GENERAL PROVISIONS (Includes ) Deductible (Medical) Annual Out-of-Pocket Maximum Baby Yourself A $150 per person per calendar year deductible for medical services (maximum of 3 medical deductibles per family). $2,500 per person per calendar year; $7,150 per family. All coinsurance, deductibles and copays for in-network covered health benefits apply to the in-network out-of-pocket maximum There is no out-of-pocket maximum. including out-of-network emergency services for mental health and substance abuse, but excluding prescription drugs. A benefit that offers the opportunity to have a Blue Cross & Blue Shield of Alabama registered nurse case manager to monitor a covered member s pregnancy while enrolled in this medical plan. Note: The $350 inpatient hospital copay per admission will be waived for Baby Yourself participants who enroll within the first trimester of pregnancy and continue participation until the baby is born. Individual Case Management A voluntary program to assist employees and their families in coordinating care in the event of a lengthy illness. Disease Management A voluntary program that coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease. Air Medical Services Air ambulance service to a network hospital near the member s home if hospitalized while traveling more than 150 miles from home. To arrange transportation, call AirMed at 1-877-872-8624. PHYSICIAN SERVICES (Includes ) Precertification is required for some physician benefits and physician-administered drugs; please see your benefit booklet. If precertification is not obtained, no benefits are available. Office Visits & Outpatient Consultations Rendered by a a $35 office visit copay and the medical Primary Care Physician (includes, Internist, Family & General Practitioner, Pediatrician, OB/GYN & Geriatrician, Psychiatrist, Psychologist and Master s Level Licensed Counselor) Office Visits & Outpatient Consultations rendered by a Specialist ER Physician Services Surgery Performed in a Physician s Office Inpatient Visits, Consultations, Surgery & Anesthesia a $40 office visit copay and the medical a $35 office visit copay and the medical a $35 office visit copay and the medical deductible if performed by a Primary Care Physician or a $40 office visit copay and the medical deductible if performed by a Specialist. a $35 office visit copay and the medical services apply to the in-network out-ofpocket maximum. In and Outside Alabama: Covered at 80% of the
Maternity Diagnostic X-rays & Lab Exams However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catheterizations covered at 100% of the allowance, subject to a $35 copay and the medical However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catheterizations covered at 60% of the allowance, subject to a $35 copay and However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catheterizations covered at 80% of the allowance, subject to a $35 copay and the medical Nurse Practitioner/Nurse Midwife and Physician Assistant s Office Visits & Consultations a $20 office copay and Services must be rendered under the supervision of a doctor. INPATIENT HOSPITAL FACILITY SERVICES (Includes ) Inpatient Facility Services Covered at 100% of the allowance for semi- (Including Residential private room and board, intensive care units, Treatment Facilities) general nursing services and usual hospital ancillaries, subject to a $350 per admission copay and the medical deductible (maximum of 3 inpatient per admission copays per person per calendar year); 365 days per confinement. Preadmission Certification In Alabama: Not covered unless in cases of medical emergency or accidental injury. allowance for semi-private room and board, intensive care units, general nursing services and usual hospital ancillaries, subject to a $350 per admission copay and the medical deductible (maximum of 3 inpatient per admission copays per person per calendar year); 365 days per confinement. Preadmission certification required for all inpatient admissions (except emergency hospital admission and maternity); notification within 48 hours for emergencies. Call 1-800-248-2342 for precertification. If precertification is not obtained, no benefits are available. OUTPATIENT HOSPITAL FACILITY SERVICES (Includes ) Precertification is required for some outpatient hospital benefits and physician-administered drugs; please see your benefit booklet or call 1-800-248-2342. If precertification is not obtained, no benefits are available. Surgery Facility Diagnostic Lab, X-ray & Tests However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catheterizations covered at 100% of the allowance, subject to the $125 copay and the medical $125 facility copay and medical However, MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, colonoscopy, endoscopy and heart catheterizations covered at 80% of the allowance, subject to $125 copay and
Hemodialysis, Chemo, Radiation & IV Therapy ER - Medical Emergency ER - Non-Emergency ER - Accidental Injury Intensive Outpatient Program (IOP) & Partial Hospitalization Program (PHP) Routine Preventive Services $125 facility copay and Covered at 100% of the allowance, subject to a $40 daily hospital copay and the medical 100% of the allowance, no deductible or copay. See AlabamaBlue.com/preventiveservices for a listing of specific covered preventive services and immunizations or call our Customer Service Department for a printed copy. medical a $125 facility copay and services apply to the in-network out-ofpocket maximum. $125 facility copay and a $125 facility copay and medical deductible; in Alabama, not covered. Not covered. In addition to the standard services, the following are also covered by this plan: One CBC and one urinalysis each year TB skin testing one each year through age 6; one between ages 7 and 18; one between ages 19 and 34 and one age 35 and older Cholesterol testing (beginning at age 19; once every 5 years) Thyroid profile (one each calendar year, beginning at age 50) Routine EKG (one each calendar year, beginning at age 50) SMA 22 lab test (or lesser automated panel test) beginning at age 19, one each calendar year Chest x-ray beginning at age 35 CA 125 blood test covered for females Routine bone density screening (one every two calendar years beginning at age 40) Pneumonia-beginning at age 65 or earlier if warranted. Malaria (when approved) Cervical cancer vaccine for females age 9 to 26 OTHER COVERED SERVICES (Includes ) Precertification is required for some other covered services; please see your benefit booklet or call 1-800-248-2342. If precertification is not obtained, no benefits are available. Participating Chiropractor Services Nutritionist Visits Covered at 80% of the allowance, subject to the medical deductible when services are subject to the medical deductible when services provided by a participating in-network are provided by an out-of-network chiropractor. chiropractor. Note: Limited to a maximum of 24 visits per person each calendar year. a $20 office visit copay and Limited to a maximum of eight visits per person each calendar year. Note: Employee is also responsible for any charges above the allowance.
Routine Vision Covered at 80% of the allowance subject to the medical deductible for one routine eye exam per person each calendar year. Physical Therapy Covered at 80% of the Rehabilitative Speech and Occupational Therapy Habilitative Speech and Occupational Therapy Durable Medical Equipment Allergy Testing and Treatment Ambulance Services Covered at 80% of the Limited to a maximum of 20 visits per person per therapy each calendar year. Covered at 80% of the Limited to a maximum of 20 visits per person per therapy each calendar year. Covered at 80% of the medical Covered at 80% of the Preferred Home Health Care Preferred Hospice Care In Alabama: No benefits are available if a nonpreferred provider is used. In Alabama: No benefits are available if a nonpreferred provider is used. PRESCRIPTION DRUG BENEFITS Prescription Drugs Prescription drug benefits are not administered by Blue Cross and Blue Shield of Alabama. This is not a contract, benefit booklet or Summary Plan Description. Benefits are subject to the terms, limitations & conditions of the group contract. Check your benefit booklet for more detailed information. Statement of Nondiscrimination Blue Cross and Blue Shield of Alabama complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Foreign Language Assistance Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-216-3144 (TTY: 711) Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 1-855-216-3144 (TTY: 711) Group #79912 Revised 11-02-2016
Pharmacy Benefits are administered by OptumRx and employees who participate in the UA Medical Plan are automatically enrolled. You will receive a separate Member ID card for Rx. RETAIL PHARMACY Deductible (Pharmacy) Annual Out-of-Pocket Maximum A $150 per person per calendar year deductible for pharmacy benefits (maximum of 3 prescription drug deductibles per family). Only one deductible will apply if an individual uses a retail pharmacy and/or the mail order program. $2,500 per person per calendar year; $7,150 per family. All coinsurance, deductibles and copays for in-network covered pharmacy benefits apply to the in-network out-of-pocket maximum. The out-of-pocket maximum does not apply to out-ofnetwork (non-ppo) pharmacy benefits. The first prescription for a drug on the maintenance list requires a 31 day supply. Subsequent refills for 60 or 90 days can be made at a participating pharmacy. Diabetic supplies are only covered under your prescription drug program; limited to a 60 or 90 day supply at an in-network retail pharmacy or through mail order. Insulin, insulin needles & syringes purchased on the same day will require only one copay. Blood glucose strips & lancets purchased on the same day will require only one copay. Glucose monitors will always require a separate copay. IN-NETWORK (PPO) Participating Pharmacy: Prescription drugs will be covered at 100% of the allowed charge after the prescription drug deductible is met & subject to the following copays: Type of Drugs (available for maintenance & nonmaintenance drugs) 61-90 day supply OUT-OF-NETWORK (NON-PPO) Non-Participating Pharmacy: Prescription drugs will be covered at 75% of the allowed charge after the prescription drug deductible is met & subject to the following copays: (available for maintenance & non- Tier 1 (Generic) $15 copay $30 copay $45 copay $15 copay $30 copay Tier 2 (Preferred Brand) $45 copay $90 copay $135 copay $45 copay $90 copay Tier 3 (Non-Preferred Brand) $55 copay $110 copay $165 copay $55 copay $110 copay Tier 3 (Non-Preferred Brand with a Generic Alternative) $65 copay $130 copay $195 copay $65 copay $130 copay Tier 4 (Specialty) $125 copay N/A N/A $125 copay N/A Note: View more information and Drug Lists that apply to the plan at http://hr.ua.edu/optumrx-pharmacy-benefits, or call OptumRx at 1-844-265-1771. MAIL ORDER PROGRAM The first prescription for a drug on the maintenance list requires a 31 day supply. Subsequent refills for 60 or 90 days can be made at a participating pharmacy. For diabetic supplies, please refer to the same copay limitations and days-supply restrictions enumerated in the retail pharmacy section above. Provided through OptumRx. Enroll online at optumrx.com/mycatamaranrx or call 1-844-265-1771. Mail Order Program: Prescription drugs will be covered at 100% of the allowed charge after the deductible & subject to the following copays: Type of Drugs (available for maintenance & non- 61-90 day supply Tier 1 (Generic) $10 copay $20 copay $30 copay Tier 2 (Preferred Brand) $35 copay $70 copay $105 copay Tier 3 (Non-Preferred Brand) $40 copay $80 copay $120 copay Tier 3 (Non-Preferred Brand with a Generic Alternative) $55 copay $110 copay $165 copay This is not a contract, benefit booklet or Summary Plan Description. Benefits are subject to the terms, limitations & conditions of the group contract. Check your benefit booklet for more detailed information. Statement of Nondiscrimination OptumRx complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This information is available in other formats like large print. To ask for another format, please call the toll-free Customer Service number on the back of your member ID card 1-844-265-1771 (TTY: 711) Foreign Language Assistance Spanish: ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación. Chinese: 請注意 : 如果您說中文, 我們免費為您提供語言協助服務 請撥打會員卡所列的免付費會員電話號 Group #79912 Revised 11-02-2016