2012 Plan Design Product Grid

Transcription

1 Prime (HMO-POS) Select Value PLAN DEDUCTIBLE Out-of-pocket Maximum Part B Drugs Including chemo therapy Inpatient Hospital Care Skilled Nursing Facility Home Health Care none none none $2,800 Combined in network and point-of-service Does not include premium or Part D out-of-pocket, but includes cost shares paid at in and out-of-network. Authorization authorization days 1 20; $135 copay per day for days Authorization 2012 Plan Design Product Grid Authorization In-network $3,400 Does not include premium or Part D out-of-pocket Authorization authorization days 1 20; $135 copay per day for days Authorization Combined $5,100 In- and out-of-network. Does not include premium or Part D out-of-pocket 30% coinsurance days $3,400 Does not include premium Authorization authorization days 1 20; $135 copay per day for days Authorization Hospice Care Must receive care from Medicare certified hospice Must receive care from Medicare certified hospice Must receive care from Medicare certified hospice Unless noted, all services are Medicare- only

2 Prime (HMO-POS) Select Value Doctor Office Visits Primary Care $5 copay per PCP visit Members must sign up with network PCP $35 copay per PCP visit when member is out of the service area $20 copay per PCP visit $25 copay per PCP visit $5 copay per PCP visit Members must sign up with network PCP Specialist Emergency Care Urgently Needed Care Outpatient Services/Surgery $30 copay specialist visit Authorization may be allowed for non network specialist visit when a network provider is not available. $35 copay specialist visit $50 copay per emergency room visit Worldwide coverage. $35 copay per visit $300 copay for outpatient Authorization $325 copay for outpatient Authorization $35 copay specialist visit Authorization may be allowed for non network specialist visit when the member is in the service area. $50 copay per emergency room visit Worldwide coverage. $35 copay per visit $325 copay for outpatient Authorization $25 copay specialist visit Authorization for non-network provider $50 copay per emergency room visit Copay waived if admitted within 24 hours. Worldwide coverage. $35 copay per visit Copay waived if admitted within 24 hours. $325 copay for outpatient Authorization Ambulance Services $125 copay per trip in or out of network $150 copay per trip in- or out of network $150 copay per trip in- or out of network Chiropractic Services $20 copay per visit, $35 copay per visit, $20 copay per visit,, Medicare $20 copay per visit, Unless noted, all services are Medicare- only

3 Prime (HMO-POS) Select Value Dental Services $30 copay for Medicare-covered dental benefits $35 copay for Medicarecovered dental benefits Podiatry Services Hearing Services Vision Services $30 copay per visit, $30 copay per visit for $30 copay for each $35 copay per visit, $35 copay per visit for $35 copay per visit, $35 copay per visit for Medicare-covered dental benefits no deductible, Medicare $25 copay for Medicarecovered dental benefits $25 copay per visit, $25 copay per visit for Unless noted, all services are Medicare- only

4 Prime (HMO-POS) Select Value Durable Medical Equipment Prosthetic/Medical Supplies Diabetes Self monitoring training and supplies Outpatient Rehabilitation Physical Therapy, Occupational Therapy and Speech Therapy Outpatient clinical, diagnostic, therapeutic services all equipment and medical supplies may require all supplies $20 copay for each visit Authorization most all equipment may require all supplies visit Authorization most all equipment may require all supplies $20 copay for each visit Authorization most Unless noted, all services are Medicare- only therapy most all equipment may require all supplies visit Authorization most

5 Prime (HMO-POS) Select Value Cardiac Rehab $20 copay $25 copay 30% coinsurance $25 copay Chemotherapy authorization authorization authorization chemotherapy visit authorization Medical Nutritional services Outpatient Blood Preventive Care Inpatient Mental Health No copays for all Medicare : immunizations, pap/pelvic, colorectal screening; bone mass measurement; mammograms; prostate cancer screening; Annual Wellness Visit; Welcome to Medicare exam; HIV screening; diabetes training; smoking cessation counseling No copays for all Medicare : immunizations, pap/pelvic, colorectal screening; bone mass measurement; mammograms; prostate cancer screening; Annual Wellness Visit; Welcome to Medicare exam; HIV screening; diabetes training; smoking cessation counseling for Medicare covered immunizations including seasonal flu or pneumococcal vaccinations; 30% coinsurance for pap/pelvic exam, colorectal screening, bones mass measurement, mammograms and prostate cancer screening; Annual Wellness Visit; Welcome to Medicare exam; HIV screening; diabetes training; smoking cessation counseling No copays for all Medicare : immunizations, pap/pelvic, colorectal screening; bone mass measurement; mammograms; prostate cancer screening: Annual Wellness Visit; Welcome to Medicare exam; HIV screening; diabetes training; smoking cessation counseling Unless noted, all services are Medicare- only

6 Outpatient Mental Health Care and Substance Abuse Care Prime (HMO-POS) Select Value $30 copay for each $20 copay for each $50 copay partial hospitalization MH/SA Additional Services (Member Reimbursement) Wig Reimbursement Wig for hair loss due to chemotherapy and/or radiation therapy, member reimbursed up to $350 lifetime maximum. $50 copay partial hospitalization MH/SA Wig for hair loss due to chemotherapy and/or radiation therapy, member reimbursed up to $350 lifetime maximum. $15 copay for each $50 copay partial hospitalization MH/SA Wig for hair loss due to chemotherapy and/or radiation therapy, member reimbursed up to $350 lifetime maximum. Pharmacy Benefit Part D Deductible None None No Part D benefit Part D Copays: retail and mail-order Four tiers (retail): $5, $40, $70 copay, 30% coinsurance; mail-order for 3 month supply is 2.5 times monthly retail. Four tiers (retail): $5, $40, $70 copay, 30% coinsurance; mail-order for 3 month supply is 2.5 times monthly retail. No Part D benefit Unless noted, all services are Medicare- only