2016 Rochester Regional Health CDHP Medical Plan Summary

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1 Out of Annual Deductible The family deductible is met for all when one or more people on the coverage meets the total family deductible. Integrated prescription applies to the deductible. The amounts are combined across all s. $1,500 $1,500 $1,500 Annual Out of Pocket Maximum Annual Out of Pocket Maximum includes deductible, coinsurance, and integrated prescription expenses. The amounts are combined across all s. $12,000 $12,000 $12,000 $9,000 $18,000 $18,000 $18,000 Office Visits Primary Care Physician Visit & In-Office (including routine labs and minor office procedures) - Peds Specialist Physician Visit and In-Office (including routine labs & minor office procedures) - Peds Prescription Drugs Tier 1 Generic $10 co-pay $25 co-pay No coverage Tier 2 Brand Preferred Drugs $30 co-pay $50 co-pay No coverage Tier 3 Brand Non-Preferred Drugs $50 co-pay $90 co-pay No coverage Emergency Emergency Room Visit - Peds Free Standing Urgent Care Visit - Peds Ambulance Service Preventative Care* Well Child Care & Immunizations 1

2 Out of Preventative Care* (continued) Routine Physical Exams (1 per calendar year) Immunizations Adult & Pediatric (includes Flu Shot, Pneumonia & H1N1 Vaccines) Annual Mammogram Pap Smears (not including exam) Gynecologist Exam (1 per calendar year) Bone Density Testing Annual Prostate Cancer Screening (PSA) Routine Colonoscopy Vision Routine Eye Exam Adults (1 exam per every 2 calendar years) Routine Eye Exam Pediatric (1 exam per every calendar year) Routine Eyewear Adults $60 reimbursement every 2 years Routine Eyewear Pediatric $60 reimbursement every year Physician Office Diagnostic Primary Care Physician Visit & In-Office (including routine labs & minor office procedures) - Peds Diagnostic Specialist Physician Visit & In-Office (including routine labs & minor office procedures) - Adults - Peds Diagnostic Imaging (X-ray, CAT, MRI, PET & Ultrasounds) - Peds Diagnostic Laboratory & Pathology Adults - Peds 2

3 Out of Physician Office (continued) Allergy Testing Adults Allergy Testing Pediatric Allergy Shots Adults (per visit) Allergy Shots Pediatric (per visit) Chemotherapy Adults Chemotherapy Pediatric Radiation Therapy Adults Radiation Therapy Pediatric Maternity Pre-Natal Maternity Care Hospital Care for Mother (Inpatient Stay) Newborn Nursery Care 40% Coinsurance Hospital Inpatient Adult Hospital Admissions 40% Coinsurance Pediatric Hospital Admissions Physician Visits in the Hospital - Peds Physical Rehabilitation Admissions (60 days per calendar year) 40% Coinsurance- Adults - Peds Surgery - Peds 3

4 Out of Hospital Inpatient (continued) Anesthesia - Peds Hospital Outpatient or Surgical Center Pre-admission/Pre-operative testing - Peds Ambulatory Surgery Adults Ambulatory Surgery Pediatric Diagnostic Imaging (Facility Fee) (X-ray, CAT, MRI, PET) - Peds Diagnostic Lab and Pathology (Facility Fee) - Peds Chemotherapy (Facility Fee) - Peds Radiation Therapy (Facility Fee) - Peds Dialysis Visits - Peds Dialysis Facility Visit - Peds Mental Health Adult Acute Inpatient Mental Health Care 40% Coinsurance Pediatric Inpatient Mental Health Care Acute Outpatient Mental Health ( must be rendered by a licensed psychiatrist, certified clinical psychologist, social worker, or psychiatric social worker.) - Peds fa 4

5 Out of Mental Health (continued) Inpatient Substance Use Rehabilitation & Detoxification 40% Coinsurance Adults Peds Outpatient Substance Use Care - Peds Hearing Routine Hearing Evaluations No coverage No coverage Diagnostic Hearing Evaluations Hearing Aids Adults No coverage No coverage Hearing Aids Pediatric Other Care and Chiropractic Office Visit & In-Office (limit of 30 visits per calendar year) Acupuncture (10 visits per calendar year) 1 hearing aid every three years OptiFast Nutrition & Weight Management Center (one program per year) Subject to deductible Subject to deductible Subject to deductible Diabetic Supplies (co-pay applies to each 30 day supply; individual co-pays required for insulin, test strips and syringes) Diabetic Supplies Pediatric (co-pay applies to each 30 day supply; individual co-pays required for insulin, test strips and syringes) Skilled Nursing Facility (120 days per calendar year, 360 days lifetime maximum. Custodial care not covered.) - Peds Durable Medical Equipment (prior authorization required over $200) Medical Supplies Home Healthcare Visits & (40 visits per calendar year) - Peds 5

6 Out of Other Care and (continued) Hospice Care (includes 5 bereavement counseling visits, unlimited visits per calendar year) - Peds Rehabilitative Therapy (Physical, Occupational, Speech combined total of 30 visits per calendar year) - Peds Cardiac Rehabilitation 40% Coinsurance- Adults - Peds External Prosthetics (foot orthotics excluded) 10% co-insurance Foot Orthotics No coverage No coverage Dental (Non-Accidental ) No coverage No coverage * Preventative Care benefits follow PPACA guidelines for age and frequency Definitions: : Includes Rochester General Hospital, Newark-Wayne Community Hospital, Unity Hospital, all Health affiliates and all Health Medical staff (including courtesy, attending and consulting physicians). drug co-pays apply only to prescriptions filled at The General Apothecary, Park Ridge Apothecary, Unity St. Mary s Apothecary, Wayne-Clifton Pharmacy or through mail order using Wegmans Home Delivery or Express Scripts Home Delivery. : All local and national BlueCross/BlueShield PPO participating health care providers who are not in the. Out of : Any physician, hospital or other health care provider that is not in the Health or Excellus BlueCross/BlueShield PPO network. Dependent: Qualified dependents are covered until age 26. Pediatric: Dependent children up to age 19. Pre-Authorization/ Pre-Certification: You must call Excellus BlueCross/BlueShield in advance for the following services: Inpatient Hospital Admissions (excluding maternity and emergency admissions); durable medical equipment over $200, Home Infusion services, Home Care services, MRI, CT scans and PET scans. If you fail to make obtain prior authorization, you will be subject to a $500 or 50% penalty, whichever is less. NOTE: Health believes that the health insurance that has been offered to you satisfies both the affordability test and the minimum value test under the Affordable Care Act (the Act ). This means that it is unlikely that you will be eligible for any subsidies or cost sharing reductions if you decline enrollment and instead obtain coverage through the health insurance exchange. Additionally, please remember that if you fail to obtain health insurance coverage you may be subject to a penalty under the Act s Individual Mandate. 6

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