2019 University of Rochester Complementary Care Plan with Major Medical

Transcription

1 2019 University of Rochester Complementary Care Plan with Major Medical INPATIENT HOSPITAL Semi-private Room and Board Physician and Surgeon Services OUTPATIENT HOSPITAL Diagnostic X-Ray Lab & Pathology; Chemotherapy/Radiation Therapy Physical, Speech and Occupational Therapy Surgery Outpatient Doctor s Office Care Emergency Care Urgent Care Center Ambulance MENTAL HEALTH CARE Inpatient Semi-private Room and Board Inpatient Physician and Surgeon Services Outpatient (all services are considered Doctor s Office Care) ALCOHOL/SUBSTANCE ABUSE CARE Inpatient Semi-private Room and Board Covers Medicare Part A inpatient deductible and co-pay up to 120 days per calendar year; additional days covered at 80% after Major Medical deductible, less any Medicare Payment deductible, less any Medicare payment deductible, less any Medicare Payment deductible, less any Medicare payment for emergency use and medically necessary transfers, less any Medicare payment Covers Medicare Part A inpatient deductible and co-pay up to 120 days per calendar year; additional days covered at 80% after Major Medical deductible, less any Medicare payment deductible, less any Medicare payment. Includes coverage for autism the same as any other illness Covers Medicare Part A inpatient deductible and co-pay up to 120 days per calendar year; additional days covered at 80% after Major Medical deducible, less any Medicare payment

2 Inpatient Physician and Surgeon Services Outpatient (all services are considered Doctor s Office Care) PRESCRIPTION DRUGS Non-Maintenance Drugs & Maintenance Drugs deductible Covered at 80% 1 after Prescription Drug deductible. Specialty Drug Program: Specialty drug prescriptions must be filled through a specific pharmacy designated by your TPA (Aetna or Excellus BlueCross BlueShield) Diabetic Equipment and Supplies The following supplies are covered at 80% (deductible waived) up to a 90-day supply for retail and mail order drugs (expenses not included in out-of-pocket maximum); less any Medicare payment: Needles and syringes, Lancets and lancing devices, Test strips, Insulin, Glucose tablets, Alcohol swabs and Oral Medications Blood Glucose monitors, external infusion pump and supplies and injection aids are covered under the durable medical equipment benefit OTHER SERVICES Skilled Nursing Facility Care (excludes custodial care) Home Health Care Hospice Care Routine Vision Care Hearing Care Durable Medical Equipment (DME) Allergy Test & Injections Covers Medicare Skilled Nursing Facility coinsurance for days , and full coverage for days ; additional days covered at 80% after Major Medical deductible (deductible waived), less any Medicare payment. Including visiting nurse care. Each visiting nurse care of four hours of less count as one home health visit. Each such shift of over four hours and up to eight hours, counts as two home health care visits, less any Medicare payment No coverage for routine care. Diagnostic exams for disease or injury are covered at 80% after Major Medical deductible, less any Medicare payment. No coverage for routine care. Diagnostic evaluations covered at 80% after Major Medical deductible, less any Medicare payment. Hearing aids covered in full after Major Medical deductible for accidental injury only, less any Medicare payment after Major Medical deductible, less any Medicare payment deductible, less any Medicare payment

3 Chiropractic Care Acupuncture Podiatry PREVENTIVE CARE Physicals Pap Smears and Pelvic Exams Mammograms Bone Mass Colorectal Screening Exams Prostate Cancer Screening Exams Immunizations ANNUAL MEDICAL DEDUCTIBLE & OUT OF POCKET MAXIMUM Medical Deductible deductible, less any Medicare payment (based on medical necessity) deductible, if performed by a licensed physician to treat a diagnosis Covered at 80% for medically necessary foot care, less any Medicare payment (annual GYN exam covered in full); less any Medicare payment; one allowed per year, less any Medicare payment; one allowed per year for annual screening, less any Medicare payment, less any Medicare payment for flexible sigmoidoscopy every 5 years; colonoscopy every 10 years; less any Medicare payment, less any Medicare payment; one allowed per year for pneumonia, flu, H1N1, shingles, tetanus and Hepatitis B vaccines; less any Medicare payment $126 per person Annual Stop Loss Protection for Major Medical (out-ofpocket maximum) ANNUAL PRESCRIPTION DRUG DEDUCTIBLE & OUT OF POCKET MAXIMUM Prescription Drug Deductible $300 per person $829 per person Annual Stop Loss Protection for Major Medical (out-of-pocket maximum) $1,700 per person Residency Requirement: To be eligible for the UR Complementary Care plan, you can reside anywhere in the world. The University Complementary Care plan with Major Medical will not duplicate benefits provided by Medicare Part A, Part B, Part C, or Part D. These plans are grandfathered health plans under the Patient Protection and Affordable Care Act. This plan coordinates with Medicare, and services are paid through Medicare first. 1 Refer to Non-Maintenance Drugs and Maintenance Drugs. In cases of selected brand-name drugs where there is an FDA-approved generic substitute available, your benefit will be based on the cost of the generic drug rather than the cost of the brand-name drug. If you or your doctor choose the brandname drug, you will have to pay the difference, plus any applicable co-pay. If your prescription does not have an approved generic substitute, your benefit will not be affected. As the FDA approves new drugs the plan will determine the possibility of covering the drug, including researching its value, safety, and possible advantages over existing covered drugs. The plan will also determine any limits to coverage the new drug.

4 2019 Preferred Gold HMO-POS with University Major Medical DOCTOR VISITS Primary Care $10 Specialist and Outpatient Mental Health $15 Chiropractor $15 Allergy Injection (allergy serum covered) $10 Primary Care; $15 Specialist Acupuncture (10 visits) 50% PREVENTIVE CARE Annual Wellness Exam Medicare-covered screenings mammogram, prostate, Pap tests, bone mass measurement Pneumonia and Flu Shots HOSPITAL SERVICES Inpatient Acute Hospital Stays $0 per stay Inpatient Mental Health Care (190 days per lifetime) Observation Stays OUTPATIENT SERVICES Ambulatory Surgical Center same day surgery & other services Outpatient Hospital same day surgery & other services Home Health Services Hospice Covered by Medicare EMERGENCY CARE Emergency Room Care worldwide coverage $65 Urgently Needed Care worldwide coverage $15 Ambulance Transportation $50 (per use) DIAGNOSTIC SERVICES office visit copay may apply X-rays (Radiology) $15 Lab Tests $0 CT Scans, PET Scans, MRIs, Nuclear Medicine $15 REHABILITATION Skilled Nursing Facility $0 each day, days 1-20; $135 each day, days Physical, Occupational, and Speech Therapy (therapy caps apply) $15 OUT-OF-NETWORK AND TRAVEL COVERAGE (POS) Care from providers (doctors, hospitals and other facilities) that are not part of MVP s network. (Not all services are covered out of network.) No Deductible. Member pays 30%. $5000 maximum annual benefit. MEMBER PROTECTION Maximum Annual Out-of-Pocket Protection In and Out of Network (Excludes: Part D costs, acupuncture, eyewear, hearing aids and dental if applicable) $4000

5 ADDITIONAL COVERAGE Diabetic Glucose Strips must be preferred brands 0% Other Diabetic Supplies 10% Durable Medical Equipment (DME) 20% Prosthetic Devices such as artificial limbs, braces 20% Part B Drugs (including chemotherapy) $15 Radiation Therapy $0 Outpatient Dialysis $0 Eyewear Allowance Hearing Aid Allowance $100 eyewear allowance every two years $600 hearing aid allowance every three years WELL-BEING PROGRAMS 24 Hour Nurse Line Nurse available 24 hours per day, 7 days per week to answer health questions via telephone or . Wellness Rewards The SilverSneakers Fitness Program $75 gift card when certain preventive services are completed. Free fitness center membership benefits at any participating fitness center near you, including use of equipment and other amenities. Exclusions & Non-covered Services Neither MVP nor Original Medicare will pay for certain items or services, including cosmetic surgery, custodial care, and experimental procedures and items. For a complete list of excluded services, refer to your Evidence of Coverage (your contract). Unless expressly indicated in the contract, all non-medically necessary services are not covered. Even if you receive the services at an emergency facility, the excluded services are still not covered. This information is a brief summary, not a comprehensive description of benefits. For more information, refer to your Evidence of Coverage (your contract). Residency Requirement: To be eligible for the Preferred Gold HMO-POS plan with University Major Medical you must have a permanent/legal address in the following New York State Counties: Allegany, Cattaragus, Chautauqua, Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Seneca, Wayne, Wyoming, or Yates. HMO - Buy-Up - MRX098A/B

6 2019 Preferred Gold Standard HMO-POS with Part D Prescription Drug Coverage DOCTOR VISITS Primary Care $15 Specialist and Outpatient Mental Health $30 Chiropractor $20 Allergy Injection (allergy serum covered) $15 Primary Care; $30 Specialist Acupuncture (10 visits) 50% PREVENTIVE CARE Annual Wellness Exam Medicare-covered screenings mammogram, prostate, Pap tests, bone mass measurement Pneumonia and Flu Shots HOSPITAL SERVICES Inpatient Acute Hospital Stays $250 per stay Inpatient Mental Health Care (190 days per lifetime) $750 maximum per year Observation Stays $60 OUTPATIENT SERVICES Ambulatory Surgical Center same day surgery & other services $30 Outpatient Hospital same day surgery & other services $60 Home Health Services Hospice Covered by Medicare EMERGENCY CARE Emergency Room Care worldwide coverage $75 Urgently Needed Care $30 Ambulance Transportation $100 (per use) DIAGNOSTIC SERVICES office visit copay may apply X-rays (Radiology) $30 Lab Tests $10 CT Scans, PET Scans, MRIs, Nuclear Medicine $60 REHABILITATION Skilled Nursing Facility $0 each day, days 1-20; $172 each day, days Physical, Occupational, and Speech Therapy (therapy caps apply) $30 OUT-OF-NETWORK AND TRAVEL COVERAGE (POS) Care from providers (doctors, hospitals and other facilities) that No Deductible. Member pays 30%. are not part of MVP s network. (Not all services are covered out of $5000 maximum annual benefit. network.) MEMBER PROTECTION Maximum Annual Out-of-Pocket Protection In Network (Excludes: Part D costs, acupuncture, eyewear, hearing aids and dental if applicable) $4000

7 ADDITIONAL COVERAGE Diabetic Glucose Strips must be preferred brands* 0% Other Diabetic Supplies 10% Durable Medical Equipment (DME) 20% Part B Drugs Purchased at Pharmacy 20% Part B Drugs Professionally Administered (chemotherapy) 20% Radiation Therapy 20% Outpatient Dialysis 20% Eyewear Allowance Hearing Aid Allowance $100 eyewear allowance every two years $600 every 3 yrs. (also TruHearing discounts) ENHANCED PRESCRIPTION DRUG COVERAGE Initial Coverage Stage Retail Pharmacy (30 day supply) Mail Order (up to a 90 day supply) Tier 1 Preferred generic drugs $0 copayment $0 copayment Tier 2 Generic drugs $10 copayment $20 copayment Tier 3 Preferred brand-name drugs $35 copayment $70 copayment Tier 4 Non-preferred drugs 50% coinsurance 50% coinsurance Tier 5 Specialty drugs 33% coinsurance Not Available Coverage Gap Stage If your total drug costs (paid by both you and MVP Health Plan, Inc.) reach $3,820, you will pay 37% for generic drugs, 25% for Medicare-contracted Brand-name drugs, and 100% of the drug cost for Non-Medicare-contracted Brand-name drugs. You will continue to pay $0 for Tier 1 drugs. Catastrophic Coverage Stage When you have paid $5,100 out of pocket, your cost for prescriptions is reduced to 5% or $3.40 for generics and $8.50 for all other drugs, whichever is greater. Additional Coverage Non-Part D drugs are not covered. WELL-BEING PROGRAMS 24 Hour Nurse Line Nurse available 24 hours per day, 7 days per week to answer health questions via telephone or . Wellness Rewards The SilverSneakers Fitness Program $75 gift card when certain preventive services are completed. Free fitness center membership benefits at any participating fitness center near you, including use of equipment and other amenities. Exclusions & Non-covered Services Neither MVP nor Original Medicare will pay for certain items or services, including cosmetic surgery, custodial care, and experimental procedures and items. For a complete list of excluded services, refer to your Evidence of Coverage (your contract). Unless expressly indicated in the contract, all non-medically necessary services are not covered. Even if you receive the services at an emergency facility, the excluded services are still not covered. This information is a brief summary, not a comprehensive description of benefits. Some services may require prior authorization from MVP. For more information, refer to your Evidence of Coverage (your contract). Residency Requirement: To be eligible for the Preferred Gold Standard HMO-POS plan you must have a permanent/legal address in New York State or Vermont (excludes New York City and Long Island). * Preferred Brand Diabetic Test Strips: Precision, OneTouch and Freestyle Brands HMO - Standard - (MRX121A/B, MRX127A/B)

8 2019 GoldAnywhere PPO with Part D Prescription Drug Coverage In-Network Out-of-Network DOCTOR VISITS Primary Care $10 $25 Specialist and Outpatient Mental Health $15 $25 Chiropractor $15 $20 Allergy Injection (allergy serum covered) $10 Primary Care $15 Specialist $25 Primary Care $25 Specialist Acupuncture (10 visits) 50% 50% PREVENTIVE CARE Annual Wellness Exam $25 Medicare-covered screenings mammogram, prostate, Pap tests, bone mass measurement Pneumonia and Flu Shots (Office visit copay may apply) (Office visit copay may apply) (Office visit copay may apply) (Office visit copay may apply) HOSPITAL SERVICES Inpatient Acute Hospital Stays 20% Inpatient Mental Health Care (190 days per lifetime) Observation Stays 20% OUTPATIENT SERVICES Ambulatory Surgical Center same day surgery & other 20% services Outpatient Hospital same day surgery & other services 20% Home Health Services 20% Hospice Covered by Medicare EMERGENCY CARE Emergency Room Care worldwide coverage $65 $65 Urgently Needed Care $15 $15 Ambulance Transportation $35 (per use) $35 (per use) DIAGNOSTIC SERVICES office visit copay may apply X-rays (Radiology) $15 $25 Lab Tests 20% CT Scans, PET Scans, MRIs, Nuclear Medicine $15 20% REHABILITATION Skilled Nursing Facility $0 days % days Physical, Occupational, and Speech Therapy (therapy caps apply) $15 $25

9 MEMBER PROTECTION Maximum Annual Out-of-Pocket Protection (Excludes: Part D costs, acupuncture, eyewear, hearing aids and dental if applicable) $4,000 Combined ADDITIONAL COVERAGE In-Network Out-of-Network Diabetic Glucose Strips must be preferred brands * 0% 20% Other Diabetic Supplies 10% 20% Durable Medical Equipment (DME) 20% 20% Part B Drugs Purchased at Pharmacy 20% 20% Part B Drugs Professionally Administered (chemotherapy) $15 $25 Radiation Therapy $0 20% Outpatient Dialysis $0 $0 Eyewear Allowance Hearing Aid Allowance $100 eyewear allowance every two years $600 every 3 yrs. (also TruHearing discounts) ENHANCED PRESCRIPTION DRUG COVERAGE Initial Coverage Stage Retail Pharmacy (30 day supply) Mail Order (up to a 90 day supply) Tier 1 Preferred generic drugs $0 copayment $0 copayment Tier 2 Generic drugs $10 copayment $20 copayment Tier 3 Preferred brand-name drugs $30 copayment $60 copayment Tier 4 Non-preferred drugs $60 copayment $120 copayment Tier 5 Specialty drugs $60 copayment Not Available Coverage Gap Stage If your total drug costs (paid by both you and MVP Health Plan, Inc.) reach $3,820, you will pay either the copayments as listed above or less. You will continue to pay $0 for Tier 1 drugs. Catastrophic Coverage Stage When you have paid $5,100 out of pocket, your cost for prescriptions is reduced to 5% or $3.40 for generics and $8.50 for all other drugs, whichever is greater. You will never pay more in Catastrophic Coverage than you did in the Initial Coverage stage Additional Coverage Your plan also covers the following: Erectile dysfunction drugs, weight-loss agents, and additional barbiturates (butalbital/aspirin/caffeine). WELL-BEING PROGRAMS 24 Hour Nurse Line Nurse available 24 hours per day, 7 days per week to answer health questions via telephone or . Wellness Rewards $75 gift card when certain preventive services are completed. The SilverSneakers Fitness Program Free fitness center membership benefits at any participating fitness center near you, including use of equipment and other amenities. Exclusions & Non-covered Services Neither MVP nor Original Medicare will pay for certain items or services, including cosmetic surgery, custodial care, and experimental procedures and items. For a complete list of excluded services, refer to your Evidence of Coverage (your contract). Unless expressly indicated in the contract, all non-medically necessary services are not covered. Even if you receive the services at an emergency facility, the excluded services are still not covered. This information is a brief summary, not a comprehensive description of benefits. Some services may require prior authorization from MVP. For more information, refer to your Evidence of Coverage (your contract). Residency Requirement: To be eligible for the GoldAnywhere PPO plan you must have a permanent/legal address in New York State or Vermont (excludes NYC and Long Island). * Preferred Brand Diabetic Test Strips: Precision, OneTouch and Freestyle Brands GA - Buy-Up -MRXP129A/B

10 2019 University of Rochester USA Care PPO with Part D Prescription Drug Coverage DOCTOR VISITS Primary Care $15 Specialist and Outpatient Mental Health $20 Chiropractor $20 Allergy Injection (allergy serum covered) $15 Primary Care; $20 Specialist Acupuncture (10 visits) 50% PREVENTIVE CARE Annual Wellness Exam Medicare-covered screenings mammogram, prostate, Pap tests, bone mass measurement Pneumonia and Flu Shots HOSPITAL SERVICES Inpatient Acute Hospital Stays Inpatient Mental Health Care (190 days per lifetime) $100 per stay $300 maximum per year Observation Stays OUTPATIENT SERVICES Ambulatory Surgical Center same day surgery & other services Outpatient Hospital same day surgery & other services Home Health Services Hospice Covered by Medicare EMERGENCY CARE Emergency Room Care worldwide coverage $75 Urgently Needed Care $20 Ambulance Transportation $35 (per use) DIAGNOSTIC SERVICES office visit copay may apply X-rays (Radiology) $20 Lab Tests $0 CT Scans, PET Scans, MRIs, Nuclear Medicine $20 REHABILITATION Skilled Nursing Facility $0 each day, days 1-20; $172 each day, days Physical, Occupational, and Speech Therapy $20 (therapy caps apply) MEMBER PROTECTION Maximum Annual Out-of-Pocket Protection (Excludes: Part D costs, acupuncture, eyewear, hearing aids and dental if applicable) $4,000 Combined

11 ADDITIONAL COVERAGE Diabetic Glucose Strips must be preferred brands * 0% Other Diabetic Supplies 10% Durable Medical Equipment (DME) 20% Part B Drugs Purchased at Pharmacy 20% Part B Drugs Professionally Administered (chemotherapy) 20% Radiation Therapy 20% Outpatient Dialysis 20% Eyewear Allowance Hearing Aid Allowance $100 eyewear allowance every two years $600 every 3 yrs. (also TruHearing discounts) ENHANCED PRESCRIPTION DRUG COVERAGE Initial Coverage Stage Retail Pharmacy (30 day supply) Mail Order (up to a 90 day supply) Tier 1 Preferred generic drugs $0 copayment $0 copayment Tier 2 Generic drugs $10 copayment $20 copayment Tier 3 Preferred brand-name drugs $30 copayment $60 copayment Tier 4 Non-preferred drugs $60 copayment $120 copayment Tier 5 Specialty drugs $60 copayment Not Available Coverage Gap Stage If your total drug costs (paid by both you and MVP Health Plan, Inc.) reach $3,820, you will pay either the copayments as listed above or less. You will continue to pay $0 for Tier 1 drugs. Catastrophic Coverage Stage When you have paid $5,100 out of pocket, your cost for prescriptions is reduced to 5% or $3.40 for generics and $8.50 for all other drugs, whichever is greater. You will never pay more in Catastrophic Coverage than you did in the Initial Coverage stage Additional Coverage Your plan also covers the following: Erectile dysfunction drugs, weight-loss agents, and additional barbiturates (butalbital/aspirin/caffeine). WELL-BEING PROGRAMS 24 Hour Nurse Line Nurse available 24 hours per day, 7 days per week to answer health questions via telephone or . Wellness Rewards The SilverSneakers Fitness Program $75 gift card when certain preventive services are completed. Free fitness center membership benefits at any participating fitness center near you, including use of equipment and other amenities. Exclusions & Non-covered Services Neither MVP nor Original Medicare will pay for certain items or services, including cosmetic surgery, custodial care, and experimental procedures and items. For a complete list of excluded services, refer to your Evidence of Coverage (your contract). Unless expressly indicated in the contract, all non-medically necessary services are not covered. Even if you receive the services at an emergency facility, the excluded services are still not covered. This information is a brief summary, not a comprehensive description of benefits. Some services may require prior authorization from MVP. For more information, refer to your Evidence of Coverage (your contract). Residency Requirement: To be eligible for the USA Care PPO plan you can reside anywhere in the US or Puerto Rico. * Preferred Brand Diabetic Test Strips: Precision, OneTouch and Freestyle Brands USA - Standard -MRXPU128A/B