Health Savings PPO (Modified) Benefits-at-a-Glance Trinity Health Deductible, Copays, Coinsurance and Dollar Maximum Deductible - per calendar $1,300 per member The full family deductible must be met under a two $2,600 per family person or family contract before benefits are paid for any person on the contract. Health Savings PPO seed money Amount prorated based upon date of enrollment Copays No Copay Fixed Dollar Copays In-Network $3,500 per member $7,000 per family Out-of-Network $650 single $1,300 family $200 copay for: Outpatient surgery-facility fee only $1000 copay for: Inpatient admissions Coinsurance Percent Coinsurance 10% 40% Note: Services without a network are covered at the in-network level. Out-of-Pocket Maximum All members on the contract can contribute to the family out of pocket maximum; however, a single member will not exceed the individual out of pocket maximum. Lifetime Maximum $2,600 per member $5,200 per family $7,000 per member $14,000 per family Includes deductible, coinsurance and copays for all Includes deductible, coinsurance covered services including prescription drugs Unlimited Note: 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 In-network, eligible care will be covered for the rest of the plan. Preventive Services Health Maintenance Exam - beginning age 4; one Covered - 100% per calendar Routine Physical Related Test Covered - 100% X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam- two per calendar Covered - 100%, in addition to health maintenance exam Pap Smear Screening - one per calendar Covered - 100% Mammography Screening - beginning age 35; 1 Covered - 100% base line age 35-40; annual age 40+ 3D mammography not covered Contraceptive Methods and Counseling Prostate Specific Antigen (PSA) Screening - one Covered - 100% per calendar age 40 and over Endoscopic Exams - one per calendar Covered - 100% Well Child Care Covered - 100% 8 visits, birth through 12 months 6 visits, 13 months through 35 months 2 visits, 36 months through 47 months Visits beyond 47 months are limited to one per member per calendar under the health maintenance exam benefit. Immunizations- pediatric and adult Covered - 100% Routine Hearing Exam one per calendar Covered - 100%
In-Network Out-of-Network Physician Office Services Office Visits Includes: -Primary care and specialist physicians -Initial visit to determine pregnancy Office Consultation Pre-Surgical Consultation Emergency Medical Care Hospital Emergency Room Qualified medical emergency Non-Emergency use of the Emergency Room Urgent Care Services Ambulance Services - Medically Necessary Transport Facility and Professional Diagnostic Services MRI, MRA, PET and CAT Scans and Nuclear Medicine Diagnostic Tests, X-rays, Laboratory & Pathology Radiation Therapy and Chemotherapy Maternity Services Provided by a Physician Prenatal Care Visits Covered - 100% deductible waived 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) Postnatal Care Visits Covered - 100% after deductible Delivery and Nursery Care High Risk Specialist Visits Ultrasounds and Pregnancy Diagnostic Lab test Anemia Screening and Gestational Diabetes Covered 100% deductible waived screening Amniocentesis (Professional Charges) Amniocentesis (Facility Charges) Covered 90% after deductible Covered 60% after deductible after $200 copay NOTE: Mom and Baby s claims are processed separately under their own claims and both may be subject to the Deductible and OOP Max. Hospital Care Semi-Private Room, Inpatient Physician Care, Covered- 60% after deductible after $1000 copay General Nursing Care, Hospital Services and Supplies Inpatient Medical Care Alternatives to Hospital Care Hospice Care Covered - 100% after deductible Home Health Care Limited to a maximum of 120 visits per calendar Skilled Nursing Limited to a maximum of 120 days per calendar Covered- 60% after deductible after $1000 copay
In-Network Surgical Services Surgery (includes related surgical services) Covered Professional -90% after deductible Facility-90% after deductible Sterilization - males only; excludes reversal sterilization Sterilization - females only; excludes reversal sterilization Out-of-Network Covered Professional -60% after deductible Facility-60% after deductible after $200 copay Human Organ Transplants Specified Organ Transplants Not covered except in designated facilities in designated facilities only, when coordinated through BCBSM Human Organ Transplant Program (800-242-3504) Kidney, Cornea, Bone Marrow and Skin Behavioral Health Care and Substance Abuse Treatment Services Inpatient Behavioral Health Care and Substance Abuse Treatment Outpatient Behavioral Health Care and Substance Abuse Treatment Covered- 60% after deductible after $1000 copay Autism Spectrum Disorders, Diagnoses and Treatment- Up to and including age 18 Applied Behavioral Analysis (ABA) Physical, Occupational and Speech Therapy Limited to 60 visits maximum per therapy per calendar Nutritional Counseling Other Services Cardiac Rehabilitation Maximum 36 visits in a 12 week period Chiropractic Spinal Manipulation Limited to a maximum of 20 visits per calendar Durable Medical Equipment Prosthetic and Orthotic Devices Private Duty Nursing Limited to a maximum of 120 visits per calendar Allergy Testing and Therapy Therapy Services Physical, Occupational, and Speech Therapy (Speech Therapy is payable when related to an Limited to 60 visits maximum per therapy per calendar Accidental Injury only) Note: The following services require preapproval: Inpatient Care, select Radiology and Diagnostic Services, Inpatient Behavioral Health Care and Substance Abuse Treatment, and Skilled Nursing 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 deductible and/or copay. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.
Selecting a Provider In-network: Participating 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 deductibles, 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. Out-of-Network: Non-participating 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 deductibles, copayments, and coinsurances required by your plan along with charges for non- covered services. Weight Loss Reimbursement Program The Plan will cover nutritional and/or behavioral based counseling services for the purpose of non-surgical weight loss. These benefits are not subject to Deductible and Out-of-Pocket Maximums. Upon successful completion of the non-surgical weight loss program, benefits are payable at 100% up to a $500 annual maximum, to include: Outpatient counseling or therapy; Office visits rendered by a licensed Physician; Lab services performed during a course of treatment; Behavioral and/or nutritional counseling services for weight loss rendered by a Trinity Health Regional Health Ministry; and Nationally recognized programs that include behavioral modification and/or nutrition counseling as part of their programs (such as the behavioral health and/or nutritional counseling program offered by Jenny Craig, Weight Watchers and LA Weight Loss), for the purpose of non-surgical weight loss. Not covered are: Charges for food and/or nutritional supplements Health clubs, gyms, personal trainers, exercise classes or exercise equipment Services administered exclusively in a Web-based forum Pharmacotherapy and/or injection expenses associated with weight loss Charges for over-the-counter diet aids Charges in connection with acupuncture, hypnotism, and/or biofeedback training Services and/or programs not approved and/or provided in the United States
Case Management / Disease Management Program 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. Notes: Cancer Treatment Centers of America (CTCA) there is no In- 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 their facilities. Services performed at Mayo Clinic (facility and professional) will be subject to the out of network cost share. Dialysis s services performed by an out of network provider are not covered.
Prescription Drugs Administered directly by CVS Caremark Retail 34-day supply Mail Order 90 day supply Ministry owned on-site pharmacies 34-day supply Ministry owned on-site pharmacies 90 day supply 80% subject to deductible (Deductible and out-of-pocket maximum based on "Trinity Health" / Tier 1 benefit level) * Generic preventive drugs are covered at 100% (no deductible) 80% subject to deductible (Deductible and out-of-pocket maximum based on "Trinity Health" / Tier 1 benefit level) * Generic preventive drugs are covered at 100% (no deductible) 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 50-59 male; age 12-59, 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 ) 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