Health Savings PPO Benefits-at-a-Glance Trinity Health Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Health Savings PPO seed money Amount prorated based upon date of enrollment Copays/Coinsurance Fixed Dollar Copays Tier 1 Trinity Health Facilities and Aligned Professional Providers $1,300 per member $2,600 per family No copay Tier 2 PPO In-Network Facility $2,500 per member $5,000 per family $650 Single $1,300 Family $100 copay: Outpatient surgeryfacility fee only $500 copay: Inpatient Admission Tier 3 Out-of-Network Facility $3,500 per member $7,000 per family $200 copay: Outpatient surgeryfacility fee only $1,000 copay: Inpatient Admission Percent Coinsurance 10% 20% 40% Note: Services without a network are covered at the in-network level. Out-of-Pocket Maximum Includes, coinsurance and copays for all covered services including prescription drugs $2,600 per member $5,200 per family $5,000 per member $10,000 per family $7,000 per member $14,000 per family If any individual in the plan reaches the single out-of-pocket expenses before the family out-of-pocket maximum is met, the cost of that individual's innetwork, eligible care will be covered for the rest of the plan year. Preventive Services Health Maintenance Exam - one per Covered - 100% Covered - 100% Covered - 60% after calendar year (age 18 and over) Routine Physical Related Test Covered - 100% Covered - 100% Covered - 60% after X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam - one per Covered - 100% Covered - 100% Covered - 60% after calendar year, in addition to health maintenance exam Pap Smear Screening - one per calendar Covered - 100% Covered - 100% Covered - 60% after year Mammography Screening - one per Covered - 100% Covered - 100% Covered - 60% after calendar year (one baseline age 35 39 then one annually age 40 and over) Prostate Specific Antigen (PSA) Covered - 100% Covered - 100% Covered - 60% after Screening - one per calendar year age 40 and over Endoscopic Exams - one per calendar year Covered - 100% Covered - 100% Covered - 60% after
Tier 1 Trinity Health Facilities and Aligned Professional Providers Tier 2 PPO In-Network Facility Tier 3 Out-of-Network Facility Well Child Care 7 visits, birth through 12 months Covered - 100% Covered - 100% Covered - 60% after 3 visits, 13 months through 36 months 2 visits, 37 months through 47 months 1 visit per year thereafter through age 17 Immunizations -Pediatric & Adult Covered - 100% Covered - 100% Covered - 60%after Routine Hearing Exam One per calendar year Covered - 100% Covered - 100% Covered - 60%after Physician Office Services Office Visits Includes: Primary care and specialist physicians Presurgical consultations Initial visit to determine pregnancy Covered - 90% after Covered - 80% after Covered - 60% after Emergency Medical Care Hospital Emergency Room Covered - 90% after Covered - 90% after Covered - 90% after Qualified medical emergency Non-Emergency use of the Emergency Covered - 90% after Covered - 80% after Covered - 60% after Room Urgent Care Services Covered - 90% after Covered - 90% after Covered - 90% after Ambulance Services - Medically Necessary Transport Covered - 90% after Covered - 80% after Covered - 80% after Facility Diagnostic and Therapeutic Services MRI,MRA, PET and CAT Scans and Covered - 90% after Covered - 80% after Covered - 60% after Nuclear Medicine Diagnostic Tests, X-rays, Laboratory & Covered - 90% after Covered - 80% after Covered - 60% after Pathology Radiation Therapy and Chemotherapy Covered - 90% after Covered - 80% after Covered - 60% after Professional Diagnostic and Therapeutic Services MRI,MRA, PET and CAT Scans and Covered - 90% after Covered - 80% after Covered - 60% after Nuclear Medicine Diagnostic Tests, X-rays, Laboratory & Covered - 90% after Covered - 80% after Covered - 60% after Pathology Radiation Therapy and Chemotherapy Covered - 90% after Covered - 80% after Covered - 60% after
Tier 1 Trinity Health Facilities and Aligned Professional Providers Maternity Services Provided by a Physician Pre-Natal and Post-Natal Care for physician office visits including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood pressure, and fetal heart rate check) Tier 2 PPO In-Network Facility Tier 3 Out-of-Network Facility Covered 100% waived Covered 100% waived Covered 60% of R&C after High Risk Specialist Visits 100% after 100% after Covered 60% of R&C after Delivery and Nursery Care Ultrasounds and Pregnancy Diagnostic Lab Tests Anemia Screening and Gestational Diabetes Screening Amniocentesis (Professional Charges) Amniocentesis (Facility Charges) Covered 90% of R&C after Covered 90% of R&C after Covered 80% of R&C after Covered 80% of R&C after Covered 60% of R&C after Covered 60% of R&C after Covered 100% waived Covered 100% waived Covered 60% of R&C after Covered 90% of R&C after Covered 90% of R&C after after $50 copay Covered 80% of R&C after Covered 80% of R&C after after $100 copay Mom and Baby s claims are processed separately under their own files and both may be subject to the Deductible and OOP Max. Hospital Care Covered 60% of R&C after Covered 60% of R&C after after $50 copay Semi-Private Room, General Nursing Covered - 90% after Covered - $500 copay, then 80% Covered - $1,000 copay, then Care, Hospital Services and Supplies after 60% after Inpatient Medical Care Covered - 90% after Covered - 80% after Covered - 60% after Alternatives to Hospital Care Hospice Care Covered - 100% after Covered - 100% after Covered - 60% after Home Health Care Covered - 90% after Covered - 80% after Covered - 60% after Limited to 120 visits per calendar year Skilled Nursing Limited to 120 days per calendar year Covered - 90% after Covered - $500 copay, then 80% after Covered - $1,000 copay, then 60% after Surgical Services (Outpatient) Surgery (includes related surgical services) Covered - 90% after Covered - $100 copay then; 80% after Covered - $200 copay then; 60% after Sterilization Not Covered Not Covered Not Covered
Tier 1 Trinity Health Facilities and Aligned Professional Providers Tier 2 PPO In-Network Facility Tier 3 Out-of-Network Facility Human Organ Transplants Specified Organ Transplants in designated Covered - 90% after Covered - 80% after Not covered facilities only, when coordinated through BCBSM Human Organ Transplant Program (800-242-3504) Kidney, Cornea, Bone Marrow and Skin Covered - 90% after Covered - 80% after Covered - 60% after Behavioral Health and Substance Abuse Services Inpatient Behavioral Health and Inpatient Substance Abuse Care Covered - 90% after Covered - 90% after * Covered - $1,000 copay, then 60% after Outpatient Behavioral Health Covered - 90% after Covered - 90% after * Covered - 60% after Outpatient Substance Abuse Care Covered - 90% after Covered - 90% after * Covered - 60% after *Tier 1 Other Services Cardiac Rehabilitation Covered - 90% after Covered - 80% after Covered - 60% after Maximum 36 visits in a 12 week period Chiropractic Services Covered - 90% after Covered - 80% after Covered - 60% after 20 visit maximum per calendar year Durable Medical Equipment Covered - 90% after Covered - 80% after Covered - 60% after Prosthetic and Orthotic Devices Covered - 90% after Covered - 80% after Covered - 60% after Private Duty Nursing Covered - 90% after Covered - 80% after Covered - 60% after 120 visits per calendar year Allergy Testing Covered - 90% after Covered - 80% after Covered - 60% after Allergy Therapy Covered - 90% after Covered - 80% after Covered - 60% after Therapy Services Physical, Occupational and Speech Therapy Covered - 90% after Covered - 80% after Covered - 60% after Limited to 60 visits maximum per therapy per calendar year The information in this document is based on BCBSM s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA b becomes available. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM s approved amount, less any applicable and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-At-A-Glance and any applicable plan document, the plan document will control.
Selecting a Provider Tier 1: Trinity Health Facilities When you use Trinity Health facilities, satellite locations and/or aligned physicians with Trinity Health, you receive the highest benefit payment level. A listing of eligible facilities is available online at bsbsm.com. Tier 2: Network Providers Network providers have signed agreements with BCBS, which means they agree to accept our approved payment for a covered benefit as payment in full. You will only pay for the s, copayments and coinsurances required by your coverage. Ask your physician if he or she participates with the BCBS PPO network in your plan area. If you need help locating a network provider, please call the phone number to locate a BCBS network provider or visit the Web site listed on the inside front cover of this handbook. When you go to network providers, you do not have to send a claim to us. Network providers submit claims to BCBS for you, and they are paid directly by BCBS. Tier 3: Nonparticipating (Out-of-Network) Providers Nonparticipating providers have not signed agreements with BCBS. This means they may or may not choose to accept the BCBS approved amount as payment in full for your health care services. If your present providers do not participate with BCBS, ask if they will accept the amount we approve as payment in full for the services you need. This is called participating on a "per claim" basis and means that the providers will accept the approved amount as payment in full for the specific services. You are responsible for any s, copayments, and coinsurances required by your plan along with charges for non-covered services. Trinity Health Incentive Programs Non-Surgical Weight Loss Therapy Along with the existing benefits for bariatric surgery, the plan will cover additional services for non-surgical weight loss treatment. Benefits are payable 100% up to an annual benefit maximum of $500* and include: Outpatient counseling or therapy, Office visits rendered by a licensed physician for the treatment of weight loss Lab services performed during a course of treatment, and Services for weight loss rendered by a Trinity Health Ministry Organization or national recognized programs such as Jenny Craig, Weight Watchers and LA Weight Loss. Weight-loss expenses that are not covered are: Services administered exclusively through an Internet-based forum, Medication or injection expenses for weight loss, unless otherwise covered for an unrelated medical condition Charges for food or nutritional supplements, unless included in the initial program fee, Charges for over-the counter diet aids, Health clubs or exercise equipment, Services or programs that are not approved in the United States, and Charges in connection with acupuncture, hypnotism or biofeedback training. *Please note that the non-surgical weight loss therapy incentive is considered taxable income to the subscriber.
Case Management / Disease Management Program The Case Management / Disease Management Program is available to you and/or your covered dependents (18 or older) and minor dependents (17 and younger). A parent/guardian will need to provide approval for a BCBSM nurse to speak to a minor. If you agree to participate a BCBSM nurse case manager will administer an assessment and an individualized plan that includes condition and goals based on your assessment results. If you agree to participate a BCBSM nurse case manager will administer an assessment and an individualized plan that includes condition and goals based on your assessment results. The nurse will work with you via telephone to address your specific health concerns and goals. Once you have completed the program you will receive a case closure letter via mail and a call explaining that you have completed your program. Note: Cancer Treatment Centers of America (CTCA) there is no Network or Out-Network coverage for both health care services provided by the facility; and health care services provided by physicians and other health care professionals at any of these facilities.
Prescription Drugs Administered directly by CVS Caremark Retail 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name Mail Order 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name Ministry owned on-site pharmacies 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name Ministry owned on-site pharmacies 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name 80% subject to (Deductible and out-of-pocket maximum based on "Trinity Health" / Tier 1 benefit level) * Generic preventive drugs are covered at 100% (no ) 80% subject to (Deductible and out-of-pocket maximum based on "Trinity Health" / Tier 1 benefit level) * Generic preventive drugs are covered at 100% (no ) 50% coinsurance for infertility drugs dispensed through pharmacy (no maximum) Pharmacy copays and coinsurance will track to Tier 1 out-of-pocket max If the brand drug has a specific equivalent generic drug available and the plan participant receives the brand, then in addition to the copay, the plan participant must also pay the difference between the ingredient cost of the brand drug and the generic drug. Specialty medications must be filled at a Trinity Health pharmacy or through the CVS Caremark Specialty program; prescriptions limited to a 30 day supply. Mandatory Maintenance is required for each maintenance medication after an initial retail prescription and two refills. Coverage of Preventive Services Medications (under the Patient Protection and Affordable Care Act (No copay): Prescription required - Iron supplements (Ages 6 months through 12 months), Oral Fluorides (Ages 5 and younger), Aspirin (ages 45 and older, male and female; age 12 and older, female), Folic Acid (women age 55 and younger), Immunizations, Vitamin D (Ages 65+), Bowel Preparation Medications Prescription only (ages 50 through 74), and Breast Cancer Drugs (female age 35+) Prescription required (total 168-day supply) - Tobacco Cessation - Nicotine replacement products, including Nicotine patch, gum & lozenges. Also covers generic Zyban or Chantix Exclusions:
Cosmetic medication Anti-wrinkle agents, Hair growth / removal, etc Erectile Dysfunction (ED) Medications Non-Sedating Antihistamine (NSA) Drugs Compound pain patches and bulk powders Hypoactive Sexual Desire Disorder (Addyi) The following is a list of the drugs that need prior authorization to be covered (not intended to be an all-inclusive list): (Your physician must call 1-800-626-3046 to obtain approval for a period of up to one year) Topical acne Oral contraceptives Compounds $300 an greater Specialty medications Anti-obesity agents Narcolepsy Anabolic steroids The following is a list of most but not all of the drugs that have a quantity limit imposed: Flu medication Migraine medication Due to the large number of available medicines, this list is not all inclusive. Please note that this list does not guarantee coverage and is subject to change. Your prescription benefit plan may not cover certain products or categories, regardless of their appearance on this list. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. For a complete description of benefits please see the applicable summary plan descriptions. If there is a discrepancy between this summary and any applicable plan document, the plan document will control. More information is available through Caremark.com to help you manage your prescription drug program. You will be able to locate a pharmacy, order mail service refills, track mail service orders, and ask questions. For additional information contact Caremark at 800-966-5772