Lee s Summit School District

Transcription

1 Plan Type Plan Description (Visit our website at to receive a complete listing of network hospitals and physicians) Lee s Summit School District Effective Date: 1/1/16 Health Benefit Plan Summary This Benefit Summary provides only a highlight of the services covered by Blue Cross and Blue Shield of Kansas City. Preferred-Care Blue/BlueSaver QHDHP A Preferred Provider Organization (PPO) Members can receive services from any hospital or physician but receive greater benefits when they use the Preferred-Care Blue network. Deductible $3,000 per individual/$6,000 per family + An Individual must meet their INDIVIDUAL deductible before benefits are paid on that individual +BlueSaver Plan Members NOT completing enhancement program requirements will have a $3,150/6,300 deductible. Coinsurance (1) Network: / Non-network: 80% Out-of-Pocket Maximum (2) Network: $3,000 individual/$6,000 family; +BlueSaver Plan Members NOT completing enhancement program requirements will have a $3,150/6,300 out of pocket max Non-network: $6,000 individual/$12,000 family + BlueSaver Plan Members NOT completing enhancement program requirements will have a $6,300/12,600 out of pocket max Physician Office Visits Network: Deductible then Network: Deductible then Lab Performed in a Physician s Office/Independent Lab Lab Performed in a Hospital/Outpatient Facility Network: Deductible then X-ray and Other Radiology Procedures Network: Deductible then Routine Preventive Care (Contract lists covered services) Network Routine Services: Office Visit/Wellness Exam: Mammograms, Pap Smears and PSA tests Network: Inpatient Hospital Services/Outpatient Surgery* Network: Deductible then Emergency Room Deductible then (Copay waived if admitted to a network hospital) Urgent Care Network: Deductible then Ambulance Deductible then Durable Medical Equipment* Network: Deductible then Allergy Testing, Treatment, Injections Network: Deductible then Home Health Services* Network: Deductible then Skilled Nursing Facility* Network: Deductible then 1 Portion of covered charges paid by BCBSKC after you satisfy your deductible and required copayments. 2 Total of deductible, coinsurance and copays members pay each year toward covered charges before BCBSKC pays of benefits. 3 Other services/procedures not specified on this benefit schedule that are performed in a physician s office are subject to the Network Deductible and Coinsurance level. 4 Diagnostic services performed at a Non-Participating Imaging Center inside Our Service Area are limited to a $200 calendar year. Inpatient hospital services in a Non-Participating Hospital inside our service area are limited to a $200 per day and are limited to 30 days per calendar year. Outpatient services at a Non-Participating Provider Hospital or at a Non-Participating Provider outpatient facility (including an ambulatory surgical center) inside our service area are limited to a $200 calendar year. 5 Other services/procedures that are performed by an urgent care provider are subject to the Network Deductible and Coinsurance level.

2 Outpatient Therapy (Speech, Hearing, Physical and Occupational)* Preferred-Care Blue/BlueSaver QHDHP Network: Deductible then Physical and Occupational: Combined 40 visit calendar year Speech and Hearing: Combined 20 visit calendar year Chiropractic Services* Network: Deductible then Inpatient Mental Illness/Substance Abuse Network: Deductible then Outpatient Mental Illness/Substance Abuse Network: Deductible then Organ Transplant* Network: Deductible then Inpatient Hospice Facility* Network: Deductible then Women s Contraceptive devices, implants, injections and elective sterilization (includes insertion of devices) Network: Covered at Prescription Drugs* BCBSKC Rx Network: Annual Deductible then ; Tier 1 Contraceptives covered at Non-network: Deductible, then 50% after: $15 copay for Type 1 drug; $40 copay for Type 2 brand drug; $65 copay for Type 3 brand drug Prescription Drugs: Express Scripts: Mail Annual Deductible then ; Tier 1 Contraceptives covered at order drug program 102 day supply Lifetime Maximum Unlimited Dependent Coverage End of the year the children reach age 26 Prior Authorization Penalty* You are responsible for prior authorization for services received from non-network and out-of-area providers. If prior authorization is not obtained for services which require prior authorization, you are responsible for the cost of the services. Late Enrollees For employees or dependents applying after the eligibility period and not within a special enrollment period, coverage will become effective only on the group s anniversary date. Detailed Benefit Information Exclusions and Call a Customer Service Representative or consult your booklet/certificate. The certificate will govern in all cases. Limitations Customer Service or *Prior Authorization will be required for elective inpatient admissions, durable medical equipment (DME), infusion therapy and self injectables, organ and tissue transplants, some outpatient surgeries and services, hi-tech scans, prosthetics and appliances, mental health and chemical dependency, some outpatient prescriptions, skilled nursing facility, dental implants and bone grafts, and chiropractic services received from a non-network chiropractor. This list of services is subject to change. Please refer to your contract for the current list of services, which require Prior Authorization. **Use of in-network benefits reduces out-of-network benefits and use of out-of-network benefits reduces in-network benefits where applicable. The covered services described in the Benefit Schedule are subject to the conditions, limitations and exclusions of the contract.

3 Plan Type Plan Description (Visit our website at to receive a complete listing of network hospitals and physicians) Lee s Summit School District Health Benefit Plan Summary This Benefit Summary provides only a highlight of the services covered by Blue Cross and Blue Shield of Kansas City. Preferred-Care Blue PPO Effective Date: 1/1/16 A Preferred Provider Organization (PPO) Members can receive services from any hospital or physician but receive greater benefits when they use the Preferred-Care Blue network. Deductible $1,000 per individual/$3,000 per family Coinsurance (1) Network: 90% / Non-network: 70% Out-of-Pocket Maximum (2) Network: $3,000 individual/$6,000 family; Non-network: $6,000 individual/$12,000 family Physician Office Visits Network: PCP $40 copay (office visit only) (3) Specialist $80 copay (office visit only) (3) Lab Performed in a Physician s Network: Office/Independent Lab Lab Performed in a Hospital/Outpatient Network: Deductible then 90% Facility X-ray and Other Radiology Procedures Network: Deductible then 90% (4) Routine Preventive Care Network: (Contract lists covered services) Related Office Visit: Mammograms, Pap Smears and PSA tests Network: Inpatient Hospital Services/Outpatient Network: Deductible then 90% Surgery* (4) Emergency Room $200 copay then Deductible then 90% (Copay waived if admitted to a hospital) Urgent Care Network: $80 copay (office visit and lab only) (5) Ambulance Deductible then 90% Durable Medical Equipment* Network: Deductible then 90% Allergy Testing, Treatment, Injections Network: Deductible then 90% Home Health Services* Network: Deductible then 90% Skilled Nursing Facility* Network: Deductible then 90% 1 Portion of covered charges paid by BCBSKC after you satisfy your deductible and required copayments. 2 Total of deductible, coinsurance and copays members pay each year toward covered charges before BCBSKC pays of benefits. 3 Other services/procedures not specified on this benefit schedule that are performed in a physician s office are subject to the Network Deductible and Coinsurance level. 4 Diagnostic services performed at a Non-Participating Imaging Center inside Our Service Area are limited to a $200 calendar year. Inpatient hospital services in a Non-Participating Hospital inside our service area are limited to a $200 per day and are limited to 30 days per calendar year. Outpatient services at a Non-Participating Provider Hospital or at a Non-Participating Provider outpatient facility (including an ambulatory surgical center) inside our service area are limited to a $200 calendar year. 5 Other services/procedures that are performed by an urgent care provider are subject to the Network Deductible and Coinsurance level.

4 Outpatient Therapy (Speech, Hearing, Physical and Occupational)* Preferred-Care Blue PPO Network: Deductible then 90% Physical and Occupational: Combined 40 visit calendar year Speech and Hearing: Combined 20 visit calendar year Chiropractic Services* Network: $80 copay (office visit only) (5) Inpatient Mental Illness/Substance Abuse Network: Deductible then 90% Outpatient Mental Illness/Substance Abuse Network: Office Visit $40 copay All other services Deductible then 90% Organ Transplant* Network: Deductible then 90% Inpatient Hospice Facility* Network: Deductible then 90% Women s Contraceptive devices, implants, injections and elective sterilization (includes insertion of devices) Prescription Drugs* Prescription Drugs: Express Scripts: Mail order drug program 102 day supply Lifetime Maximum Network: Covered at BCBSKC Rx Network $150 Individual Rx Deductible/$450 Family Rx Deductible $15 copay for Tier 1 drug; Tier 1 contraceptives covered at $40 copay for Tier 2 brand drug; $65 copay for Tier 3 brand drug Non-network: 50% after copay Members NOT completing the enhancement program requirements will have a $300 Individual Rx Deductible/$900 Family Rx Deductible $30 copay for Tier 1 drug; Tier 1 contraceptives covered at $80 copay for Tier 2 brand drug; $130 copay for Tier 3 brand drug Unlimited Dependent Coverage End of the year the children reach age 26 Prior Authorization Penalty* You are responsible for prior authorization for services received from non-network and out-of-area providers. If prior authorization is not obtained for services which require prior authorization, you are responsible for the cost of the services. Late Enrollees For employees or dependents applying after the eligibility period and not within a special enrollment period, coverage will become effective only on the group s anniversary date. Detailed Benefit Information Exclusions and Call a Customer Service Representative or consult your booklet/certificate. The certificate will govern in all cases. Limitations Customer Service or *Prior Authorization will be required for elective inpatient admissions, durable medical equipment (DME), infusion therapy and self injectables, organ and tissue transplants, some outpatient surgeries and services, hi-tech scans, prosthetics and appliances, mental health and chemical dependency, some outpatient prescriptions, skilled nursing facility, dental implants and bone grafts, and chiropractic services received from a non-network chiropractor. This list of services is subject to change. Please refer to your contract for the current list of services, which require Prior Authorization. **Use of in-network benefits reduces out-of-network benefits and use of out-of-network benefits reduces in-network benefits where applicable. The covered services described in the Benefit Schedule are subject to the conditions, limitations and exclusions of the contract. Log on to for Provider Directories, claims status and much more!

5 Lee s Summit School District Effective Date: 1/1/16 Health Benefit Plan Summary This Benefit Summary provides only a highlight of the services covered by Blue Cross and Blue Shield of Kansas City. Blue-Care Basic HMO Blue-Care Buy Up HMO Plan Type A Health Maintenance Organization (HMO) A Health Maintenance Organization (HMO) Plan Description (Visit our website at to receive a complete listing of network hospitals and physicians) Members choose a primary care physician. Members may self-refer to physician specialists in the Blue-Care network. Urgent care and an exclusive network of specialists are also covered; other services must be ordered by an HMO Physician. Members choose a primary care physician. Members may self-refer to physician specialists in the Blue-Care network. Urgent care and an exclusive network of specialists are also covered; other services must be ordered by an HMO Physician. Deductible N/A N/A Coinsurance (1) N/A N/A Out-of-Pocket Maximum (2) $6,500 Individual/$13,000 Family $4,000 Individual/$8,000 Family Physician Office Visits PCP office visits: $40 copay Specialists: $80 copay PCP office visits: $40 copay Specialists: $80 copay Lab Performed in Physician s Office/Independent Lab Lab Performed in Hospital/Outpatient Facility X-ray and Other Radiology Procedures Routine Preventive Care No Copay No Copay (Contract lists covered services) Mammograms, Pap Smears and PSA tests Routine Vision Care (3) $10 copay $10 copay Childhood Immunizations Inpatient Hospital Services/Outpatient Surgery* $500 copay per day up to $2,500 per member calendar year $400 copay per day up to $2,000 per member calendar year MRI, MRA, CT and PET scans performed in a Physician s Office, Imaging Center or Other Outpatient Setting (including a hospital) $200 copay Only one copay will apply for each provider on a specified date of service even if multiple scans are performed $200 copay Only one copay will apply for each provider on a specified date of service even if multiple scans are performed Emergency Room/Urgent Care (Copay waived if admitted to a hospital) $200 copay; $80 copay if services are received in an urgent care center. $200 copay; $80 copay if services are received in an urgent care center. Ambulance Durable Medical Equipment* Allergy Testing, Treatment, Injections for injections; $100 copay for testing for injections; $100 copay for testing Home Health Services* Skilled Nursing Facility* Outpatient Therapy (Speech, Hearing, Physical and Occupational)* Physical and Occupational: Combined 40 visit calendar year Speech and Hearing: Combined 20 visit calendar year Physical and Occupational: Combined 40 visit calendar year Speech and Hearing: Combined 20 visit calendar year Chiropractic Services 1 Portion of covered charges paid by BCBSKC after you satisfy your deductible and required copayments. 2 Total of deductible, coinsurance and copays members pay each year toward covered charges before BCBSKC pays of benefits. 3 Vision Care: You may receive one vision exam per year (PCP referral not required). Log on to for Provider Directories, claims status and much more!

6 Blue-Care Basic HMO Blue-Care Buy Up HMO Inpatient Mental Illness/Substance Abuse $500 copay per day up to $2,500 per calendar year $400 copay per day up to $2,000 per calendar year Outpatient Mental Illness/Substance Abuse Office Visit and Therapy: $40 copay Office Visit and Therapy: $40 copay Organ Transplant* Inpatient Hospice Facility* Women s Contraceptive devices, implants, injections and elective sterilization (includes insertion of devices) Prescription Drugs* Prescription Drugs: Express Scripts: Mail order drug program 102 day supply Applicable copays $250 copay per day up to $2,500 per calendar year Copayments paid for Inpatient Hospice apply to the amount you pay for inpatient services and outpatient surgery in any calendar year Network: Non-network: Not Covered BCBSKC Rx Network $150 Individual Rx Deductible/$450 Family Rx Deductible $15 copay for Tier 1 drug; Tier 1 contraceptives covered at $40 copay for Tier 2 brand drug; $65 copay for Tier 3 brand drug Non-network: 50% after copay Members NOT completing the enhancement program requirements will have a $300 Individual Rx Deductible/$900 Family Rx Deductible $30 copay for Tier 1 drug; Tier 1 contraceptives covered at $80 copay for Tier 2 drug; $130 copay for Tier 3 brand drug Applicable copays $200 copay per day up to $2,000 per calendar year Copayments paid for Inpatient Hospice apply to the amount you pay for inpatient services and outpatient surgery in any calendar year Network: Non-network: Not Covered BCBSKC Rx Network $150 Individual Rx Deductible/$450 Family Rx Deductible $15 copay for Tier 1 drug; Tier 1 contraceptives covered at $40 copay for Tier 2 brand drug; $65 copay for Tier 3 brand drug Non-network: 50% after copay Members NOT completing the enhancement program requirements will have a $300 Individual Rx Deductible/$900 Family Rx Deductible $30 copay for Tier 1 drug; Tier 1 contraceptives covered at $80 copay for Tier 2 drug; $130 copay for Tier 3 brand drug Lifetime Maximum Unlimited Unlimited Dependent Coverage Missouri Mandate: Dependent daughters covered for maternity on Blue-Care. End of the year the children reach age 26 End of the year the children reach age 26 Prior Authorization Penalty* Late Enrollees Prior authorization is the responsibility of the network provider. For employees or dependents applying after the eligibility period and not within a special enrollment period, coverage will become effective only on the group s anniversary date. Prior authorization is the responsibility of the network provider. For employees or dependents applying after the eligibility period and not within a special enrollment period, coverage will become effective only on the group s anniversary date. Detailed Benefit Information Call a Customer Service Representative or consult your Call a Customer Service Representative or consult your Exclusions and Limitations booklet/certificate. The certificate will govern in all cases. booklet/certificate. The certificate will govern in all cases. Customer Service or or *Prior Authorization will be required for elective inpatient admissions, durable medical equipment (DME), infusion therapy and self injectables, organ and tissue transplants, some outpatient surgeries and services, hi-tech scans, prosthetics and appliances, mental health and chemical dependency, some outpatient prescriptions, skilled nursing facility, dental implants and bone grafts. This list of services is subject to change. Please refer to your contract for the current list of services, which require Prior Authorization. The covered services described in the Benefit Schedule are subject to the conditions, limitations and exclusions of the contract.