Central Care Plan Medical and Prescription Plan Comparison Grid

Transcription

1 Medical Plan Carrier/Network Annual Deductible (Benefit Plan Year: 7/1-6/30) Coinsurance (Percent Copays) Note: Coinsurance s apply once the has been met. Flat Dollar Copays Central Care Plan $200 per member $400 per family 50% of approved for private duty nursing care $20 copay for office visits, office consultations, urgent care and chiropractic visits $100 copay for emergency room visits $400 per member $800 per family Note: Out-ofnetwork s also count toward the innetwork 50% of approved for private duty nursing care 20% of approved for mental health care and substance abuse treatment 20% of approved for most other services $100 copay for emergency room visits Blue Cross Blue Shield (BCBS) $400 per member $800 per family 50% of approved for private duty nursing care 20% of approved for mental health care and substance abuse treatment 20% of approved for most other covered services $20 copay for office visits, office consultations, urgent care and chiropractic visits $100 copay for emergency room visits $800 per member $1,600 per family Note: Out-ofnetwork s also count toward the innetwork 50% of approved for private duty nursing care 40% of approved for mental health care and substance abuse treatment 40% of approved for most other services $100 copay for emergency room visits $1,300 per member $2,600 per family $2,600 per member $5,200 per family Notes: The full family must be met under a two-person or family contract before benefits are paid for any person on the contract. No 4 th quarter carry-over. This means claims incurred during the plan s 4 th quarter (April June) will not be applied to the following plan year s. None 20% of approved for most covered services None None January 1, 2018 Page 1

2 Annual Out-of-pocket Maximum (Applies to s for all covered services - s, copays, and coinsurance) Medical Plan Prescription Plan Total Out-of- Pocket Maximum $800 per member $1,600 for two or $4,000 for two or $2,800 per member $5,600 for two or more members Preventive Care Health Maintenance Exam or (Includes chest x- copay), one per ray, EKG, cholesterol screening & other select lab procedures) Note: Additional well-women visits may be allowed based on medical necessity Gynecological Exam Note: Additional well-women visits may be allowed based on medical necessity or copay), one per $2,400 per member $4,800 for two or $4,000 for two or $4,400 per member $8,800 for two or $1,600 per member $3,200 for two or $4,000 for two or $3,600 per member $7,200 for two or or copay or copay $3,800 per member $7,600 for two or $4,000 for two or $5,800 per member $11,600 for two or more members $1,300 per member $2,600 for two or $4,000 for two or $3,300 per member $6,600 for two or ), one. ), one $5,600 per member $11,200 for two or $4,000 for two or $7,600 per member $15,200 for two or January 1, 2018 Page 2

3 Pap Smear Screening (Lab & pathology services) Voluntary Sterilization for Females Contraceptive Injections Well Baby & Child Care or copay), one per or copay) or copay) or copay) 8 visits, birth through 12 months 6 visits, months 6 visits, months 2 visits, months Visits beyond 47 months are limited to one per or copay or copay / coinsurance) or copay / coinsurance) or copay / coinsurance) 8 visits, birth through 12 months 6 visits, months 6 visits, months 2 visits, months Visits beyond 47 months are limited to one per ), one ) ) ) 8 visits, birth through 12 months 6 visits, months 6 visits, months 2 visits, months Visits beyond 47 months are limited to one per January 1, 2018 Page 3

4 January 1, 2018 Page 4

5 Adult & Childhood Preventive & Immunizations (As recommended by the USPSTF, ACIP, HRSA or other sources as recognized by BCBSM that are in compliance with the provisions of the Patient Protection and Affordable Care Act) Fecal Occult Blood Screening Flexible Sigmoidoscopy Exam Prostate Specific Antigen (PSA) Screening Central Care Plan or or copay ) copay) / coinsurance) or copay), one per or copay), one per or copay), one per or copay or copay or copay per ), one ), one ), one plan year January 1, 2018 Page 5

6 Routine Mammogram & Related Screening Note: Subsequent medically necessary mammograms performed during the same are subject to and coinsurance. Colonoscopy (Routine or medically necessary) Note: Subsequent colonoscopies performed during the same are subject to your and coinsurance or copay), one per Central Care Plan 60% after out-of- network network or copay), one per Note: Out-of-network reading & interpretations are payable only when the screening mammogram itself is performed by an in-network provider. Physician Office (Must be medical necessary) Office Visits $20 copay per visit Outpatient & Home Medical Care Visits Office Consultations $20 copay per office consultation Urgent Care Visits $20 copay per visit Online Visits Medical: $5 Medical & copay/visit Behavioral: 80% Behavioral after out-of-network Health: $20 copay/visit or copay or copay Note: Out-ofnetwork reading & interpretations are payable only when the screening mammogram itself is performed by an innetwork provider. $20 copay per visit 60% after out-of- network $20 copay per office consultation $20 copay per urgent care visit Medical: $5 copay/visit Behavioral Health: $20 copay/visit Medical & Behavioral: 60% after out-ofnetwork ), one ), one Medical: $49 charge/visit Behavioral Health: Note: Out-ofnetwork reading & interpretations are payable only when the screening mammogram itself is performed by an innetwork provider. Medical & Behavioral: 80% after out-ofnetwork January 1, 2018 Page 6

7 Emergency Medical Care Hospital Emergency $100 copay per visit (copay waived for $100 copay per visit (copay waived for 100% after in network Room inpatient hospitalization or accidental injury) inpatient hospitalization or accidental injury) Ambulance 100% after in-network 80% after in-network 100% after in-network (Must be medically necessary) Diagnostic Laboratory & Pathology Diagnostic Tests & X-Rays Therapeutic Radiology Maternity Pre- and Post-Natal Care Visits or copay) or copay/coinsurance) ) Postnatal Care Delivery & Nursery Care Hospital Care Inpatient Hospital Care (Semi-private room, inpatient physician care, general nursing care, hospital services & supplies) Note: Nonemergency care must be rendered in or copay/coinsurance January 1, 2018 Page 7

8 a participating hospital. Inpatient Consultations Chemotherapy Alternatives to Hospital Care Skilled Nursing Care (Must be in a participating skilled nursing facility) 100% after in-network 80% after in-network 100% after in-network Note: Limited to a maximum of 120 days per member per Hospice Care (Must be in a participating hospice program) Note: Limited to 28 pre-hospice services; when elected, four 90-day periods provided through a participating hospice program only; limited to dollar maximum that is reviewed and adjusted periodically (after reaching dollar maximum, member transitions into or copay) or copay / coinsurance) 100% after in-network January 1, 2018 Page 8

9 individual case management Home Health Care (Must be medically necessary and provided by participating home health care agency) Infusion Therapy (Must be medically necessary and provided by participating Home Infusion Therapy provider or in a participating freestanding Ambulatory Infusion Center. May use drugs that require pre- authorization consult with your doctor.) Surgical Surgery (Includes related surgical services & medically necessary facility services by a participating ambulatory surgery facility) Pre-surgical Consultations Central Care Plan 100% after in-network 80% after in-network 100% after in-network 100% after in-network 80% after in-network 100% after in-network or copay) 80 after in-network or copay / coinsurance) January 1, 2018 Page 9

10 Voluntary Sterilization for Males Central Care Plan Human Organ Transplants Specified Human or copay) in Organ Transplants designated facilities only (Must be in a designated facility and coordinated through BCBSM Human Organ Transplant Program ) or copay / coinsurance) in designated facilities only 100% after in-network in designated facilities only Bone Marrow Transplant (Must be coordinated through BCBSM Human Organ Transplant Program ) Specified Oncology Clinical Trials Note: BCBSM covers clinical trials in compliance with PPACA. Kidney, Cornea & 80% after in- 60% after out-of- 100% after in- Skin Transplants network network network network network Mental Health and Substance Abuse Treatment *Some mental health and substance abuse services are considered by BCBSM to be comparable to an office visit. When a mental health and substance abuse service is considered by BCBSM to be comparable to an office visit, you pay only for an office visit. Inpatient Mental 80% after in- 60% after out-of- 100% after in- Health Care & network network network network network Substance Abuse Treatment (In an Unlimited days Unlimited days Unlimited days Unlimited days Unlimited days Unlimited days approved facility) January 1, 2018 Page 10

11 Residential Psychiatric Treatment Facility (Covered mental health services must be performed in residential psychiatric treatment facility. Treatment must be preauthorized subject to medical criteria) Outpatient Mental Health Care* (In participating facilities only) Outpatient Substance Abuse Treatment* (In an approved facility 80% after in- 60% after out-of- 100% after in- network network network network network Facility and Clinic Physician's Office* Autism Spectrum Disorders, Diagnoses & Treatment Applied Behavioral Analysis (ABA) Treatment (When rendered by an approved board-certified behavioral analyst is covered through age 18, subject to preauthorization) Facility and Clinic Physician s Office* (In-network costsharing will apply if there is no PPO network) Facility and Clinic Physician's Office* Facility and Clinic Physician's Office* (In-network costsharing will apply if there is no PPO network) Facility and Clinic Physician s Office* 100% after in-network 80% after in-network Note: Applied behavioral analyses treatment limited to an annual maximum of $50,000 per member, through age 18 (limited may be waived on an individual consideration basis) Facility and Clinic 100% after in network Physician s Office* (In-network costsharing will apply if there is no PPO network) 100% after out-ofnetwork Note: Applied behavioral analyses treatment limited to an annual maximum of $50,000 per member, through age 18 (limited may be waived on an individual consideration basis) January 1, 2018 Page 11

12 Outpatient Physical/Speech/ Occupational Therapy, Nutritional Counseling Other Covered Including Mental Health 80% after in- 60% after out-of- 100% after in- network network network. network network Other Covered Outpatient Diabetes Management for diabetes medical Program supplies for diabetes medical supplies. for diabetes medical supplies Note: Screening services required under the provisions of PPACA are covered at 100% of the approved with no in network cost-sharing when rendered by a network provider. or copay) for diabetes self-management training or copay / coinsurance) for diabetes selfmanagement training ) for diabetes selfmanagement training Note: When you purchase diabetic supplies via mail order will lower out of pocket costs January 1, 2018 Page 12

13 Allergy Testing & Therapy Chiropractic Care Chiropractic spinal manipulation & Osteopathic manipulation therapy Note: Limited to 24 visits per member per Outpatient Physical, Speech & Occupational Therapy (Provided for rehabilitation Note: Limited to a combined 60 maximum visits per Durable Medical Equipment Note: For a list of covered DME items required under the PPACA call BCBSM. Prosthetic & Orthotic Appliances or copay) $20 copay per office visit Central Care Plan 60% after out-of- 100% after in- or copay / network network network coinsurance) Note: at non-participating outpatient physical therapy facilities are not covered $20 copay per office visit 80% after in-network Note: at non-participating outpatient physical therapy facilities are not covered Note: at nonparticipating outpatient physical therapy facilities are not covered 100% after in-network 80% after in-network 100% after in-network 100% after in-network 80% after in-network 100% after in-network January 1, 2018 Page 13

14 Private Duty Nursing 50% after in-network 50% after in-network 100% after in-network Hearing Care Audiometric Exam 100% of approved 100% of approved 100% of approved (One every 36 months) Hearing Aid Evaluation (One every 36 months) 100% of approved 100% of approved 100% of approved Ordering & Fitting the Hearing Aid (Monaural hearing aid & binaural hearing aids) Hearing Aid Conformity Test (One every 36 months) Monaural hearing aids: 100% of approved up to $1,800 Binaural hearing aids: 100% of approved up to $3, % of approved Monaural hearing aids: 100% of approved up to $1,800 Binaural hearing aids: 100% of approved up to $3, % of approved Monaural hearing aids: 100% of approved up to $1,800 Binaural hearing aids: 100% of approved up to $3, % of approved Prescription Carrier/Network CVS Caremark BCBS of Michigan Deductible None None Percent copay applies after Annual Out-of-Pocket Maximum $4,000 for two or $4,000 for two or $4,000 for two or 30-Day Supply (Retail) Generic 10% copay 50% copay 10% copay 50% copay 10% copay 50% copay Preferred 20% copay 50% copay 20% copay 50% copay 20% copay 50% copay Non-Preferred 30% copay 50% copay 30% copay 50% copay 30% copay 50% copay 90-Day Supply (Retail & Mail Order) Generic 10% copay 10% copay 10% copay Preferred 20% copay 20% copay 20% copay Non-Preferred 30% copay 30% copay 30% copay This benefits summary is intended for use only as a source of reference. Official benefits, conditions, exclusions, and limitations are documented in the certificate and amendments. January 1, 2018 Page 14