Super Blue Plus 2000 WVHTC High Option-B (Non-Grandfathered) $200 Deductible
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1 BENEFIT HIGHLIGHTS 1 Super Blue Plus 2000 WVHTC High Option-B (Non-Grandfathered) $200 Group Effective Date December 1, 2017 Benefit Period (used for and Coinsurance limits) January 1 through December 31 (Calendar Year) (Network and Non-Network s do not cross apply.) Individual $200 $400 Family (may be met collectively) $400 $800 Note: All Services are subject to the unless otherwise specified. Carry-Over Period Coinsurance Limit: (Network and Non-Network Coinsurance dollars do not cross apply. Does not include ) Individual $1,000 $2,500 Family (may be met collectively) $2,000 $5,000 Total Maximum Out-of-Pocket 5 (Includes, Copays, and Coinsurance per Benefit Period, Network only) Individual $6,600 Not Applicable Family (may be met collectively) $13,200 Not Applicable Non-Network Liability Lifetime Maximum Benefit for all Covered Services None UNLIMITED UNLIMITED Primary Care Medical Office Visit / Office Consultation - Applies to Charges for Visit only. Does not apply to other Services received during Visit. Specialist Care Medical Office Visit / Office Consultation (Includes Specialist Virtual Visits). Applies to Charges for Visit only. Does not apply to other Services received during Visit. Urgent Care Copay Co-Pay applies to Charges for Visit only. Does not apply to other Services received during Visit. Co-Pays do not apply to or Coinsurance limits. BDTC (7) $15 per Office Visit, 100% thereafter, No Non-BDTC $20 per Office Visit, 100% thereafter, No $35 per Office Visit, 100% $35 per Office Visit, 100% $20 per Office Visit, 80% $35 per Office Visit, 80% $35 per Office Visit, 80% Virtual Visit Originating Site Telemedicine 3 $10 per Visit, 100% thereafter, Not Covered No PRESCRIPTION DRUGS 6 Prescription Drug NETWORK 3 NON-NETWORK 3 Individual None No Benefits Family None No Benefits Prescription Drugs are provided through a Preferred Retail Pharmacy Network If you choose Brand over Generic, you will pay the difference between the Brand and Generic Allowance, in addition to your Coinsurance, unless the physician writes brand necessary (DAW) on the prescription, or if no generic equivalent exists. Maximum 34 day Supply. Note: Prescription s, Copayments and/or Coinsurance amounts apply toward the Total Maximum Out-of-Pocket. Member pays 30% or $5 Minimum Coinsurance, whichever is greater. No for Generic/Brand Maximum out of pocket $75 Specialty Drugs: Member pays 30% Coinsurance, No Maximum out of pocket $100 No Benefits Additional Preventive Prescription Benefits 4 Guidelines as determined by certain Governmental Agencies. You may access this information at You may also contact Member Services. Mail Order Drugs - If you choose Brand over Generic, you will pay the difference between the Brand and Generic Allowance, in addition to your Coinsurance, unless the physician writes "brand necessary" (DAW) on the prescription, or if no generic equivalent exists. Maximum 90 day supply. Note: Prescription s, Copayments and/or Coinsurance amounts apply toward the Total Maximum Out-of-Pocket 1 100%, No No Benefits Generic/Brand : Member pays 30% or $5 Minimum Coinsurance, whichever is greater. No. Maximum out of pocket $100 Specialty Drugs: Member pays No Benefits
2 30% Coinsurance, No Maximum out of pocket $200 2
3 PREVENTIVE CARE SERVICES 4 Routine Adult Physical exams Adult immunizations Colorectal cancer screening Routine gynecological exams, including a Pap Test Routine: 100%, No Mammograms, annual routine and medically necessary Medically Necessary: 80%, No 100%, No deductible Diagnostic services and procedures Routine Pediatric Physical exams Pediatric immunizations Diagnostic services and procedures AUTISM SPECTRUM DISORDER Services for diagnosis and treatment of Autism Spectrum Disorder. (See Section V for additional information.) Covered Services will be paid according to the benefit category (e.g. speech therapy, office visit). PHYSICIAN SERVICES In-Hospital Medical Visit Surgery, Assistant to Surgery, Anesthesia Second Surgical Opinion Consultants (Outpatient) 100%, No 100%, No Maternity Care - Dependent daughters are covered. Newborn Care including circumcision. Occupational Therapy (Rehabilitative and Habilitative) Physical Therapy- (Rehabilitative and Habilitative) Spinal Manipulations- (Rehabilitative and Habilitative) Respiratory Therapy Cardiac Rehabilitation Therapy Dialysis Chemotherapy Radiation Therapy Infusion Therapy Speech Therapy (Rehabilitative and Habilitative) when necessary due to a medical condition. Temporomandibular Joint Dysfunction / Craniomandibular Disorders Diagnostic, X-ray, Lab and Testing Allergy Testing and Treatment 3
4 INPATIENT HOSPITAL / FACILITY SERVICES Unlimited Days Semi-Private Room and Board Ancillaries, Drugs, Therapy Services, X-ray and Lab General Nursing Care Surgical Services Birthing Center Care / Maternity Services - Dependent daughters are covered. OUTPATIENT HOSPITAL / FACILITY SERVICES Pre-Admission Testing Diagnostic, X-ray, Lab and Testing Surgery, Operating Room Occupational Therapy (Rehabilitative and Habilitative) Maximum 30 visits per Benefit Period. Limitations are for Network and Non-Network, Rehabilitative and Habilitative, combined. Physical Therapy- (Rehabilitative and Habilitative) Maximum 30 visits per Benefit Period. Limitations are for Network and Non-Network, Rehabilitative and Habilitative, combined. Respiratory Therapy Cardiac Rehabilitation Therapy Dialysis Chemotherapy Radiation Therapy Infusion Therapy Speech Therapy (Rehabilitative and Habilitative) when necessary due to a medical condition. BEHAVIORAL HEALTH SERVICES Outpatient Mental Health Services Outpatient Substance Abuse Services Inpatient Mental Health Care Services Inpatient Substance Abuse Care Services EMERGENCY CARE SERVICES Emergency Accident Care and /or Emergency Medical Care provided in the ER- ER copay does not apply to or Coinsurance limits. $100 per visit, 100% thereafter, No $100 per visit, 100% thereafter, No Emergency Ambulance 100%, No 100%, No Non-Network Liability coverage up to $100, maximum per Occurrence 8 NON-EMERGENCY CARE SERVICES Non-Emergency Medical Care provided in the ER 80% 80% Non-Emergency Ambulance Services 80% 80% 4
5 Private Duty Nursing - Maximum 35 visits per calendar year Note: Maximums are Network and Non-Network combined. Skilled Nursing Facility Maximum 200 days per calendar year OTHER COVERED SERVICES 80% 80% Day 1-100, 100%, No Day , 80%, No Day 1-100, 80%, No Day , 60%, No Durable Medical Equipment and Oxygen at home 80% 80% Orthotic Devices and Prosthetic Appliances 80% 80% Home Health Care - Maximum 200 Visits Visit 1-100, 100%, No Visit 1-100, 80%, No Note: Maximums are Network and Non-Network combined. Visit , 80%, No Visit , 60%, No Hospice Care Diabetes Education & Control HUMAN ORGAN TRANSPLANT / BONE MARROW PROCEDURES Human Organ Transplant Includes transportation, meals and lodging. Bone Marrow Procedures Includes transportation, meals and lodging. Eligible Dependent Age Limitation Coverage stops at the end of the month of the 26th birthday for an adult dependent who is an Eligible Dependent. 1 ALL SERVICES ARE SUBJECT TO A DETERMINATION OF MEDICAL NECESSITY BY HIGHMARK WV. MEDICAL MANAGEMENT & POLICY MUST BE CONTACTED PRIOR TO A PLANNED ADMISSION OR WITHIN 48 HOURS OF AN EMERGENCY OR MATERNITY-RELATED INPATIENT ADMISSION. BE SURE TO VERIFY THAT YOUR PROVIDER IS CONTACTING MM&P FOR PRECERTIFICATION. IF THIS DOES NOT OCCUR AND IT IS LATER DETERMINED THAT ALL OR PART OF THE INPATIENT STAY WAS NOT MEDICALLY NECESSARY OR APPROPIRATE, YOU MAY BE RESPONSIBLE FOR PAYMENT OF ANY COSTS NOT COVERED. 2 PAYMENT IS BASED ON THE PLAN ALLOWANCE. THE PLAN ALLOWANCE WILL GENERALLY BE LESS FOR SERVICES RECEIVED FROM A NON-NETWORK PROVIDER. IN ADDITION, YOU WILL BE RESPONSIBLE FOR THE NON-NETWORK LIABILITY. 3 SERVICES ARE PROVIDED FOR ACUTE CARE FOR MINOR ILLNESSES. SERVICES MUST BE PERFORMED BY A HIGHMARK APPROVED TELEMEDICINE PROVIDER. VIRTUAL BEHAVIORAL HEALTH VISITS PROVIDED BY A HIGHMARK APPROVED TELEMEDICINE PROVIDER ARE ELIGIBLE UNDER THE OUTPATIENT MENTAL HEALTH/SUBSTANCE ABUSE BENEFIT. 4 SERVICES ARE LIMITED TO THOSE LISTED ON THE HIGHMARK PREVENTIVE SCHEDULE (WOMEN'S HEALTH PREVENTIVE SCHEDULE MAY APPLY). AGE AND FREQUENCY LIMITS MAY APPLY. FOR A CURRENT SCHEDULE OF COVERED SERVICES, LOG ONTO YOUR HIGHMARK WV MEMBER WEBSITE, AT OR CALL MEMBER SERVICE AT THE TOLL- FREE NUMBER LISTED ON THE BACK OF YOUR ID CARD. 5 EFFECTIVE WITH PLAN YEARS BEGINNING ON OR AFTER JANUARY 1, 2017, THE NETWORK TOTAL MAXIMUM OUT- OF-POCKET AS MANDATED BY THE FEDERAL GOVERNMENT MUST INCLUDE DEDUCTIBLE, COINSURANCE, COPAYS, AND ANY QUALIFIED MEDICAL AND PRESCRIPTION EXPENSES. THE TOTAL MAXIMUM OUT-OF-POCKET CANNOT BE MORE THAN $7,150 FOR INDIVIDUAL AND $ FOR TWO OR MORE PERSONS. 6 ANTI-CANCER MEDICATIONS ORALLY ADMINISTERED OR SELF-INJECTED. DEDUCTIBLE, COPAYMENT AND COINSURANCE AMOUNTS FOR PATIENT ADMINISTERED ANTI-CANCER MEDICATIONS THAT ARE COVERED BENEFITS ARE APPLIED ON NO LESS FAVORABLE BASIS THAN FOR PROVIDER INJECTED OR INTRAVENOUSLY ADMINISTERED ANTI-CANCER MEDICATIONS. 7 COPAY DIFFERENTIALS APPLY TO HIGHMARK BDTC PCP PROVIDERS IN PA, WV & DE. 8 BENEFITS FOR EMERGENCY AMBULANCE SERVICES RENDERED BY A NON-NETWORK PRVIDER WILL BE SUBJECT TO THE SAME COST-SHARING AMOUNT, IF ANY, THAT IS APPLICABLE TO NETWORK SERVICES. THE MEMBER WILL BE RESPONSIBLE FOR ANY AMOUNTS BILLED BY THE NON-NETWORK PROVIDER FOR EMERGENCY AMBULANCE SERVICES THAT ARE IN EXCESS OF THE AMOUNT THAT HIGHMARK WV PAYS. 5
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