2015 Medical Plan Comparison Charts

Transcription

1 2015 Comparison Charts REGION NATIONWIDE CALIFORNIA Description Calendar year deductible Annual out-ofpocket (includes deductible) Lifetime benefit UHC High Deductible HSA Plan UHC Choice Plus (North and South) In-Network Out-of-Network In-Network Out-of-Network Provides benefit after you pay a deductible. Varian contributes $400 to the HSA for individual coverage ($600 for other coverage). You can contribute up to $3,350 for an individual or $6,650 for a family to a health savings account (HSA) with pre-tax deductions from your paycheck. Any remaining funds in your HSA will be rolled over from year to year. Single: $1,500 Family: $3,000 Single: $2,500 Family: $5,000 Single: $3,000 Family: $6,000 Single: $4,000 Family: $8,000 Benefits based on negotiated discounts using UHC Choice Plus PPO network $350 per person $700 per family $2,350 per person $4,700 per family A single out-of-pocket applies to all coverage under the plan, including medical, prescription drug, mental health and substance abuse disorder benefits. Benefits based on 110% MNRP 1 ; providers of your choice $700 per person $1,400 per family $4,700 per person $9,400 per family Care provided through Kaiser hospitals, medical centers, and physicians $1,500 per person $3,000 per family OUTPATIENT SERVICES Doctor s office visit Preventive examination Immunization and allergy injection Plan pays 100%; deductible Immunization: 100% covered; deductible Allergy injection: Immunization: Allergy injection: Plan pays 100%; deductible Immunization: Plan pays 100%; deductible Allergy injection: care physician visit or $35 for ; covered at 100% if no office visit billed Prenatal care You pay $25 for first visit only Well-baby care 100% covered; deductible 100% covered; deductible Plan pays 100% immunizations; you pay $5 per visit for allergy injections Plan pays 100% Plan pays 100% up to age 2 Hospital room and board ; pre-service notification is required ; pre-service notification is required Text in Bold and Italic denotes changes from last year. 1 Benefits for covered expenses subject to deductible (note: for the UHC High Deductible HSA Plan, if you elect family coverage, you must satisfy the family deductible before any benefits are payable); out-of-network benefits are subject to Maximum Non-Network Reimbursement Program (MNRP). These MNRP limits assure that expenses allowed under the Plan represent the fees set by UnitedHealthcare based on a percentage of the published rates allowed by Medicare for the same or similar service or available data resources of competitive fees in that geographic area. For details, please refer to the Summary Plan Description. 8

2 REGION UTAH GEORGIA NEVADA Description SelectHealth Select Med HMO Care provided through Select Med network SelectHealth Select Med Plus POS In-Network Care provided through Select Med network Out-of-Network Provides benefits based on usual and customary rates for the provider of your choice Georgia Care provided through Kaiser hospitals, medical centers, and physicians Health Plan of Nevada Care provided through the HPN HMO provider network Calendar year deductible $650 per person $1,300 per family Annual out-ofpocket (includes deductible) $2,000 per person $4,000 per family $2,000 per person $4,000 per family $4,000 per person $8,000 per family $6,500 per person Lifetime benefit OUTPATIENT SERVICES Doctor s office visit care physician visit; $35 for You pay $15 for primary care physician visit; $30 for ; referral required for visit Preventive Plan pays 100% Plan pays 100% Plan pays 100% Plan pays 100% examination 2 Immunization and allergy injection Plan pays 100% Plan pays 100% You pay $25 per visit for allergy injections immunizations and allergy serum immunizations You pay $30/visit for allergy shots Prenatal care Well-baby care You pay $25 for first visit only You pay $25 for first visit only Hospital room and board You pay $25 per visit Plan pays 100% You pay $15 per visit You pay $25 per visit Plan pays 100% up to age 2; you pay $25 per visit after 29 months You pay $250 per admission after $250 hospital copay with pre-authorization Plan pays 100% You pay $300 per admission; prior 9

3 REGION NATIONWIDE CALIFORNIA UHC High Deductible HSA Plan UHC Choice Plus In-Network Out-of-Network In-Network Out-of-Network (North and South) Mental Health (MH) and Substance Abuse (SA) for inpatient or outpatient MH/SA treatment for inpatient or outpatient MH/SA treatment; prior authorization is required from the MH/SA Designee for inpatient MH/SA treatment; 100% for outpatient MH/SA treatment after you pay $25 copay for inpatient or outpatient MH/SA treatment; prior authorization is required from the MH/SA Designee Mental Health: for inpatient MH; you pay $25 per visit for outpatient individual MH therapy; $12 per visit for outpatient group MH therapy Substance Abuse: for inpatient SA detox and $100 per transitional residential recovery; you pay $25 per visit for outpatient individual SA therapy; $5 per visit for outpatient group SA therapy Emergency care for emergency and urgent care for emergency and urgent care; pre-service notification is required if admitted emergency after $100 2 copay per visit; Plan pays 100% for urgent care after $50 copay per visit emergency after $100 2 copay per visit; pre-service notification is required if admitted; Plan pays 70% 1 for urgent care You pay $100 2 per visit for emergency in- or out-of-area; you pay $25 per visit for urgent care OTHER SERVICES Infertility Physical therapy for up to 20 visits per year up to $4,000 lifetime (in- and out-of-network for up to 20 visits per year; pre-service notification is required for certain for up to 60 visits per year in- and out-of-network combined up to $4,000 lifetime (in- and out-of-network for up to 60 visits per year in- and out-of-network combined; pre-service notification is required for certain Plan pays 50% for diagnosis only; Gamete Intrafallopian Transfer (GIFT) not covered Plans pays 100% for inpatient after $250 hospital copay; you pay $25 per visit for outpatient Chiropractic and Acupuncture for up to 30 chiropractic visits per year and up to 30 acupuncture visits per year, in- and out-ofnetwork combined Text in Bold and Italic denotes changes from last year. for up to 30 chiropractic visits and up to 30 acupuncture visits, in- and out-ofnetwork combined; preservice notification is required for certain for up to 30 chiropractic visits per year and up to 30 acupuncture visits per year, in- and out-of-network combined for up to 30 chiropractic visits and up to 30 acupuncture visits, in- and out-of-network combined; pre-service notification is required for certain You pay $15 per visit for up to 20 chiropractic or acupuncture visits per year through American Specialty Health Plans; $50 per year allowance for equipment or supplies 1 Benefits for covered expenses subject to deductible (note: for the UHC High Deductible HSA Plan, if you elect family coverage, you must satisfy the family deductible before any benefits are payable); out-of-network benefits are subject to Maximum Non-Network Reimbursement Program (MNRP). These MNRP limits assure that expenses allowed under the Plan represent the fees set by UnitedHealthcare based on a percentage of the published rates allowed by Medicare for the same or similar service or available data resources of competitive fees in that geographic area. For details, please refer to the Summary Plan Description. 2 Copay waived if admitted. 10

4 REGION UTAH GEORGIA NEVADA SelectHealth Select Med HMO SelectHealth Select Med Plus POS In-Network Out-of-Network Georgia Health Plan of Nevada Mental health (MH) and Substance Abuse (SA) You pay $250 per admission for inpatient MH/SA treatment; you pay $25 per visit for outpatient MH/SA treatment for inpatient MH/SA treatment; you pay $25 per visit for outpatient MH/SA treatment for inpatient MH/SA treatment; then plan pays 70% 1 with pre-authorization; plan pays 70% 1 for outpatient MH/SA treatment for MH treatment; inpatient SA treatment is not covered; you pay $25 per visit for individual outpatient MH/SA treatment; you pay $12 for group outpatient MH treatment and $25 for group outpatient SA treatment You pay $300 per admission for inpatient MH/SA treatment; you pay $30 per visit for outpatient individual MH/SA treatment; $15 per visit for group outpatient MH/SA treatment; prior Emergency care You pay $100 2 per visit for emergency at participating facilities; $150 2 per visit at nonparticipating facilities; $35 per visit at urgent care facility You pay $100 per visit for emergency You pay $150 per visit for emergency You pay $100 2 per visit for at hospital; you pay $45 for at designated urgent care clinic You pay $75 2 per visit to emergency room; non-emergency NOT covered; you pay $20 per visit to in-area urgent care clinic; $40 per visit to out-of-area urgent care clinic OTHER SERVICES Infertility Plan pays 50% up to $1,500 per year; $5,000 lifetime benefit Plan pays 50% up to $1,500 per year; $5,000 lifetime benefit for select You pay $35 for diagnosis; prescriptions and treatment not covered You pay $30 per visit; for surgical treatments, surgery copayments apply; prior Physical therapy Plan pays 100% up to 40 visits per year for inpatient ; you pay $35 per visit ($25 if provided by your primary care physician) for outpatient up to 20 visits per year Plan pays 100% up to 40 visits per year for inpatient (in- and out-ofnetwork ; you pay $35 per visit ($25 if provided by your primary care physician) for outpatient up to 20 visits per year/therapy type (in- and out-of-network up to 40 visits per year for inpatient (in- and out-ofnetwork and up to 20 visits per year for outpatient (in- and out-ofnetwork You pay $35 per visit up to 20 visits per year (physical and occupational therapy ; you pay $35 per visit up to 20 visits per year for speech therapy You pay $15 per visit up to 60 visits per year; prior Chiropractic and Acupuncture You pay $20 per chiropractic visit up to 20 visits per year; Acupuncture are not covered You pay $20 per chiropractic visit up to 20 visits per year; Acupuncture are not covered Acupuncture and chiropractic are not covered You pay $35 per visit for up to 30 chiropractic visits per year and up to 30 acupuncture visits per year You pay $30 per chiropractic visit up to 60 visits per year; Acupuncture are not covered 11

5 REGION NATIONWIDE CALIFORNIA OTHER SERVICES (CONTINUED) Prescription 30-day supply Mail-order prescription 90-day supply X-ray and lab tests UHC High Deductible HSA Plan UHC Choice Plus (North and South) In-Network Out-of-Network In-Network Out-of-Network for Tier 3 after deductible has been met 3 You pay $5 copay for core preventive drugs, not subject to deductible You pay $25 for Tier 1, $75 for Tier 2, and $125 for Tier 3 after deductible has been met 3 You pay $10 copay for core preventive drugs, not subject to deductible Mandatory mail order for specialty drug prescriptions preventive for Tier 3 after deductible has been met 3 You pay $5 copay for core preventive drugs, not subject to deductible You pay the in-network copay plus the difference between non-network pharmacy charge and network pharmacy charge for Tier 3 3 You pay $5 copay for prescription medications to treat high blood pressure, high blood cholesterol, and diabetes You pay $25 for Tier 1, $75 for Tier 2, and $125 for Tier 3 3 You pay $10 copay for prescription medications to treat high blood pressure, high blood cholesterol, and diabetes Mandatory mail order for specialty drug prescriptions preventive for Tier 3 3 You pay $5 copay for prescription medications to treat high blood pressure, high blood cholesterol, and diabetes You pay the in-network copay plus the difference between non-network pharmacy charge and network pharmacy charge $30 for brand; up to 30-day supply at Kaiser pharmacy You pay $30 for generic; $60 for brand; up to 100-day supply at Kaiser pharmacy Plan pays 100% Vision care NOTE: Additional vision coverage through VSP is available as a separate election. ; 1 exam every two years You pay $25 copay; 1 exam every two years exams at Kaiser facility; hardware not covered Text in Bold and Italic denotes changes from last year. 1 Benefits for covered expenses subject to deductible (note: for the UHC High Deductible HSA Plan, if you elect family coverage, you must satisfy the family deductible before any benefits are payable); out-of-network benefits are subject to Maximum Non-Network Reimbursement Program (MNRP). These MNRP limits assure that expenses allowed under the Plan represent the fees set by UnitedHealthcare based on a percentage of the published rates allowed by Medicare for the same or similar service or available data resources of competitive fees in that geographic area. For details, please refer to the Summary Plan Description. 2 Copay waived if admitted. 3 The Pharmacy Drug List (PDL) is subject to change January 1 and July 1 each year. 12

6 REGION UTAH GEORGIA NEVADA SelectHealth Select Med HMO SelectHealth Select Med Plus POS In-Network Out-of-Network Georgia Health Plan of Nevada OTHER SERVICES (CONTINUED) Prescription 30-day supply formulary; $45 for brand formulary; $45 for brand not in formulary formulary; $45 for brand not in formulary You pay $15 for generic and brand at Kaiser pharmacies; $25 at any Rite Aid or Walgreens pharmacy; limitations apply formulary; $45 for brand Mail-order prescription 90-day supply $60 for brand within formulary; $135 for brand $60 for brand within formulary; $135 for brand $60 for brand within formulary; $135 for brand You pay $30 for generic and brand 90-day supply at Kaiser pharmacies You pay $30 generic within formulary; $60 for brand within formulary; non-formulary not covered X-ray and lab tests minor ; you pay $50 for major (e.g. CT scans, MRI/NMR, neurologic and cardiovascular diagnostics) minor ; you pay $50 for major (e.g. CT scans, MRI/NMR, neurologic and cardiovascular diagnostics) Plan pays 100% in doctor s office (you pay $35 per visit for high tech radiology in office); you pay $50 per visit in outpatient hospital setting (you pay $50 for high tech radiology in hospital) You pay $15 per visit for diagnostic test, $30 for MRI or CT; prior Vision care NOTE: Additional vision coverage through VSP is available as a separate election. Routine eye exam by SelectHealth provider covered with office visit copay Routine eye exam by SelectHealth provider covered with office visit copay Routine eye exam by SelectHealth provider covered with office visit copay You pay $35 for annual exam at network providers; hardware not covered You pay $10 for annual exam Discounts available at network providers 13