Your Policy gives You important information about Your health care benefits. It includes information such as Pre-Authorization requirements. This Schedule of Benefits is issued to You with Your Policy. It summarizes Your benefits and gives their effective date. Please keep Your Schedule of Benefits with Your Policy. will notify You if any changes are needed. Coverage Information Policy Holder: Policy Number: [Policy Holder Name] [Policy Number] Plan Name: Phoenix Choice Silver HMO Abrazo and Phoenix Children s Hospital + Dental/Vision (73% AV CSR) Covered Person(s): Primary: [Member #1] Dependents: [Member #2] [Member #3] [Member ##] Date these benefits take effect: [Member #1] [Member #2] [Member #3] [Member ##] [MM/DD/YYYY] [MM/DD/YYYY] [MM/DD/YYYY] [MM/DD/YYYY] The applies to all Covered Services except: Preventive care services as defined under federal law and in Your Policy Primary care provider office visit (only the office copayment is exempt from the ) Specialist office visit (only the office copayment is exempt from the ) Routine pre/postnatal care Telehealth Urgent care Home health Outpatient lab (blood work) Diagnostic imaging (x-ray) Mental health/substance abuse office visit Diabetes care education Medical Foods gastric disorder formula and inherited metabolic disorder Pediatric vision services Other adult vision services Fitness benefit PHXSilverAPCHDV73_65441AZ008000204 Page 1 of 9
Prescription drugs Other dental care services (adult and pediatric) 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): $2600 Per Plan Year (for all covered family Members): $5200 Drug : Per Plan Year (for covered individual Member): $0 Per Plan Year (for all covered family Members): $0 Please note that separate s apply to pediatric and adult dental Covered Services. See Your Schedule of Benefits Dental for more information. 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 Pre-Authorization, adult dental services, other adult vision services, fitness benefit and health care the plan does not cover. Medical Out-of-Pocket Maximum: Per Plan Year (for covered individual Member): $5350 Per Plan Year (for all covered family Members): $10700 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 Pediatric Dental Services Out-of-Pocket Maximum: PHXSilverAPCHDV73_65441AZ008000204 Page 2 of 9
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, Emergency Ambulance, out-of-service Area Urgent Care or Pre-Authorized by Us Office Visits Primary Care Office Visit Specialist Office Visit $60 Copay per visit 100% of allowed costs Routine Prenatal/Postnatal Visit Telehealth Visit Preventive Care 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 Policy Well-Baby/Child No charge 100% of allowed costs Emergency Medical & Urgent Care Emergency Room Services $150 Copay per visit after (Copay waived if admitted) 100% of allowed costs and Urgent Care Services $80 Copay per visit 100% of allowed costs Emergency Ambulance Services after PHXSilverAPCHDV73_65441AZ008000204 Page 3 of 9
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 and Travel Expenses Bariatric Surgery Maternity Services (including delivery and nursery care) Outpatient Surgery (including hospital and physician services) Ambulatory Surgery Care Services after after after after after after after after Alternatives to Hospital Care Skilled Nursing Hospice after after 90 days per Plan Year Home Health Care 0% Coinsurance 100% of allowed costs 42 visits per Plan Year Lab & Diagnostic Services Outpatient Lab (blood work) Diagnostic Imaging (x-ray) $40 Copay per visit (Copay not collected if test part of office visit) 100% of allowed costs $40 Copay per visit 100% of allowed costs PHXSilverAPCHDV73_65441AZ008000204 Page 4 of 9
(Copay not collected if test part of office visit) 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 after after after Other Services Allergy (testing and treatment) after Autism Spectrum Disorder (therapies and services) after Cancer Clinical Trials (routine patient costs) after Chemotherapy after Chiropractic Care Services after 20 visits per Plan Year Dental Services (accidental dental, orthognathic surgery, TMJ) after PHXSilverAPCHDV73_65441AZ008000204 Page 5 of 9
Diabetes Care Education Diabetes Care Equipment and Supplies Dialysis Durable Medical Equipment (DME) Family Planning Foot Care (care for diabetes/diabeticrelated conditions) Habilitative Care Services Hearing Aid Hearing Exam Infusion/IV Medication Administration Therapy $0 Copay per visit 100% of allowed costs after after after after after after after after after Combined total of 60 visits per Plan Year 1 hearing aid per ear per Plan Year 1 hearing exam per Plan Year Medical Foods and Formula Gastric Disorder Formula Medical Foods and Formula Inherited Metabolic Disorder Nutritional Evaluation and Counseling 25% Coinsurance 75% of allowed costs 50% Coinsurance 50% of allowed costs after Prosthetic Devices after Rehabilitative Therapy after Combined total of 60 visits per Plan Year PHXSilverAPCHDV73_65441AZ008000204 Page 6 of 9
Vision Care Services Pediatric Vision Services (through month of 19th birthday) Adult Vision Screening Other Adult Vision Services $15 Copay per pair 100% of allowed costs after Copay after $25 Copay per visit 100% of allowed costs 1 eye exam per Plan Year 1 pair of eyeglasses per Plan Year (contact lenses, in lieu of eyeglasses, once per Plan Year when determined to be Medically Necessary and appropriate in the treatment of certain conditions) 1 vision screening, performed as part of annual physical to determine need for vision correction 1 eye exam per Plan Year $100 allowance per Plan Year for hardware Prescription Drugs Prescription Drug Amount for Covered Prescription Drugs You Pay Purchased from a Participating Retail Pharmacy Purchased from a Participating Retail or Mail-Order Pharmacy Purchased a Participating Mail- Order Pharmacy 1 to 30-Day 31 to 60-Day 61 to 90-Day 61 to 90-Day Preventive No charge No charge No charge No charge Tier 1 Preferred Generic Tier 2 Generic Tier 3 Preferred Brand $3 Copay per $10 Copay per $50 Copay per $6 Copay per $20 Copay per $100 Copay per $9 Copay per $30 Copay per $150 Copay per $7.50 Copay per $25 Copay per $125 Copay per PHXSilverAPCHDV73_65441AZ008000204 Page 7 of 9
Prescription Drug Tier 4 Non- Preferred Brand Tier 5 Preferred Specialty Tier 6 Non- Preferred Specialty Amount for Covered Prescription Drugs You Pay Purchased from a Participating Retail Pharmacy Purchased from a Participating Retail or Mail-Order Pharmacy 1 to 30-Day $100 Copay per 35% Coinsurance per 50% Coinsurance per 31 to 60-Day $200 Copay per 61 to 90-Day $300 Copay per Purchased a Participating Mail- Order Pharmacy 61 to 90-Day $250 Copay per NOTE: If You elect to get a brand name drug when the allows for a generic drug substitution, You may be responsible for the difference in cost between the generic and brand name drug. Fitness Benefit Policy Holders and their Covered Dependent spouse/domestic partner 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 Policy Holder and $100 for his/her Covered Dependent spouse/domestic partner OR the cost of membership for a six-month period. Please see Your Policy for details. Other Dental Care Services This plan covers the following types of dental care services for Members as follows: Pediatric Dental Services Pediatric dental benefits are available for Members through the month of their 19 th birthday. This plan includes coverage of pediatric dental services as required under the PPACA: Class I services: diagnostic and preventive services Class II services: restorative and other basic dental services Class III services: complex and major restorative dental services Class IV services: orthodontic services (Medically Necessary Orthodontic Treatment) NOTE: There is a waiting period of 24 months from the Effective Date of coverage for each Member under this Policy before that Member becomes eligible for Medically Necessary Orthodontic Treatment. Adult Dental Services PHXSilverAPCHDV73_65441AZ008000204 Page 8 of 9
Limited dental services in Class I and Class II are available for Members age 19 and older. The plan will cover up to $500 in Covered Services per Plan Year. NOTE: There is no coverage for Class III and Class IV adult dental services. We are partnering with DentaQuest to provide the pediatric and adult dental services that are covered under this plan. Covered Services are provided by DentaQuest. Please see the attached Schedule of Benefits Dental for a list of Covered Services by current dental terminology (CDT) code, Benefit Maximums/limitations, exclusions, cost shares and other important information. Please call Our Customer Service Department if You have any questions: 855-463-7275 (toll-free) or TTY: 855-463-7279 7878 N. 16th, Suite 105 Phoenix, AZ 85020 855-463-7275 (toll-free) TTY: 855-463-7279 PHXSilverAPCHDV73_65441AZ008000204 Page 9 of 9