Benefit Name In Network Out of Network Limits and Additional Information. N/A Pharmacy. N/A Pharmacy
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1 Excellus BluePPO Drug Coverage Excluded Benefit Time Period: 01/01/ /31/2018 HOBART & WILLIAM SMITH COLLEGES General Information Cost Sharing Expenses Deductible - Single $0 $500 Deductible - Family $0 $1,500 Each individual does not exceed the single deductible. Coinsurance 0% 20% Annual Out of Pocket Maximum - Single Annual Out of Pocket Maximum - Family $4,200 Medical $2,400 Pharmacy $8,400 Medical $4,800 Pharmacy $4,200 Medical N/A Pharmacy $8,400 Medical N/A Pharmacy Out-of-pocket maximums accumulate the coinsurance amount and include the deductible and medical Co-pays. Rx Copays accumulate to RX OOP. Out-of-pocket maximums accumulate the coinsurance amount and include the deductible and medical Co-pays. Rx Copays accumulate to RX OOP. Each individual does not exceed the single out of pocket maximum. Office Visit Cost Shares Cost Share - Primary Care Cost Share - Specialist $25 $40 Plan Limits Plan/Calendar Year Diabetic Preauthorization and Step Therapy Calendar Year Benefits No Who is Covered Domestic Partner Coverage Covered Inpatient Services Inpatient Facility 1 of /04/ :00:14
2 Inpatient Hospital Services Mental Health Care Substance Use Detoxification Skilled Nursing Facility $400 $400 $400 Covered in Physical Rehabilitation Covered in 60 Days per year 60 Days per year Limits are combined INN and OON. Maternity Care $400 Inpatient Professional Services Inpatient Hospital Surgery Anesthesia Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. Outpatient Facility Services Outpatient Facility Services SurgiCenters and Freestanding Ambulatory Centers Surgical Care Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy $100 $40 Covered in Covered in Covered in Infusion Therapy Inclusive of Primary Service Inclusive of Primary Service Dialysis Mental Health Care Substance Use Care Covered in $40 $40 Advanced Imaging Services includes PET scans, MRI, nuclear medicine, and CAT scans. Is inclusive in the Home Care benefit and not covered as a separate benefit. Includes Partial Hospitalization Includes Partial Hospitalization Home and Hospice Care Home Care Home Care Covered in 25% Coinsurance Subject to $50 Deductible Hospice Care 2 of /04/ :00:14
3 Hospice Care Inpatient Covered in Outpatient and Office Professional Services Professional Services Office Surgery Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Dialysis Mental Health Care Maternity Care TeleMedicine Program Chiropractic Care Allergy Testing Allergy Treatment Including Serum PCP - $25 Specialist - $40 PCP/Specialist - $40 PCP/Specialist - Inclusive of Primary Service PCP/Specialist - $40 PCP/Specialist - $15 PCP - $25 Specialist - $40 Inclusive of Primary Service Hearing Evaluations Routine PCP/Specialist - Is inclusive in the Home Care benefit and not covered as a separate benefit. Allergy Testing includes injections and scratch and prick tests. Includes desensitization treatments (injections & serums). Rehab and Habilitation Outpatient Facility Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation Covered in Covered in Covered in Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. Outpatient Professional Services 3 of /04/ :00:14
4 Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. Preventive Services Preventive Professional Services Meeting Federal Guidelines* Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Pre/Post-Natal Care Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional Covered in 1 Exam per year Preventive Facility Services Meeting Federal Guidelines* Cervical Cytology Preventative Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility Covered in Covered in Covered in Covered in Preventive services in addition to those required under Federal Guidelines - Professional Prostate Cancer Screening Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional PCP/Specialist - $40 Preventive services in addition to those required under Federal Guidelines - Facility 4 of /04/ :00:14
5 Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility Covered in $100 $40 Other Benefits Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Equipment Durable Medical Equipment (DME) Medical Supplies PCP/Specialist - 20% Coinsurance PCP/Specialist - 20% Coinsurance Acupuncture PCP/Specialist - Private Duty Nursing PCP/Specialist - Limited to a 30 day supply for retail pharmacy or a 90 day supply for mail order pharmacy. Other PCP Copay for Pump & Pump Supplies (Codes: A4230, A4231, A4232, A9274, E0784). Continuous Glucose & Supplies Monitors (Codes: S1030,S1031 A9276,A9277,A9278). Emergency Services ER Facility Facility Emergency Room Visit $100 $100 Prior Authorization may not apply to any emergency care services. Emergency services are covered worldwide if provided by a hospital facility. Transportation Prehospital Emergency and Transportation - Ground or Water $40 $40 Urgent Care Urgent Care Center Facility Visit $25 Ancillary Benefits Vision 5 of /04/ :00:14
6 Adult Eye Exams - Routine Adult Eyewear - Routine Pediatric Eye Exams - Routine Pediatric Eyewear - Routine Rx Benefits Rx Plan Rx Plan Retail $10 / $30 / $50 Mail Order $20 / $60 / $100 Generics for Children to age 18, $0 Copay Rx Benefits Days Supply Per Retail Order 30 Days Supply Per Mail Order 90 Coverage Provided by OptumRx Coverage Provided by OptumRx Copays Per Mail Order Supply N/A Coverage Provided by OptumRx This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined by the terms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of the contract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits are combined limits for both in and out of network benefits. * For non-grandfathered groups, Preventive Services coverage required by the Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive Services Task Force list of items and services rated "A" or "B" that are covered pursuant to the Patient Protection and Affordable Care Act requirements. 6 of /04/ :00:14
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