Annual Deductible Annual Health Savings Account Funding (UC) $1500 individual $3,000 family Varies by Annual Base Pay as of 1/1/18 $3,000 per person $6,000 family Varies by Annual Base Pay as of 1/1/18 $300 individual $600 family Not applicable $600 individual $1200 family Not applicable Copayment/co- insurance As specified As specified As specified As specified Annual Out-of-Pocket Maximum* $3,000 individual $6,000 family (includes in network medical and pharmacy expenses) $6,000 individual $12,000 family (includes out of network medical and pharmacy expenses) $1,500 individual $3,000 family (Medical services only, excludes office visit and Rx copays) $3,000 individual $6,000 family (Medical services, excludes copays) Plan Maximum Out-of Pocket (per calendar year)** $3,000 individual $6,000 family (non-embedded deductible) (includes in network medical and pharmacy expenses) $6,000 individual $12,000 family (includes in network medical and pharmacy expenses) $7350 individual $14,700 family (includes copays medical and pharmacy ) Not applicable (no limit on your out- of- pocket expenses) Maximum Lifetime Benefit No maximum, except as specified No maximum, except as specified No maximum, except as specified No maximum, except as specified Acupuncture Allergy Testing and Treatment/Serum 85% after deductible Ambulance 85% after deductible 85% after deductible Anesthesia 85% after deductible -1-
Covered Service In network Out-of-network In network Out of network Chiropractic Services $25 copay Maximum 20 visits per calendar year Maximum 20 visits per calendar year Maximum 20 visits per calendar year Maximum 20 visits per calendar year Diagnostic Tests (e.g., MRI, CAT, MRA, PET, etc.) and X-Rays Durable Medical Equipment 85% after deductible 80% after deductible Emergency Room Visit (covered emergency) Same as in network benefit $200 emergency room copay (waived if admitted) $250 copay non-emergency use of ER $200 emergency room copay (waived if admitted) Eye Exams/Refraction Eyewear - Lenses and Frames 100% 100% VSP Vision Plan VSP Vision Plan VSP Vision Plan VSP Vision Plan Hearing 100% - screening only No coverage 100% - screening only No coverage Hospitalization Room 85% after deductible and Board Immunizations (covered by plan and age appropriate) 100% -2-100%
Infertility Services Refer to Plan Documents No coverage Refer to Plan Documents No coverage Inpatient Services 85% after deductible Maternity Care (specialist office visit copay applies) $45 copay first visit only by participating providers at participating facilities Mental Health Inpatient 85% after deductible Mental Health Outpatient (primary care office visit co-pay applies) $35 copay per visit 70% without pre-authorization Office visit- primary $25 copay Office visit-specialist Outpatient services (e.g., surgery, pathology, MRI, surgical supplies, etc.) $45 copay 85% after deductible Physician Services - inpatient -3-85% after deductible
Retail Health Clinic LiveHealth Online Routine Physical Exams (including associated diagnostic tests and X- rays) $25 copay (primary) $45 (specialist) 100% (as recommended by the American Medical Association) 100% (as recommended by the American Medical Association) (as recommended by the American Medical Association) Skilled Nursing Facilities 85% after deductible Substance Abuse Inpatient 85% after deductible Substance Abuse Outpatient Paid on the same basis as other outpatient treatment Paid on the same basis as other outpatient treatment Therapy Services (e.g., Physical, Speech, Occupational) Outpatient: $25 copay Urgent Care Center $50 copay Well-Baby/ Well- Child Care (ROUTINE) 100% (as recommended by the American Academy of Pediatrics) (as recommended by the American Academy of Pediatrics) 100% (as recommended by the American Academy of Pediatrics) (as recommended by the American Academy of Pediatrics) -4-
Prescription Drugs (Anthem Rx4) Retail pharmacy copay per prescription(1): $15 Tier 1: Drugs that offer greatest value including generic versions of brand name drugs. $35 Tier 2: Brand name drugs that are generally more affordable; may also include preferred drugs. $50 Tier 3: Higher cost brand name drugs (may have generic version Tier 1) Tier 4: 25% co-insurance ($250 per prescription/purchase maximum) specialty drugs used to treat chronic conditions; may require special handling or management. 90 day prescription fills are not available at a retail pharmacy. Mail order for a 90-day supply (mandatory mail order for maintenance medications see below): $30 Tier 1 $70 Tier 2 $100 Tier 3 Tier 4: 34 day supply available through mail order Pharmacy copays apply to Plan Out-of-Pocket Maximum; see Page 1. *Outof- network subject to co-insurance and deductible. Mandatory Mail Order your copay will double if your purchase your maintenance meds at a retail pharmacy after the 2 nd 30 day fill. Anthem Home Delivery is available for maintenance medical purchases. DIABETIC SUPPLIES DIABETIC SUPPLIES 80% diabetic supplies such as lancets, pen needles, test strips and autolet devices. Excludes drugs not requiring a prescription (except injectable insulin), drugs administered while hospitalized or covered by Workers Compensation, and therapeutic devices and appliances. -5-
Additional Information Searching for an Anthem provider? Visit www.anthem.com. Click on the Find a Doctor link. Then under Search as a Guest select Search by Selecting a Plan or Network. Enter the information requested in the search parameters, including the network name Blue Access PPO for both the PPO and the HSA/HSHP. Looking for information about medical service prices or quality reviews? Visit www.anthem.com. Establish a password protected account. Then click Know Your Cost tab; log in to Castlight, a free Anthem-partnered service, populated with your claim data. Be Well UC: Visit this site to learn more about your one-stop resource for wellness at UC: http://www.uc.edu/hr/bewelluc.html. For details about the plans and to find more information about Behavioral Health services contact Anthem at 844-249- -537.2. Coverage and payment for services subject to the Mental Health Parity Act. Discounts available through University of Cincinnati Physicians. Exclusions and Limitations: All plans are subject to exclusions, limitations and periodic updates. To receive maximum benefits under the plans, eligible services must be provided by participating providers. Any services provided outside the plan s specifications may not be eligible for benefits. All non-network services under the plans are subject to Usual, Customary, and Reasonable (UCR) limits. UCR limits are determined by the insurance company and subject to change. Acceptance of UCR limits is at the discretion of the non-network provider. If the non-network provider does not accept the UCR limit, you are responsible for any amount not covered by UCR in addition to the deductible, copay and out-of-pocket limit. All services must be medically necessary. Pre-approval must be obtained for all non-routine services. Advance approval for elective admission is required. The plan must be notified immediately upon emergency admission. A medically appropriate length of stay is assigned for each admission, and the need for continued hospital stay is evaluated during the admission to avoid unnecessary hospital stay. Case management may authorize coverage for low-esr cost treatment alternatives which are also medically appropriate. The Plan Document governs payment of benefits. * The out-of-pocket maximum limits the amount of money you will pay during a calendar year for medical expenses. It includes your deductible and any coinsurance you pay for qualified medical expenses during the calendar year. ** The Plan out-of-pocket maximum includes all expenses paid toward the annual out- of- pocket maximum, as well as copays for office visits and prescription drugs. After you have paid the amount in the chart the Anthem plan will pay 100% of all eligible medical and prescription expenses for the calendar year for you and your family, if applicable. For further information see http://www.uc.edu/hr/benefits.html. -6-
HSA/HDHP The HSA/HDHP has a non-embedded deductible. If you elect to cover dependents, all family member s expenses are pooled together to reach the family deductible. Once the family deductible is met ($3000), the plan will pay 90% of each family member s covered expenses until the annual out-of-pocket maximum is reached ($6000). The individual deductible does NOT apply when family members are covered. The HSA/HDHP plan has also has a non-embedded out-of-pocket which means if you, the subscriber, are the only person covered by this plan, only the individual amounts apply to you. If you also cover dependents (other family members under the plan, the family amounts apply. The family out-of-pocket amounts can be satisfied by one family member or a combination of family members. Once the family out-of-pocket is met, it is considered met for all family members. The network and out-of-network pocket maximums are separate and cannot be. PPO The PPO has an embedded deductible. If you elect to cover dependents, both the individual and family deductible amounts apply. The family deductible amounts can be satisfied by any combination of family members but you could satisfy your own individual deductible before the family deductible is met. Once you meet your individual deductible, the plan will pay 85% (80% for diabetic supplies) of your eligible expenses. This may occur before another family member reaches his/her deductible. Once the family deductible of $600 is met, all family member s eligible expenses will be paid at 85% until the family out-of-pocket maximum is met. The PPO plan has an embedded out-of-pocket which means if you, the subscriber, are the only person covered by this plan, only the individual amounts apply to you. If you also cover dependents (other family members) under this plan, both the individual and family amounts apply. The family out-of-pocket amounts can be satisfied by any combination of family members but you could satisfy your own individual out-of-pocket amount before the family amount is met. You will never have to satisfy more than your own individual out-of-pocket amount. If you meet your individual amount, other family members claims will still accumulate towards their own individual out-of-pocket and the overall family amounts. This continues until your other family members meet their own individual out-ofpocket or the entire family out-of-pocket is met. The network and out-of-network out-of-pocket maximums are separate and cannot be. Note: Medical out-of-pocket does not apply to the pharmacy out-ofpocket. The pharmacy out-of-pocket for an individual is $3150 per person per calendar year. The family maximum out-of-pocket (medical and pharmacy) is $14,700 per family per calendar year. The network and out-of-network out-of-pocket maximums are separate and cannot be. Explanations above based on network services. 09/2017-7-