SUMMACARE BRONZE 4000Q-15 SCHEDULE OF BENEFITS

Transcription

1 SUMMACARE BRONZE 4000Q-15 SCHEDULE OF BENEFITS Enrollee Services Per Member/Per Family Calendar Year Deductible (In-network and out-of-network deductibles are separate. Deductible applies to all covered services subject to coinsurance.) Per Member/Per Family Calendar Year Out-of- Pocket Maximum (Includes deductible, coinsurance and copays. Inand out-of-network out-of-pockets are separate. Once the member or family out-of-pocket is met, services will be paid at 100% of the maximum allowable charge.) Coinsurance (What the member pays after the deductible is met but before the out-of-pocket maximum is reached; after the out-of-pocket maximum is reached services are covered at 100%) Annual Dollar Limits on Essential Benefits per Calendar Year Lifetime Benefit Maximum Office Services: Primary Physician Visit (Other diagnostic tests and imaging studies, pharmaceutical injections (except services covered under Preventive Care Services ) received in a physician s office are subject to the outpatient services copay(s) or coinsurance level(s) Preventive Care (Includes immunizations, well-child care and preventive services as defined by the United States Preventive Services Task Force under grades A and B preventive services. Also includes Women s Health Preventive Services effective on or after 8/1/12.) Gynecological Visits (Paid at PCP level; preventive services are provided at No Cost Share; see Preventive Care above.) Specialist Visits and Allergist Visits (Preventive services are provided at No Cost Share; see Preventive Care above) Inpatient Hospital Stay and Services: (Requires Prior Authorization) Inpatient Care (Includes charges for physician and facility) Refer to Skilled Nursing benefit for Inpatient Skilled Nursing services and limits. Surgical Services (Includes Temporomandibular (TMJ) or Craniomandibular Joint Disorder and Craniomandibular Jaw Disorder, as well as physician, facility and anesthesiologist services) $4,000/$8,000 $12,000/$24,000 $6,450/$12,900 $19,350/$38,700 20% Maximum Allowable Charge 50% Maximum Allowable Charge Unlimited Unlimited No Cost Share, no copay, coinsurance or deductible for innetwork services 50% (Subject to 20% (Subject to Injection only $0 cost share 50% (Subject to 50% (Subject to

2 Rehabilitative Services (At an inpatient hospital setting: limited to 60 inpatient days for rehabilitation combined limit for in-and out-of-network.) Maternity Services: Maternity Office Visits & Prenatal Care Hospital Services (48 hours for vaginal delivery; 96 hours for Cesarean delivery; if discharged early, home care is covered for up to 72 hours after discharge) Postnatal Care Preventive Care Services- Women s Health No Cost Share 50% (Subject to Outpatient Services X-ray, Laboratory & Other Diagnostic Services (May require prior authorization) Outpatient Surgery & Services (Includes services at a hospital or other alternative care facility or ambulatory surgical care center) Emergency/Urgent Care Services: Emergency Care (Any hospital emergency room visit inside or outside of the service area) Urgent Care (Urgently needed care that is not life- or limbthreatening) 20% (Subject to 20% (Subject to (May be subject to balance billing) Mental Health and Substance Abuse Services: Mental Health (Biologically and Non- Biologically Based Mental Health & Substance Abuse Disorders) Inpatient Outpatient Other Services: Ambulance Services Chiropractic Services (Limited to 12 visits per calendar year) 20% (Subject to 50% (Subject to Durable Medical Equipment Home Health Care (Limited to 100 visits per calendar year combined in- and out-of-network; Limits do not apply to IV Therapy and private duty nursing) Hospice Services Rehabilitative Services (Limited to 20 visits Occupational Therapy; 20 visits Physical Therapy; 20 visits Speech Therapy; 36 visits Cardiac Rehabilitation; 20 visits Pulmonary. Visit limits per calendar year combined in- and out-of-network when rendered at an outpatient rehab facility.)

3 Habilitative (Habilitative services will be determined by SummaCare and are included in the Mental Health and Rehabilitative Service Benefit. Also included are Habilitative Services for children up to the age of 21 with a medical diagnosis of Autism Spectrum disorder. Habilitative services include: Outpatient Physical Rehab, including Speech and Language Therapy and Occupational Therapy, performed by a licensed therapist, limited to 20 visits per service; Clinical Therapeutic Intervention defined as therapies supported by empirical evidence, which includes but are not limited to, Applied Behavioral Analysis, provided by or under the supervision of a professional who is licensed, certified or registered by an appropriate agency of this state to perform the services in accordance with a treatment plan, 20 hours per week; and Mental/Behavioral Health Outpatient Services performed by a licensed psychologist, psychiatrist or physician to provide consultation, assessment, development and oversight of treatment plans). Skilled Nursing Facility (Limited to 90 days per calendar year combined inand out-of-network) Pediatric Vision for Child up to Age 19 Includes: Well Vision Exam with Dilation as Necessary (One exam available per calendar year covered in full at a network pediatric vision provider) Frames (Designated available frame from Pediatric Vision Plan collection. Members can choose from select frame styles and colors. One frame per calendar year covered in full by a network pediatric vision provider.) Standard Prescription Lenses (Polycarbonate plastic or glass scratch-resistant and ultraviolet lenses are covered. One set of lenses per calendar year covered in full at a network pediatric vision provider.) Single Vision Lined Bifocal Lined Trifocal Lenticular lenses Contact Lens Fitting and Evaluation and Lenses (Contact lens fitting and evaluation is covered in full at a network pediatric vision provider) Standard contact lens fitting and evaluation Premium contact lens fitting and evaluation Elective contact lenses are covered in full at a network provider for the following: 0% (Not Subject to 0% (Not Subject to 0% (Not Subject to 0% (Not Subject to 0% (Not Subject to 0% (Not Subject to

4 Standard (one pair per calendar year; one contact lens per eye for total of 2 lenses) Monthly (six month supply:6 lenses per eye for a total of 12 lenses) Bi-weekly (three-month supply: 6 lenses per eye for a total of 12 lenses) Dailies (one-month supply:30 lenses per eye for a total of 60 lenses) Contact lenses are in lieu of frame and lenses Members can choose from any available prescription contact lenses Necessary contact lenses are covered in full for members who have specific conditions for which contact lenses provide better visual connection. Plan limitations: Two pairs of glasses instead of bifocals Replacement of lenses, frames or contacts Medical or surgical treatment Orthoptics vision training or supplemental testing Items not covered under the contact lens coverage: Insurance policies or service agreements Artistically painted or non-prescription lenses Additional office visits for contact lens pathology Contact lens modification, polishing or cleaning Dental for Child up to Age 19 Off Exchange Off Exchange Pediatric Dental Benefits as required by Federal Law to be provided by [DentaSpan] Off Exchange Pediatric Dental Benefits as required by Federal Law to be provided by [DentaSpan] On Exchange (SHOP) See the Exchanges Stand Alone Dental Plan for Pediatric Benefits for SHOP on the Exchange [DentaSpan]. See the Exchanges Stand Alone Dental Plan for Pediatric Benefits for SHOP on the Exchange [DentaSpan].

5 Prescription Drugs 30-day supply for Retail and Specialty Pharmacy 90-day supply for Mail Order Pharmacy (Day supply may be less than the amount shown due to prior authorization, quantity limits and utilization guidelines. SummaCare s pharmacy network includes national pharmacy coverage; use contracted national pharmacies in- and out-ofnetwork whenever possible to save on out-ofpocket costs. Use of specialty pharmacy innetwork for up to a 30-day supply.) Tier 1 Prescription Drugs-Generic 20% (Subject to for participating pharmacy and up to a 90-day supply mail order 50% (Subject to for Tier 2 Prescription Drugs-Preferred Brand 20% (Subject to for participating pharmacy and up to a 90 day- supply mail order 50% (Subject to for Tier 3 Prescription Drugs-Non-Preferred Brand 20% (Subject to for participating pharmacy and up to a 90-day supply mail order 50% (Subject to for Tier 4 Prescription Drugs-Specialty Drugs 20% (Subject to for up to a 30-day supply at our participating Specialty Pharmacy. No Mail Order for Specialty Tier 4 Drugs 50% (Subject to for up to a 30-day supply at a non-participating specialty pharmacy For benefits or coverage questions call SummaCare Customer Service at or (TTY ) or visit