St Peter s Health Partners EPO Plan

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2 St Peter s Health Partners EPO Plan Plan Overview: The St Peter s Health Partners (SPHP) EPO plan offers an Exclusive Network of Facilities for plan participants to receive care. The network consists of the CDPHN Network Physicians and Outpatient Facilities, and the St Peter s Health Partners Facilities only. Services rendered in an inpatient facility other than those listed, without prior authorization, will not be covered. Background: St Peter s Health Partners, unlike most Employers, plays a dual role with regard to its employees medical care: SPHP is the Employer who offers its employees a medical healthcare plan; and SPHP is a Provider who, under contract to CDPHN, offers certain medical services, not only to its employees but also to the participants of many other plans. As a result of this dual role, SPHP, as the individual s Employer, is able to provide a designated network to its plan participants. This level of benefit (the Network) applies to facility services when those services, are rendered at a St Peter s Health Partners Facility (SPHPDF). In addition, when your inpatient care is rendered at a St. Peter s Health Partners Facility, the related Inpatient Physician services are covered in full. Benefit to Employee: SPHP is actually choosing to receive reduced payment for the services it is rendering to its plan participants at its own designated facilities and is passing the cost savings on to the employee. This is an additional cost savings for the employee and enrolled dependents! The SPHP EPO plan also offers access to services with all CDPHN participating physicians and Outpatient facilities at the In Network level of benefits. SPHPDF Benefit Category Inpatient Outpatient Physical, Occupational, Speech Therapy Chemotherapy and Radiation Mental Health Outpatient Visit Dialysis SPHPDF Facility benefit Covered in full, Deductible waived Covered in full, Deductible waived $30 Copay, Deductible waived $30 Copay, Deductible waived $20 Copay, Deductible waived $30 Copay, Deductible waived Example of Facility and Professional services: When services are rendered at a hospital (whether inpatient or outpatient), there may be facility services and/or professional services for which you are responsible. Facility services include emergency room, bed & board, x-ray equipment, etc. Professional services include anesthesiologist, surgeon, radiology technician, and physician s services. SPHP Facilities (SPHPDF): Facility Charges for Inpatient and Outpatient services available & rendered at SPHPDF, are waived. Professional charges for Inpatient Physician services incurred at a SPHPDF are covered in full. Professional Charges for Outpatient services incurred at a SPHPDF are covered in full. Page 1 of 10

3 St Peter's Health Partners Facilities Name Address City State Zip Albany Memorial Hospital 600 Northern Boulevard Albany NY The Burdett Care Center 2215 Burdett Avenue, Suite 200 Troy NY Capital Region Ambulatory Surgery Center 1367 Washington Avenue Albany NY Eddy Visiting Nurse Association 433 River Street, Suite 3000 Troy NY Eddy Visiting Nurse Association 159 Jefferson Heights Catskill NY Empire Home Infusion Services Inc 10 Blacksmith Drive, Suite 2 Malta NY The Community Hospice, Inc. 445 New Karner Road Albany NY Our Lady of Mercy Life Center 2 Mercycare Lane Guilderland NY Northeast Health Imaging Center 279 Troy Road Rensselaer NY Northeast Orthopaedic Center (a/k/a OrthoNY) 3 Atrium Drive, Suite 150, Executive Woods Albany NY St. Peter's Behavioral Health Management 315 South Manning Boulevard, 6 Gabrilove Albany NY St. Peter's Hospital of the City of Albany 315 South Manning Boulevard Albany NY St. Peter's Rehabilitation and Nursing Center 301 Hackett Boulevard Albany NY St. Peter's Sleep Center 1 Pine West Plaza Albany NY St. Peter's Sleep Therapy Equipment 1 Pine West Plaza, Suite 101 Albany NY Samaritan Hospital 2215 Burdett Avenue Troy NY Samaritan Hospital- Cohoes Outpatient Service Center 244 Ontario Street Cohoes NY Samaritan Hospital-Ravena Patient Service Center Route 9W Ravena NY St. Peter's Surgery & Endoscopy Center 1375 Washington Avenue, Suite 201 Albany NY Seton/St Mary's Hospital 1300 Massachusetts Avenue Troy NY Seton Health Systems-Women's Imaging Center 147 Hoosick Street Troy NY Sunnyview Hospital & Rehab 1270 Belmont Avenue Schenectady NY St Peter's Health Partners Diagnostic Service Sites Albany Advanced Imaging 3 Atrium Drive Suite 160 Albany NY Albany Open MRI 199 Wolf Road Albany NY Bender Lab- Professional Building 62 Hackett Blvd Albany NY Bender Lab- Stuyvesant Plaza 6 Executive Park Drive Building B, 1st Floor Albany NY Bender Lab- Washington Center Med Arts 1365 Washington Avenue, Suite 106 Albany NY Clifton Park Advanced Imaging 648 Plank Rd Clifton Park NY Northeast Health Integrated Laboratories 121 Everett Road (Northeast Ortho. Suite) Albany NY Prime Care Imaging 400 Patroon Creek Albany NY Pulmonary & Critical Care Sleep Center 2 New Hampshire Avenue Troy NY Pulmonary & Critical Care Sleep Center 5 Palisades Drive Albany NY Samaritan Hospital Lab (PSC) at Hoosick Street 258 Hoosick Street, Suite 103 Troy NY Page 2 of 10

4 Non-SPHP Facilities (SPHPDF): Non SPHP Facility Charges for Inpatient services are not covered. Professional Charges are subject to the applicable liability which may include deductible, then co-insurance and/or copayment. Out of area care is not covered, unless deemed urgent or emergent. Facility services that are not available through the St. Peter s Health Partners Facilities (SPHPDF) will be provided by CDPHN Network facilities with CDPHN prior authorization subject to the. St. Peter s Health Partners EPO Plan Annual Deductible, Annual Out-of-Pocket Maximum, Lifetime Maximum Annual Deductible - (Does NOT Include Copay and Co-insurance.) Individual Coverage Two-Adult Coverage Employee + Child(ren) Family DESIGNATED NETWORK () Waived for facility based care Waived for facility based care Waived for facility based care Waived for facility based care $ 1,250* $ 2,500* $ 2,500* $ 3,750* *Not to exceed $1,250 per one family member per calendar year. Co-insurance 20% Co-insurance 20% Co-insurance Annual Out-of-Pocket Maximum (Includes Medical and Pharmacy Deductible, Copay and Co-insurance, as applicable.) Individual Coverage Two-Adult Coverage Employee + Child(ren) Family See Note** below $ 3,250 $ 6,500** $ 6,500** $ 9,750** $ 3,250 $ 6,500** $ 6,500** $ 9,750** **NOTE: Copay, Co-insurance & payment for services that apply to deductible apply to the OOP Maximum counter. Maximums are tracked for services and CDPHN services. When a family member reaches their individual OOP Maximum, the Plan pays covered services in full for that individual. When the Family OOP Maximum is met the plan pays covered services in full for all family members. The OOP Maximum may be met by any combination of one or more family members OOP expenses not to exceed $3,250 per person. Lifetime Maximum Prosthetics and DME Charges $25,000 All other Services; Unlimited Dependent Coverage: Dependent children through age 26. Dependent coverage runs through last day of the calendar year that eligibility guidelines are no longer met. Eligible Adult Plus One Page 3 of 10

5 Accidental Dental authorization required. Adult Routine Annual Physical 1x/ cal. year. Age 19 and over. Allergy Ambulance Testing Immunotherapy Pre-Hospital Emergency Paid per the benefit based on the service performed. Treatment within 12 mos. of injury. Also includes treatment needed due to congenital disease or anomaly. Labs and tests $20 PCP/$30 Specialist Office Visit Copay. $50 Copay By a certified service, includes evaluation and treatment of emergency medical condition Paid per the benefit based on the service performed. Treatment within 12 mos. of injury. Also includes treatment needed due to congenital disease or anomaly. Labs and tests $20 PCP/$30 Specialist Office Visit Copay. $50 Copay By a certified service includes evaluation and treatment of emergency medical condition Airborne Ambulance $50 Copay $50 Copay Inter-facility Transportation Anesthesia Professional Services Inpatient Professional Services Outpatient Office Surgery Blood Donation and Storage Autologous (one s own) Non-Autologous Not Covered Bone Mass Measurement Not covered Cardiac Rehab Outpatient $30 Copay Office $30 copay Chemical Abuse and Dependency Services are provided through CDPHN Behavioral Health Management services Unlimited days per Calendar Year for inpatient/outpatient and office bases services Crisis Hotline Chemotherapy & Radiation Therapy- Office Inpatient Chemical Detoxification Facility Charges Inpatient Treatment of Chemical Dependency Facility Charges - Inpatient Professional Services- Office/Outpatient - $20 Copay Inpatient Chemical Detoxification Facility Charges not covered St Peter s Health Partner s Facility Charges- Inpatient Treatment of Chemical Dependency Facility Charges - not covered St Peter s Health Partner s Facility Charges- Inpatient Professional Services-Deductible, then 20% Co-insurance St Peter s Health Partner s Facility Charges- Outpatient Facility Charges- Deductible, then 20% Co-insurance Outpatient Professional Charges not billed for this service Office- $20 Copay $80 Office Visit Copay Chemotherapy & Radiation therapy - Outpatient $30 Copay per visit Page 4 of 10

6 Childbirth Classes (One Course per pregnancy) Chiropractic Care 30 visits per calendar year combined In and OON. Colonoscopy - Routine Reimbursement of up to 50% of the cost of the class to a maximum reimbursement of $30 Outpatient- Professional Charges- Office- Not Covered $30 Copay Outpatient- Professional Charges- Office- Colonoscopy -Non-Routine Outpatient- Professional Charges- Office- Outpatient Facility Deductible, then 20% Coinsurance Charges- Professional Charges- Office -$80 Office Visit Copay Contraceptives Carved out to Prescription Plan Carved out to Prescription Plan Dental Carved Out Dental Plan Carved Out Dental Plan Diabetic Services CDPHN Resource Coordination Prior Authorization required. Durable Medical Equipment (DME) Supplies or Insulin or Oral Agents: $30 Copay per item $30 Copay per item Retail Pharmacy: Physician billed: Carved Out to Prescription Plan $30 Copay per item Carved Out to Prescription Plan $30 Copay per item Self-management education Note: Diabetic Pump Supplies, such as test strips, tubing, glucometers, etc., will require a copay only- these items will not be applied towards the Lifetime DME maximum. Only the cost of the Diabetic Pump will apply towards the Lifetime Maximum. Diagnostic Testing Outpatient Facility $20 PCP/$30 Specialist Office Visit Copay for medically necessary, relating to diet for persons with diagnosis of diabetes Outpatient Facility Charges - Professional Charges- Diagnostic Testing Office $20 PCP/$30 Specialist Office Visit Copay for medically necessary, relating to diet for persons with diagnosis of diabetes Outpatient Facility Charges Deductible, then 20% Co-insurance Charges- Professional Charges Dialysis and Hemodialysis Outpatient/Home Outpatient Facility Charges $30 Copay Professional Charges $20 PCP/30 Specialist Office Visit Copay may also apply, if billed. Charges- $30 Copay Professional Charges Page 5 of 10

7 Durable Medical Equipment (DME) Includes Prosthetics and Orthotics Prior authorization required from resource coordination for items $500 and above. Wigs are covered with a lifetime maximum of $200 combined in and out of network Emergency Prudent Lay person Guidelines apply in determining Emergency status. (If admitted to inpatient hospital from ER, see IP Hospital benefit.) CPAP/ BiPAP/Humidifier when dispensed from a designated facility, Deductible waived. 50% co-insurance. Rental or purchase. In and Out of Network $25,000 DME Lifetime maximum applies In and Out of Network $25,000 DME Lifetime maximum applies Emergency diagnosis: $125 Copay All locations Physician ER services - ER Copay waived if admitted for observation or as inpatient within 24 hrs. for the same accidental injury/illness- See Hospital Inpatient Non-emergent diagnosis: Not Covered Eye Exam Office $30 Copay. Routine Eye Exam once per 24 months Frames/Lenses/Contacts Carved out to Vision Plan Carved out to Vision Plan Gynecological Exam Office : Pap-Test Routine visit once per calendar year Medical $20 Copay: Pap-Test Hearing Aids Not covered Not covered Hearing Exam Office $30 Copay Home Health Care authorization required. Hospice Care Up to 210 days. Combined IP/OP. CDHPN Resource Coordination prior authorization required in lieu of hospitalization Professional Charges- in lieu of hospitalization Inpatient Facility Charges Not Covered Charges - Inpatient Professional Charges- Deductible, then 20% Co-insurance Inpatient Physician Charges incurred at a SPHPDF- Outpatient Facility Charges Deductible then 20% Co-insurance Charges - Hospital Facility Charges authorization required for inpatient stay. Inpatient Facility Charges Outpatient Facility Charges Outpatient Professional services Inpatient Facility Charges Not Covered Charges - Outpatient Facility Charges Deductible then 20% Co-insurance Charges - Emergency admission to any non-sphpdf- Deductible then 20% co-insurance. CDPHN Authorization Required Note: If medically necessary, and covered, facility services are not available through the St. Peter s Health Partners Facilities (SPHPDF); services will be provided by CDPHN Network facility with CDPHN prior authorization, at level of benefit. Page 6 of 10

8 Hospital Inpatient Professional Charges Outpatient Professional Charges Immunizations Adult & Child Excludes travel immunizations Includes flu immunizations $20 PCP/$30 Specialist Office Visit Copay may apply, if billed Inpatient Physician Charges incurred at a SPHPDF- Outpatient- $20 PCP/$30 Specialist Office Visit Copay may apply, if billed. Infertility Services - Limited to ages 21 through 44 for services to diagnose infertility. Includes coverage for treatment of correctable medical conditions. No coverage for assisted reproduction services Lab Services- SPHPDF and Preferred Lab Locations Lab Services Office includes Professional Charges Lab Services- All other Outpatient Facility Mammograms - Medical and Routine Maternity - Physician s services. See Inpatient Hospital for Facility benefits Inpatient/Outpatient Facility Services -Covered in Full Professional Charges All locations $20 PCP/$30 Specialist Office Visit Copay may apply if billed. -All locations Professional Charges $20 PCP/$30 Specialist Office Visit Copay may apply, if billed. Prenatal/Postnatal visits after $20 Copay for initial visit to diagnose pregnancy Associated labs and ultrasounds- Inpatient Physician s Services (Delivery) $20 PCP/$30 Specialist Office Visit Copay Inpatient Facility Services not covered Outpatient Facility Services deductible then 20% coinsurance Professional Charges deductible, then 20% Co-insurance All locations $20 PCP/30 Specialist Office Visit Copay may apply, if billed. Deductible then 20% Coinsurance -All locations Professional Charges $20 PCP/30 Specialist Office Visit Copay may apply, if billed. Prenatal/Postnatal visits after $20 Copay for initial visit to diagnose pregnancy Inpatient Physician s Services (Delivery) Deductible, then 20% Co-insurance Inpatient Physician Charges incurred at a SPHPDF- Medication Infusion/Injection- Office $20 PCP/$30 Specialist Office Visit Copay. Medication covered in full. Medication Infusion/Injection- Outpatient $30 copayment. Medication covered in full. Outpatient Facility Charges- Deductible, then 20% Coinsurance. St Peter s Health Partner s Facility Charges- $30 copayment Mental Health Services are provided through CDPHN Behavioral Health Management services Unlimited days per Calendar Year for inpatient/outpatient and office bases services Crisis Hotline Inpatient Facility Charges - Inpatient Professional Charges- Outpatient Facility Charges - $20 Copay Outpatient Professional Charges-Covered in Full Office Charges - $20 Copay per visit Professional Charges - Medication- Covered in full Inpatient Facility Charges Not Covered Charges - Inpatient Professional Charges Deductible then 20% Co-insurance. Inpatient Physician Charges incurred at a SPHPDF- Outpatient Facility Charges Deductible, then 20% Coinsurance Outpatient Professional Charges - Charges - $20 Copay Office Charges - $20 Copay per visit Page 7 of 10

9 Newborn Care Inpatient Hospital includes well-baby Nursery care Prior Authorization not required Inpatient Facility Charges- Inpatient Professional Charges- Inpatient Facility Charges Not Covered. St Peter s Health Partner s Facility Charges- Professional Charges Deductible then 20% Coinsurance Inpatient Physician Charges incurred at a SPHPDF- Nutritional Counseling Visit $20 PCP/$30 Specialist Copay $20 PCP/$30 Specialist Copay Occupational Therapy (OT) Outpatient/ Office. 120 visits per calendar year combined for PT and OT at designated and CDPHN Networks combined Organ Transplant - CDPHN Resource Coordination prior authorization required. $30 Copay All locations Professional Charges not billed for this service. Not Available at a St Peter s Facility $30 Copay All locations Professional Charges not billed for this service. Medically necessary, at approved transplant center Pap Smear Medical & Routine - $20 Office Visit Copay may apply if billed Pathology Professional Charges Physical Therapy (PT) Outpatient/ Office. 120 visits per calendar year combined for PT and OT at designated and CDPHN Networks combined Physician Office Visit -Annual Exam. Once per calendar year Physician Office Visit Primary Care Physician Physician Office Procedures (i.e.: inject/drain, skin closures, nasal endoscopy) $30 Copay, All Locations Professional Charges not billed for this service $30 Copay, All locations Professional Charges not billed for this service $20 Office Visit Copay $80 Office Visit Copay Note: Some procedures are best performed in an office setting. Please discuss the appropriate location with your provider. Physician Office Visit- Specialist Visit Physician Office Procedures ( i.e.: inject/drain, skin closures, nasal endoscopy) Note: Some procedures are best performed in an office setting. Please discuss the appropriate location with your provider. $30 Office Visit Copay $80 Office Visit Copay Podiatry Routine Not covered Not covered Prescription Drugs Carved out to Prescription Plan Carved out to Prescription Plan Preventive Services not listed specifically in this document Private Duty Nursing authorization required 1) Items with A or B rating from US Preventive Services Task Force (USPSTF); 2) Immunizations pursuant to the advisory Committee on Immunization Practices ( ACIP ) recommendations; 3) Preventive care and screenings that are provided for in the comprehensive guidelines supported by the Health Resources and Services Administration ( HRSA ) Coverage based on location of service, when medically necessary when medically necessary Page 8 of 10

10 Radiology- Outpatient Facility Professional Charges- Outpatient Facility Charges- Deductible, then 20% Coinsurance. St Peter s Health Partner s Facility Charges- Professional Charges - Radiology - Office Professional Charges $20 PCP/$30 Specialist Copay may also apply, if billed. Rehabilitation-Medical/Inpatient authorization required Inpatient Facility Charges Professional Charges Inpatient Facility Charges Not Covered. Charges- Professional Charges Deductible then 20% Coinsurance Inpatient Physician Charges incurred at a SPHPDF-. Second Surgical Opinion $30 Specialist Office Visit Copay $30 Specialist Office Visit Copay Skilled Nursing Facility - Inpatient must be ordered after hospital stay for the same injury or illness authorization required Limit 90 days/calendar year Speech Therapy (ST) Outpatient/ Office Limit 60 visits per calendar year at designated and CDPHN Network locations combined Student Out of Area Coverage Non emergency, requires CDPHN Resource Coordination prior authorization for in network level benefits to apply Prior Authorization not required for Urgent/Emergent care Routine services are not covered out of area. Surgery-Office Inpatient Facility Charges Professional Charges - $30 Copay, All Locations Professional Charges not billed for this service. Inpatient Facility Charges Not Covered Charges, Professional Charges Deductible then 20% Coinsurance. Inpatient Physician Charges incurred at a SPHPDF-. $30 Copay, All locations Professional Charges not billed for this service A provider will be identified to the student for services appropriate to the situation. Coverage is based on benefit category (e.g., office visit, x-rays, labs, urgent care center, etc.) Routine services are not covered out of area. Non Urgent/Emergent services received without prior authorization, are not covered $80 Office Visit Copay Note: Some procedures are best performed in an office setting. Please discuss the appropriate location with your provider. Surgery Outpatient/Ambulatory Note: Not all procedures are appropriate to be performed in a facility. Please discuss the appropriate location with your provider Outpatient Facility Charges- Professional Charges - Outpatient Facility Charges Deductible then 20% co-insurance. St Peter s Health Partner s Facility Charges- Professional Charges TMJ Dental Not covered Not covered Urgent Care Visits Prior Authorization Not Required $40 Copay, All locations $40 Copay, All locations Well Child Visits as recommended by PCP to age 19. Page 9 of 10

11 Note: If medically necessary, and covered, facility services are not available through the St. Peter s Facilities (SPHPDF); services will be provided by CDPHN Network facility with CDPHN prior authorization, at level of benefit. If medically necessary, covered, facility services are not available In Network through CDPHN Network providers, CDPHN will arrange for out-of-network services, appropriate to the situation, at the In-Network level of benefits (). Page 10 of 10