Benefit Copay waived if admitted Emergency Room. 100% of Allowed Benefit 100% of Allowed - for HIV screening. Benefit Emergency Room

Transcription

1 AMHIC, A Reciprocal Association Network Only Health Plan Summary of s Effective January 1, 2015 CALENDAR YEAR DEDUCTIBLE Individual None Individual and 1 Dependent None Family (Employee and 2 or more Dependents) None CALENDAR YEAR COINSURANCE MAXIMUM Individual $2,000 Individual and 1 Dependent $4,000 Family (Employee and 2 or more Dependents) $6,000 The Coinsurance Maximum is the maximum amount of benefit cost share, represented as a percentage (for example, 20%), you are responsible for paying for Covered Services during the Calendar Year. The following do not count towards the Coinsurance Maximum: prescription drug copayments, medical copayments, pre-certification penalties, expenses for non-covered Services, and charges in excess of the. CALENDAR YEAR WRAP OUT-OF-POCKET MAXIMUM Individual $6,600 Individual and 1 Dependent $13,200 Family (Employee and 2 or more Dependents) $13,200 The Wrap Out-of-Pocket Maximum is the maximum total amount you will pay toward combined coinsurance, medical copayments and prescription drug copayments for Covered Services during the Calendar Year. The following do not count toward the Wrap Out-of-Pocket Maximum: precertification penalties, expenses for non-covered Services, expenses for Out-of-Network services, and charges in excess of the. After the Wrap Out-of-Pocket Maximum is satisfied, the Plan will pay 100% of s for all eligible medical expenses for the remainder of the calendar year. TYPE OF EXPENSE Hospital and Other Facility Expenses Inpatient* - includes room, board and ancillary services Inpatient Newborn Network Provider (In-Network) Non-Network Provider (Out-of-Network) * 80% of * Skilled Nursing/Extended Care Facility* (maximum of 100 days per calendar year) Rehabilitation Facility* 80% of * $100 Copay, then 100% $100 Copay, then - Accidental Injury or Medical Emergency of 100% of Allowed Copay waived if admitted Copay waived if admitted 100% of 100% of Allowed - for HIV screening 80% of - Non-Medical Emergency Outpatient includes all services billed by the 80% of Hospital Ambulatory Surgical Facility 80% of Page 1 of 6

2 Professional Expenses Anesthesia (Inpatient and Outpatient) 80% of - Accidental Injury or Medical Emergency 100% of 100% of Allowed - for HIV screening 100% of 100% of Allowed 80% of - Non-Medical Emergency Physician Hospital Visit 80% of Physician Office Visit - Primary Care Physician (PCP) (PCP includes a General Practitioner, Family Practitioner, Internist, Pediatrician, OB/GYN, Psychiatrist and Psychologist) Physician Office Visit - Specialist $25 Copay per visit, then 100% of $35 Copay per visit, then 100% of Second Surgical Opinion 80% of Surgery (Inpatient and Outpatient) 80% of Other Eligible Expenses Acupuncture (maximum of $2,000 per calendar year) Allergy Shots/Serum (if billed separately from office visit) Allergy Testing - Primary Care Physician - Specialist Ambulance $35 Copay per visit, then 100% of 80% of $25 Copay, then 100% of $35 Copay, then 100% of $75 Copay, then 100% of Cardiac Rehabilitation 80% of Chiropractic Care (maximum of $2,000 per calendar year) 80% of Clinical Trials (Patient Costs) Covered according to place of service Durable Medical Equipment 80% of Home Health Care 80% of (maximum of 100 visits per calendar year) Home Infusion Therapy 80% of Hospice Care (maximum of 180 days per Lifetime) Infertility Testing (maximum of $1,000 per calendar year) 100% of 80% of Laboratory tests, x-rays and diagnostic tests, 100% of including specialty imaging Orthopedic Appliance 80% of Patient Education (includes diabetes management and 80% of ostomy care) Page 2 of 6

3 Pre-Admission Testing 80% of Private Duty Nursing Prosthetics 80% of Renal Dialysis 80% of Therapy Chemotherapy, Radiation, Physical, 80% of Occupational, Speech Urgent Care Center $50 Copay, then 100% of All Other Eligible Expenses 80% of Maternity Services Inpatient Hospital* * Birthing Center 80% of Anesthesia 80% of Physician s Charges for Delivery 80% of Prenatal or postnatal office visits (not billed with delivery) PCP $25 Copay per visit then 100% of Specialist $35 Copay per visit then 100% of 100% of Laboratory tests, x-rays, diagnostic tests, specialty imaging Prenatal Screening as defined under Women s 100% of Preventive Services, in compliance with the Patient Protection and Affordable Care Act of 2010 Organ Transplants Inpatient Hospital* 80% of * Anesthesia 80% of Transplant Procedure 80% of Laboratory tests, x-rays, diagnostic tests 100% of Preventive Services Preventive Services for eligible adults and children, in compliance with the Patient Protection and Affordable Care Act of 2010** 100% of ** A description of Preventive Services can be found at: Page 3 of 6

4 Women s Preventive Services, in compliance with the Patient Protection and Affordable Care Act of 2010*** 100% of *** A description of Women s Preventive Services can be found at: Nutritional Counseling 100% of Mental Health and Substance Abuse Inpatient Hospital or Residential Care in a Hospital or Non-Hospital Residential Facility* * Inpatient Physician Visits 80% of Partial Hospitalization episode of care, then 100% of * Outpatient $25 Copay per visit, then 100% of Allowed INDIVIDUAL LIFETIME MAXIMUMS Overall Medical Maximum Unlimited Hospice Care 180 days Surgery required as the result of Morbid Obesity* One surgery INDIVIDUAL CALENDAR YEAR MAXIMUMS Acupuncture $2,000 Chiropractic Care $2,000 Home Health Care 100 visits Infertility Testing $1,000 Skilled Nursing/Extended Care Facility 100 days Prescription Drugs Retail Mail Order (30-day supply) (90-day supply) Generic Drugs $10 Copay $20 Copay Formulary Brand Name Drugs $35 Copay $70 Copay Non-Formulary Brand Name Drugs $70 Copay $140 Copay Over-the-Counter Drugs related to Preventive Services, in compliance with the Patient Protection and Affordable Care Act of 2010** ** A description of Preventive Services can be found at: FDA-Approved Generic Drugs and Over-the- Counter Drugs, Devices, and Supplies related to Women s Preventive Services, including FDAapproved contraceptive methods, in compliance with the Patient Protection and Affordable Care Act of 2010*** *** A description of Women s Preventive Services can be found at: Brand Name (Chantix only) and Generic drugs and Over-the-Counter Drugs related to Smoking Cessation, in compliance with the Patient Protection and Affordable Care Act of 2010**** ****A description of Tobacco Use Preventive Services can be found at: Page 4 of 6

5 Vaccination (age appropriate flu, shingles and pneumonia at Participating Network Pharmacies in the CareFirst Administrators MD/DC/Northern VA Service Area) NOTE: A Brand Name drug that has a Generic alternative is a Multisource Brand drug. If you are prescribed a Multisource Brand drug, and you purchase a Brand Name drug when a Generic drug is available, you will pay the Generic Copay plus the difference in price between the Brand Name drug and the Generic drug. You will be required to pay this difference, even if your Physician writes Dispense as Written. Over-the-Counter Option Non-sedating antihistamines and Prilosec (Please refer to Notes 8 and 9 below) $10 Copay Important Note: Do not rely on this chart alone. It is only a summary. The contents of this summary are subject to the provisions of the Certificate of Coverage, which contains all terms, covenants and conditions of coverage. The Plan may exclude coverage for certain treatments, diagnoses, or services not noted below. The benefits shown in this summary may only be available if required Plan procedures are followed (for example, the Plan may require pre-certification or the use of specified Providers). Payments to Providers are based on the, as determined by the Claims Administrator, in the amounts specified in the summary shown below. Covered Services are subject to the pre-certification requirement, as indicated. Pre-Certification Requirement - The items marked above with an asterisk (*) require precertification. The Participant is responsible for ensuring that the pre-certification process is initiated when necessary. Failure to pre-certify will result in a penalty of 50% up to a maximum of $500. Contact Conifer/Informed prior to admittance (or within one business day after an emergency admission) to a Hospital or other facility Provider. Please call (866) NOTES: 1. s for services provided by a Network Provider are payable as shown in this - Summary of s. To obtain In-Network benefits, you must use a Network Provider. Since the list of participating Network Providers is subject to change, it is best to confirm that a particular Provider participates by calling the Provider prior to receiving services. 2. Referrals by Network Providers to Non-Network Providers will be considered as Out-of- Network services and are not covered expenses. In order to receive In-Network benefits, ask your Physician to refer you to a Network Provider. However: a. If you utilize a Network Hospital or other facility which is a Network Provider and receive services from a Non-Network Provider; or b. If Medically Necessary services are not available from a Network Provider (because the network does not contract with the appropriate specialty), then the services will be paid at the In-Network benefit level, based on the. All other limitations, requirements and provisions of this Plan will apply. This exception does not apply in the event you and/or your Physician had the opportunity to select a Network Provider and chose to receive services from a Non-Network Provider. Page 5 of 6

6 3. The Copay in the Physician s office includes diagnostic services, injections, supplies, and allergy services performed in the office and billed by the Physician. 4. Anesthesia, x-rays, laboratory, emergency room services, inpatient consultations and other diagnostic services received at a Network Hospital or other facility Provider and rendered and billed by a Non-Network Provider will be paid at the In-Network benefit level, based on the. This exception does not apply if you and/or your Physician had the opportunity to select a Network Provider and chose to receive services from a Non-Network Provider. 5. If a Network Provider performs diagnostic testing, X-rays, and other laboratory testing and the Network Provider sends the tests to a Non-Network Provider (such as a laboratory) for analysis and results, the Plan will pay at the In-Network benefit level, based on the Allowed. 6. If the Participant receives care in an emergency room for an Accidental Injury or a Medical Emergency at a Non-Network Hospital, eligible expenses will be covered at the In-Network benefit level, based on the. If the Participant is admitted on an emergency basis to a facility, benefits for eligible expenses for that admission will be paid at the In- Network benefit level, based on the. 7. The is based on Plan allowances for treatment, services or supplies, rendered by a Provider, essential to the care of the individual as determined by the Claims Administrator. Charges by a Provider must be the amount usually charged for similar services and supplies in the absence of a plan or insurance. Charges for Covered Services that do not exceed the will be reimbursed as specified in this Summary of s. A fee schedule, selected by the Claims Administrator, may be used by the Plan in determining the amount of the. 8. Guidelines for Non-Sedating Antihistamines Non-sedating antihistamines may either be obtained in over-the-counter (OTC) form or dispensed by a pharmacist. Your Physician can prescribe either type. The following guidelines explain the benefits: - Over-the-Counter s are provided for all over-the-counter non-sedating antihistamines at the Generic Copay. Examples include Claritin, Allegra, Clarinex and Zyrtec. Keep in mind that in order for the OTC drug to be covered, you must have a prescription from your Physician. - Pharmacist-dispensed Prescriptions s are not provided for non-sedating antihistamines when dispensed by a pharmacist from a written prescription. In this case, you will pay the entire amount for the drug. 9. Guidelines for Prilosec Prilosec may either be obtained in over-the-counter (OTC) form or dispensed by a pharmacist. Your Physician can prescribe either type. The following guidelines explain the benefits: - Over-the-Counter s are provided for over-the-counter Prilosec at the Generic Copay. Keep in mind that in order for OTC Prilosec to be covered, you must have a prescription from your Physician. - Pharmacist-dispensed Prescriptions s are not provided for Prilosec when dispensed by a pharmacist from a written prescription. In this case, you will pay the entire amount for the drug. Page 6 of 6