Super Blue Plus QHDHP 1 2017 HDHP Non Emb 100% Effective Date April 1, 2018 to November 31, 2018, then restart December 1, 2018. Benefit Period (used for Deductible and Coinsurances limits and certain Contract Year 2 benefit frequencies.) Note: All Services are subject to the Deductible unless otherwise specified. If you are enrolled as a "Family Plan, the Family Plan deductible, coinsurance limit and TMOOP apply. It is possible for one family member to satisfy each of these limits. Deductible (Applies to Medical and Prescription Drug benefits. Network and Non-Network Deductible dollars do not cross apply.) Employee Only Plan $1,500 $6,000 Family Plan $3,000 $12,000 Carry-Over Deductible Period NONE Coinsurance Limit: (Applies to Medical and Prescription Drug benefits. Network and Non-Network Coinsurance dollars do not cross apply.) Employee Only Plan $0 $6,000 Family Plan $0 $12,000 Total Maximum Out of-pocket 6 (Includes Deductible, Copays, and Coinsurance per Benefit Period, Network only) Employee Only Plan $1,500 Not Applicable Family Plan $3,000 Not Applicable Non-Network Liability UNLIMITED Lifetime Maximum Benefit for all Covered Services UNLIMITED BENEFIT HIGHLIGHTS Medical Office Visit / Office Consultation - (Includes Specialist / Specialist Virtual Visits) Virtual Visit Originating Site Urgent Care Center Visits Retail Clinic Visits Telemedicine Service 4 100% No Benefits PRESCRIPTION DRUGS 7 Prescription Deductible Individual Integrated with medical deductible No Benefits Family Integrated with medical deductible No Benefits Retail Drugs through a Retail Pharmacy Network - Maximum 34 day Supply If you choose Brand over Generic, you will pay the difference between the Brand and Generic Allowances, in addition to the Co-Pay or Coinsurance, unless the Physician writes Brand Necessary (DAW) on the 100% No Benefits prescription, or if no generic equivalent exists. Note: Prescription Deductibles, Copays and/or Coinsurance amounts apply toward the Total Maximum Out-of-Pocket. Maintenance Drugs through Mail Order - Maximum 90 day Supply If you choose Brand over Generic, you will pay the difference between the Brand and Generic Allowances, in addition to the Co-Pay or Coinsurance, unless the Physician writes Brand Necessary (DAW) on the prescription, 100% No Benefits or if no generic equivalent exists. Note: Prescription Deductibles, Copays and/or Coinsurance amounts apply toward the Total Maximum Out-of-Pocket. Additional Preventive Prescription Benefits 5 (Retail or Mail Order). Guidelines as determined by certain Governmental Agencies. You may access this information at www.healthcare.gov. You may also contact Member Services. 100%, No Deductible No Benefits
PREVENTIVE CARE SERVICES 5 Routine Adult Physical exams 100%, No Deductible 80% after deductible Adult immunizations 100%, No Deductible 80% after deductible Colorectal cancer screening 100%, No Deductible 80% after deductible Routine gynecological exams, including a Pap Test 100%, No Deductible 80%, No Deductible Mammograms, annual routine and medically necessary Routine: 100%, No Deductible Medically Necessary: 100% after deductible 80% after deductible Diagnostic services and procedures 100%, No Deductible 80% after deductible Routine Pediatric Physical exams 100%, No Deductible 80% after deductible Pediatric immunizations 100%, No Deductible 80%, No Deductible Diagnostic services and procedures 100%, No Deductible 80% after deductible AUTISM SPECTRUM DISORDER Services for diagnosis and treatment of Autism Spectrum Disorder (See Section V for additional information). Note: Covered Services will be paid according to the benefit category (e.g. Speech Therapy, Office Visit, etc.) PHYSICIAN SERVICES In-Hospital Medical Visit Skilled Nursing Facility Medical Surgery, Assistant to Surgery, Anesthesia Second Surgical Opinion Consultations (Outpatient) Maternity Care - Dependent daughters are covered. Newborn Care including circumcision. Occupational Therapy (Rehabilitative and Habilitative) - Maximum 30 visits per Benefit Period. Limitations are for Physician & Outpatient Facility, Network and Non-Network, Rehabilitative and Habilitative, combined. Physical Therapy (Rehabilitative and Habilitative) - Maximum 30 visits per Benefit Period. Limitations are for Physician & Outpatient Facility, Network and Non-Network, Rehabilitative and Habilitative, combined. Spinal Manipulations (Rehabilitative and Habilitative) - Maximum 30 visits per Benefit Period. Limitations are for Network and Non-Network, Rehabilitative and Habilitative, combined. Respiratory Therapy Cardiac Rehabilitation Therapy Dialysis Chemotherapy Radiation Therapy Infusion Therapy Speech Therapy (Rehabilitative and Habilitative) when necessary due to a medical condition. Temporomandibular Joint Dysfunction / Craniomandibular Disorders Diagnostic, X-ray, Lab and Testing Allergy Testing and Treatment
INPATIENT HOSPITAL / FACILITY SERVICES Unlimited Days Semi-Private Room and Board Ancillaries, Drugs, Therapy Services, X-ray and Lab General Nursing Care Surgical Services Birthing Center Care / Maternity Services - Dependent daughters are covered. OUTPATIENT HOSPITAL / FACILITY SERVICES Pre-Admission Testing Diagnostic, X-ray, Lab and Testing Surgery, Operating Room Occupational Therapy (Rehabilitative and Habilitative) - Maximum 30 visits per Benefit Period. Limitations are for Physician & Outpatient Facility, Network and Non-Network, Rehabilitative and Habilitative, combined. Physical Therapy (Rehabilitative and Habilitative) - Maximum 30 visits per Benefit Period. Limitations are for Physician & Outpatient Facility, Network and Non-Network, Rehabilitative and Habilitative, combined. Respiratory Therapy Cardiac Rehabilitation Therapy Dialysis Chemotherapy Radiation Therapy Infusion Therapy Speech Therapy (Rehabilitative and Habilitative) when necessary due to a medical condition. BEHAVIORAL HEALTH SERVICES Outpatient Mental Health Services Outpatient Substance Abuse Services Inpatient Mental Health Care Services Inpatient Substance Abuse Care Services EMERGENCY CARE SERVICES Emergency Accident Care and /or Emergency Medical Care provided in the ER Emergency Ambulance NON-EMERGENCY CARE SERVICES 100% 100% 100% 100% Non-Network Liability coverage up to $100,000.00 maximum per Occurrence 8 Non-Emergency Medical Care provided in the ER Non-Emergency Ambulance Services OTHER COVERED SERVICES Private Duty Nursing Maximum 35 visits per Benefit Period Note: Maximums are Network and Non-Network combined. Skilled Nursing Facility Durable Medical Equipment and Oxygen at home Orthotic Devices and Prosthetic Appliances Home Health Care Maximum100 Visits per Benefit Period Note: Maximums are Network and Non-Network combined. Hospice Care Diabetes Education and Control
HUMAN ORGAN TRANSPLANT / BONE MARROW PROCEDURES Human Organ Transplant Includes transportation, meals and lodging. Bone Marrow Procedures Includes transportation, meals and lodging. Eligible Dependent Age Limitation Coverage stops at the end of the month of the 26 th birthday for an adult Dependent who qualifies as an Eligible Dependent. This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings Account (HSA). On the chart above, you ll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar fee or charge (in addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital department or a satellite building of a hospital. If you enroll as an individual, the deductible and out-of-pocket maximums for the Employee Only Plan apply. If you enroll as a family, the deductible and out-of-pocket maximums for the Family Plan apply and can be satisfied by one or more of your family members. 1 ALL SERVICES ARE SUBJECT TO A DETERMINATION OF MEDICAL NECESSITY BY HIGHMARK WV. MEDICAL MANAGEMENT & POLICY MUST BE CONTACTED PRIOR TO A PLANNED ADMISSION OR WITHIN 48 HOURS OF AN EMERGENCY OR MATERNITY-RELATED INPATIENT ADMISSION. BE SURE TO VERIFY THAT YOUR PROVIDER IS CONTACTING MM&P FOR PRECERTIFICATION. IF THIS DOES NOT OCCUR AND IT IS LATER DETERMINED THAT ALL OR PART OF THE INPATIENT STAY WAS NOT MEDICALLY NECESSARY OR APPROPRIATE, YOU MAY BE RESPONSIBLE FOR PAYMENT OF ANY COSTS NOT COVERED. 2 YOUR GROUP'S BENEFIT PERIOD IS BASED ON A CONTRACT YEAR. THE CONTRACT YEAR IS A CONSECUTIVE 12- MONTH PERIOD BEGINNING ON THE FIRST DAY OF YOUR EMPLOYER'S CONTRACT EFFECTIVE DATE. CONTACT YOUR EMPLOYER TO DETERMINE THE CONTRACT EFFECTIVE DATE APPLICABLE TO YOUR PROGRAM. 3 PAYMENT IS BASED ON THE PLAN ALLOWANCE. THE PLAN ALLOWANCE WILL GENERALLY BE LESS FOR SERVICES RECEIVED FROM A NON-NETWORK PROVIDER. IN ADDITION, YOU WILL BE RESPONSIBLE FOR THE NON- NETWORK LIABILITY. 4 SERVICES ARE PROVIDED FOR ACUTE CARE FOR MINOR ILLNESSES. SERVICES MUST BE PERFORMED BY A HIGHMARK APPROVED TELEMEDICINE PROVIDER. VIRTUAL BEHAVIORAL HEALTH VISITS PROVIDED BY A HIGHMARK APPROVED TELEMEDICINE PROVIDER ARE ELIGIBLE UNDER THE OUTPATIENT MENTAL HEALTH/SUBSTANCE ABUSE BENEFIT. 5 SERVICES ARE LIMITED TO THOSE LISTED ON THE HIGHMARK WV PREVENTIVE SCHEDULE (WOMEN'S HEALTH PREVENTIVE SCHEDULE MAY APPLY). AGE AND FREQUENCY LIMITS MAY APPLY. FOR A CURENT SCHEDULE OF COVERED SERVICES, LOG ONTO YOUR HIGHMARK WV MEMBER WEBSITE, AT WWW.HIGHMARKBCBSWV.COM, OR CALL MEMBER SERVICE AT THE TOLL-FREE NUMBER LISTED ON THE BACK OF YOUR ID CARD. 6 EFFECTIVE WITH PLAN YEARS BEGINNING ON OR AFTER JANUARY 1, 2017, THE NETWORK TOTAL MAXIMUM OUT- OF-POCKET AS MANDATED BY THE FEDERAL GOVERNMENT MUST INCLUDE DEDUCTIBLE, COINSURANCE, COPAYS, PRESCRIPTION DRUG COST SHARE AND ANY QUALIFIED MEDICAL EXPENSES. THE TOTAL MAXIMUM OUT-OF- POCKET FOR A QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN CANNNOT BE MORE THAN $6,550 FOR INDIVIDUAL AND $13,100 FOR TWO OR MORE PERSONS. 7 ANTI-CANCER MEDICATIONS ORALLY ADMINISTERED OR SELF-INJECTED. DEDUCTIBLE, COPAYMENT AND COINSURANCE AMOUNTS FOR PATIENT ADMINISTERED ANTI-CANCER MEDICATIONS THAT ARE COVERED BENEFITS ARE APPLIED ON NO LESS FAVORABLE BASIS THAN FOR PROVIDER INJECTED OR INTRAVENOUSLY ADMINISTERED ANTI-CANCER MEDICATIONS. 8 BENEFITS FOR EMERGENCY AMBULANCE SERVICES RENDERED BY A NON-NETWORK PRVIDER WILL BE SUBJECT TO THE SAME COST-SHARING AMOUNT, IF ANY, THAT IS APPLICABLE TO NETWORK SERVICES. THE MEMBER WILL BE RESPONSIBLE FOR ANY AMOUNTS BILLED BY THE NON-NETWORK PROVIDER FOR EMERGENCY AMBULANCE SERVICES THAT ARE IN EXCESS OF THE AMOUNT THAT HIGHMARK WV PAYS. If you are enrolled as an individual, the deductible, coinsurance and Total Maximum Out-of-Pocket (TMOOP) for the "Employee Only" plan apply. If you are enrolled in a "Family" plan, the entire family deductible must be satisfied before any claim reimbursement begins. In addition the entire family coinsurance must be satisfied for additional claim reimbursement. Once the entire family TMOOP is satisfied, claims will be reimbursed at 100% of the allowance for covered expenses for the family, regardless of whether the individual deductible, individual coinsurance and individual TMOOP have been satisfied.