CAPE COD MUNICIPAL HEALTH GROUP IMPORTANT - PLEASE READ The attached benefit comparison chart is a high level overview of the plans offered by CCMHG. The plan documents available to registered users on the carrier websites are the documents that describe full and complete plan details. The carrier documents are the only documents that coverage is based on. Should you have a question about specific coverage, you will need to contact the Member Service number on your ID card for detail or visit the carrier website.
Deductible - applies to: In-patient Admission; Out-patient Surgery; ER, High Tech Imaging (MRI, CT, & PET) and Diagnostic Tests & Procedures. Does not apply to routine office visits or pharmacy. Per plan year (July 1 to June 30) - See plan document for full details BLUE CARE ELECT PREFERRED $300 per member $300 per member $400 per member $300 per member $300 per member $300 per member $400 per member $900 per $900 per $800 per $900 per $900 per $900 per $800 per Medical: Medical: Medical: Medical: Medical: Medical: Medical: Out-of-Pocket (OOP) $2,000 per member $2,000 per member $3,000 per member $2,000 per member $2,000 per member $2,000 per member $3,000 per member Maximum - Once your out-ofpocket $4,000 per $4,000 per $4,000 per $4,000 per $4,000 per expenses for Prescription: $3,000 Prescription: $3,000 Prescription: $3,000 Prescription: $3,000 Prescription: $3,000 applicable services reaches per member $6,000 per per member $6,000 per per member $6,000 per per member $6,000 per per member $6,000 per this amount, you pay $0 for remainder of plan year. NOTE: a separate out-ofpocket for prescription copays added effective July 1, 2015 as required by ACA (in-network only). Lifetime Benefit Maximum INPATIENT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY General Hospital/Mental Hospital/Substance Abuse Facility (semi-private room and board and special services) - $500 copay per $500 copay per for emergency/accident s $700 copay per $500 copay per $500 copay per Physician Services for emergency/accident s Skilled Nursing Facility to 100 days per to 100 days per to 100 days per calendar year benefit Limit to 100 days per Plan Year - $500 copayper Limit to 100 days per Plan Year - $500 copayper Rehabilitation Hospital to 60 days per to 60 days per to 60 days per calendar year benefit Limit to 60 days per Plan Year - $500 copay per Limit to 60 days per Plan Year - $500 copay per 2
BLUE CARE ELECT PREFERRED OUTPATIENT HOSPITAL YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Emergency Room Visits for Emergency or Accident Care - observation observation observation for first treatment of accident; $100 copay for emergency medical care Emergency Room Visits for Medical Care - if admitted) if admitted) $100 copay, waived if admitted Surgery - $250 copay $250 copay $250 copay $250 copay $250 copay Radiation and Chemotherapy Deductible Applies Diagnostic X-ray and Lab - Routine Colonoscopy (without surgery) High Cost Radiology (MRI, CT & PET) - $100 copay $100 copay $100 copay $100 copay $100 copay Hemodialysis - Physical Therapy to 60 visits per calendar year to 100 visits per calendar year to 100 visits per calendar year $20 Physician Office $20 Hospital Setting Copay Level 1 : per visit, 30 visits per Plan Year Copay Level 1 : per visit, 30 visits per Plan Year PHYSICIAN'S OFFICE YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Surgery - $20/35 co-pay $20/35co-pay $20 co-pay Copay Level 1 provider : Copay Level 1 provider : NO DEDUCTIBLE per visit Copay per visit Copay Level 2 provider : $35 per Level 2 provider : $35 per visit visit 3
BLUE CARE ELECT PREFERRED PHYSICIAN'S OFFICE YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Adult Preventative Exam (includes preventative lab tests) PCP Medical Care/ Mental Health Care/ Substance Abuse Care Well Child Care (includes preventative lab tests) Copay Level 1 : (including routine physical exams, immunizations, school, camp, sports) Copay Level 1 : (including routine physical exams, immunizations, school, camp, sports) Routine GYN Exam ( one per calendar year, includes preventative lab tests) Routine Mammogram Routine Vision Exam (once every 12 months) (once per calendar year) (once per calendar year) ( once every 24 months) Limited 1 visit per Plan Year - No Charge Limited 1 visit per Plan Year - No Charge Specialist Office Visit $45 copay $45 copay $45 copay Copay Level 2 : $45 Copay Level 2 : $45 copay copay OTHER OUTPATIENT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Visiting Nurse Home Health Care Durable Medical Equipment - After deductible, member After deductible, member After deductible, member After deductible, member After deductible, member After deductible, member pays 20%, plan pays 80% pays 20%, plan pays 80% pays 40%, plan pays 60% pays 20% until member has pays 20% until member has pays 20% coinsurance. with no limit. Wigs are with no limit. Wigs are with no limit. Wigs are paid $1,000 out of pocket, paid $1,000 out of pocket, covered in full when covered in full when covered in full when then plan pays in full. Wigs then plan pays in full. Wigs needed as a result of any needed as a result of any needed as a result of any are covered in full when are covered in full when form of cancer, leukemia, form of cancer, leukemia, form of cancer, leukemia, needed as a result of any needed as a result of any alopecia areata, alopecia alopecia areata, alopecia alopecia areata, alopecia form of cancer, leukemia, form of cancer, leukemia, totalis, or permanent hair totalis, or permanent hair totalis, or permanent hair alopecia areata, alopecia alopecia areata, alopecia totalis, or permanent hair totalis, or permanent hair Ambulance- for accident or emergency; 20% coinsurance* other medically necessary ambulance transport Routine Pediatric Dental (through age 11) Covered in full: Preventive care for children up to age 13 2 visits per member per plan year including exam, cleaning, x-rays, & flouride treatment. Covered in full: Preventive care for children up to age 13. 2 visits per member per plan year including exam, cleaning, x-rays, & flouride treatment. 4
BLUE CARE ELECT PREFERRED Chiropractor Visits Prescription Drugs Retail: (30 Retail: (30 Retail: (30 Retail: (30 Retail: (30 Retail: (30 Retail: (30 Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Tier 3: $65.00 copay Mail Order: supply) (90 day Mail Order: (90 Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 1: $25.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 2: $75.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Tier 3: $165.00 copay Fitness Benefit Non-formulary drugs No Fitness Benefit *After Deductible 5