% of allowed costs Emergency Ambulance Services after Inpatient Hospital & Surgical Care Inpatient Hospital Care (including physician services, general nursing care and supplies) Reconstructive Surgery Breast Reconstruction Surgery and Post- Mastectomy Services Transplant Surgery Maternity Services (including delivery and nursery care) Outpatient Surgery(including hospital and physician services) Ambulatory Surgery Care Services Alternatives to Hospital Care Skilled Nursing after after after after after after after after Limited to 25 days per Plan Year 63509_AHP_SOBHMOGoldStd2017_v2 Page 4 of 9

5 Hospice Home Health Care after after Limited to 60 days per Plan Year Lab & Diagnostic Services Outpatient Lab (blood work) $20 Copay per visit (Copay not collected if test part of office visit) 100% of allowed costs Diagnostic Imaging (x-ray) $20 Copay per visit (Copay not collected if test part of office visit) 100% of allowed costs Imaging (CT, PET, MRI) after Mental Health Care & Substance Abuse Treatment Inpatient Mental Health Outpatient Mental Health (office visit) Outpatient Mental Health (outpatient facility) Inpatient Substance Abuse Outpatient Substance Abuse (office visit) Outpatient Substance Abuse (outpatient facility) after $20 Copay per visit 100% of allowed costs after after $20 Copay per visit 100% of allowed costs after Other Services Acquired Brain Injury (treatment) after Allergy (testing, therapy, evaluation and injections) Autism Spectrum Disorder (Services) after after Covered Services are provided to Members 63509_AHP_SOBHMOGoldStd2017_v2 Page 5 of 9

6 who are diagnosed with Autism Spectrum Disorder from the date of diagnosis prior to the Member s 10 th birthday. If a Member is being treated for Autism Spectrum Disorder becomes 10 years of age or older and continues to need treatment, coverage will be provided as required by Texas law. Cancer/Life Threatening Clinical Trials (Medically Necessary patient costs that are directly associated with a phase I, phase II, phase III or phase IV clinical trial; see EOC for more information) after Chiropractic Care Services after Rehabilitation and chiropractic care services are limited to a total of 35 combined visits per Plan Year Diabetic Equipment, Supplies and Management after Dialysis after Durable Medical Equipment (DME), Medical Supplies and Monitoring Devices after 63509_AHP_SOBHMOGoldStd2017_v2 Page 6 of 9

7 Foot Care (care for diabetes/diabeticrelated conditions) Habilitative Care Services Hearing Aid Infertility (diagnostic services only) Infusion/IV Medication Administration Therapy Medical Foods and Formula (amino-acid based & PKU management) Oral Surgery Prosthetic Devices Rehabilitative Medicine Services TMJ Dysfunction or Syndrome Therapies for Children with Developmental Delays $40 Copay per visit 100% of allowed costs after Copay after after after after after after after after after after Habilitative care services are limited to a total of 35 visits per Plan Year One set of hearing aids every 3 years Rehabilitation and chiropractic care services are limited to a total of 35 combined visits per Plan Year Vision Care Services Pediatric Vision Services (through month of 19th birthday) Vision Exam No charge 100% of allowed costs One vision exam per Plan Year 63509_AHP_SOBHMOGoldStd2017_v2 Page 7 of 9

8 Pediatric Vision Services (through month of 19th birthday) Eyeglasses Adult Vision Screening No charge 100% of allowed costs One pair of glasses (lenses and frames) or contact lenses per Plan Year. Prescription lenses include single vision, conventional (line) bifocal, conventional (lined) trifocal, lenticular lenses and polycarbonate lenses. Lenses include a choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, ultraviolet protective coating, oversized and glass-grey #3 sunglass senses. All lenses include scratch resistant coating. Covered frames include a selection of frames from Davis Visions Collection OR retail allowance of $150 towards any frame plus 20% off balance. No charge 100% of allowed costs One vision screening, performed as part of annual physical to determine need for vision correction 63509_AHP_SOBHMOGoldStd2017_v2 Page 8 of 9

9 Prescription Drugs Prescription Drug Purchased from a Participating Retail or Mail-Order Pharmacy (30-day supply) Amount for Covered Prescription Drugs You Pay Purchased from a Participating Retail or Mail-Order Pharmacy (60-day supply) Preventive No charge No charge No charge Purchased from a Participating Retail or Mail-Order Pharmacy (90-day supply) Tier 1 Preferred Generic Tier 2 Generic Tier 3 Preferred Brand Tier 4 Non- Preferred Brand Tier 5 Preferred Specialty Tier 6 Non- Preferred Specialty $5 Copay per $15 Copay per $50 Copay per $75 Copay per 30% Coinsurance per after 50% Coinsurance per after $10 Copay per $30 Copay per $100 Copay per $150 Copay per $15 Copay per $45 Copay per $150 Copay per $225 Copay per Fitness Benefit Subscribers and their Covered spouse may be eligible to receive partial reimbursement for exercise facility/gym membership fees. Fees must be paid to the facility/gym to maintain equipment and programs that promote cardiovascular wellness. To be eligible, You must be an active member of the facility/gym and complete 50 visits in a six-month period. Reimbursement is the lesser of $200 for the Subscriber and $100 for the Subscriber s Covered spouse OR the cost of membership for a six-month period. Please see Your EOC for details. Please call Our Customer Service Department if You have any questions: [ (toll-free) or TTY: ] [4801 NW Loop 410, Ste. 380] [San Antonio, TX 78229] [ (toll-free)] [TTY: ] 63509_AHP_SOBHMOGoldStd2017_v2 Page 9 of 9