Annual Deductible Annual Health Savings Account Funding (UC) $1500 individual $3,000 family Varies by Annual Base Pay as of 1/1/2018 $3,000 per person $6,000 family Varies by Annual Base Pay as of 1/1/2018 $100 individual $200 family Not applicable $400 individual $800 family Not applicable Copayment/coinsurance As specified As specified As specified As specified Annual Out-of-Pocket Maximum* Plan Maximum Out-of Pocket (per calendar year)** Maximum Lifetime Benefit Acupuncture Allergy Testing and Treatment/Serum $3,000 individual $6,000 family (includes in network medical and pharmacy expenses) $3,000 individual $6,000 family (includes in network medical and pharmacy expenses) No maximum, except as specified $6,000 individual $12,000 family (includes out of network medical and pharmacy expenses) $6,000 individual $12,000 family (includes out of network medical and pharmacy expenses) No maximum, except as specified $1,100 individual $2,200 family (Medical services only, excludes office visit and Rx copays) $7350 individual $14,700 family (includes copays medical and pharmacy ) No maximum, except as specified $1,100 individual $2,200 family (Medical services, excludes copays) Not applicable No maximum, except as specified Based on setting where services Based on setting where Based on setting where Based on setting where received. services received. services received. services received. Ambulance Anesthesia -1-
Chiropractic Services $15 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 80% after deductible Emergency Department Visit (covered emergency) Same as in network benefit $75 emergency dept. copay (waived if admitted) $75 emergency dept. copay (waived if admitted) Eye Exams/Refraction 100% Eyewear - Lenses and Frames 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 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 Maternity Care (specialist office visit copay applies) $20 copay first visit only by participating providers at participating facilities Mental Health Inpatient Mental Health Outpatient (primary care office visit copay applies) $15 copay per visit 70% without pre-authorization Office visit- primary $15 copay Office visit-specialist Outpatient services (e.g., surgery, pathology, MRI, surgical supplies, etc.) $20 copay Physician Services inpatient -3-
Covered Service In network Out-of-network In-network Out-of-network Retail Health Clinic/ LiveHealth Online Routine Physical Exams (including associated diagnostic tests and X- rays) $15 copay (primary) $20 copay (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 Substance Abuse Inpatient 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: $15 copay Urgent Care Center $20 copay Well-Baby/ Well- Child Care (ROUTINE) 100% (as recommended by the American Academy of Pediatrics) (as recommended by the American Academy of Pediatrics) -4-100% (as recommended by the American Academy of Pediatrics) (as recommended by the American Academy of Pediatrics)
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. $25 Tier 2: Brand name drugs that are generally more affordable; may also include preferred drugs. $35 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. Mail order for a 90-day supply: $30 Tier 1 $50 Tier 2 $70 Tier 3 Tier 4: 34 day supply available through mail order Pharmacy copays apply to Plan Out-of-Pocket Maximum; see Page 1. *Out-of- Network subject to co-insurance and deductible. 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-
Effective January 1- December 31, 2017-AAUP only 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. Then 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 Coverage and payment for services subject to Mental Health Parity Act. For details about the plans and to find more information about Behavioral Health Services contact Anthem at 844-249-5372. 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 admissions 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 lowercost 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 co-insurance 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 indicated 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 AAUP members the annual maximum out-of-pocket cost for prescription co-pays is $3000 per covered person; the family maximum out-of-pocket is $14,700 regardless of the number of family members on the plan. For further information see http://www.uc.edu/hr/benefits.html. -6-
Effective January 1- December 31, 2017-AAUP only 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 amount 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 90% (80% for diabetic supplies) of your eligible expenses. This may occur before another family member reaches his/her deductible. Once the family deductible of $200 is met, all family member s eligible expenses will be paid at 90% 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. For AAUP members the annual maximum out-of-pocket cost for prescription co-pays is $3000 per covered person; the family maximum out-of-pocket is $14,700 regardless of the number of family members on the plan. 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. 9/2017-7-