Sisters of Providence Health System Non-Bargaining PPO (RJ) Effective January 1, 2018 This chart provides a summary of key services offered by your Plan. Consult your Member Agreement for a full description of your Plan s benefits and provisions. If any terms in this summary differ from those in your Member Agreement, the terms of the Member Agreement apply. Please note: When you receive services from an Provider, you are also responsible for any Remaining Balances. A Remaining Balance is that portion of an Provider s charge that is above HNE s Maximum Allowable Fee. Note about Prior Approval: Some services may require Prior Approval. These services are marked with in the chart. In some cases, if you fail to ask for Prior Approval the service will not be covered at all. In other cases, if you fail to ask for Prior Approval you may have a Reduction of up to the amount indicated below. The chart below describes the amount you must pay if you do not get Prior Approval. Remember that exclusions or limitations of this Plan still apply, even if you ask for Prior Approval. For example, services that are not Medically Necessary are not covered, even if you ask for Prior Approval. per Calendar Year: You must pay this amount for Covered Services before the Plan will begin to pay benefits. $200 per person/ $400 per family Coinsurance Maximum $0 + Coinsurance Maximum In-Plan Out-of-Pocket Maximum for Covered Services per Calendar Year: The most you pay for Cost Sharing on Essential Health s* during a Plan Year before the Plan begins to pay 100% of the Allowed Amount. $200 per person/ $400 per family $2,550 per person/ $4,700 per family $400 per person/ $800 per family $800 per person/ $1600 per family $1,200 per person/ $2,400 per family $1,500 per person/ $3,000 per family $2,200 per person/ $4,500 per family $3,700 per person/ $7,500 per family N/A Inpatient Care Acute Hospital Care* (elective admissions to facilities require Prior Approval) after after * Essential Health s (EHB) as defined by the Affordable Care Act (ACA) Page 1 of 8
Skilled Care and Inpatient Rehabilitation * Outpatient Preventive Care after Physician Office Visits* (Routine) Adult Routine Exams* (limited to one per Calendar Year) Well Child Care* Routine Eye Exams* (limited to one per Calendar Year) Annual Gynecological Exams* (limited to one per Calendar Year) Routine Mammograms* Nutritional Counseling* (limited to 12 visits per Calendar Year) Screening Colonoscopy or Sigmoidoscopy* (limited to one every five Calendar Years) Other Outpatient Care $20/visit $20/visit Physician Office Visits* (Non-Routine) $20/visit $20/visit Specialist Office Visits* $30/visit $30/visit Second Opinions* $30/visit $30/visit Urgent Care Visits* $30/visit $30/visit Diabetic-Related Items: Outpatient Services* (some services require Prior Approval) Lab/Radiological Services* Durable Medical Equipment* (some items require Prior Approval) $30/visit (only at Life Laboratories) $30/visit after Individual Diabetic Education Group Diabetic Education after after after after after after after after after after after after after after after after after after * Essential Health s (EHB) as defined by the Affordable Care Act (ACA) Page 2 of 8
Emergency Room Care* (Copay waived if admitted directly from the ER) Sleep Study (maximum of two per Calendar Year) Lab Services* Radiological Services: Ultrasound, X-rays, Non- Routine Mammograms* Diagnostic Imaging: CT Scans, MRIs, MRAs, PET Scans, Nuclear Cardiac Imaging * (Nuclear Cardiac Imaging requires Prior Approval in all outpatient settings, including outpatient facilities and doctors offices) Outpatient Short-Term Rehabilitation Services* (Limited to 35 visits per Calendar Year for physical, occupational and speech therapy, combined. The limit does not apply when services are provided to treat autism spectrum disorder.) Early Intervention Services (covered for children from birth to age three) Outpatient Surgical Services & Procedures* $100/visit $100/visit $100/visit (only at Life Laboratories) $20/visit/ treatment type after after after after $20/visit/ treatment type Physician Charges $30/visit $30/visit Facility Charges $0 $0 Allergy Testing and Treatment* $30/visit $30/visit Allergy Injections $20/visit $20/visit Maternity Care Routine Prenatal and Postpartum Care* Non-Routine Prenatal and Postpartum Care* Delivery/Hospital Care for Mother and Child* (Coverage for child limited to routine newborn nursery charges. For continued coverage, child must be enrolled within 30 days of date of birth.) $30/visit after after after after after after after after after after after after after after after after * Essential Health s (EHB) as defined by the Affordable Care Act (ACA) Page 3 of 8
Dental Services Surgical Treatment of Non-Dental Conditions:* In a doctor s office $30/visit $30/visit In a hospital or outpatient surgical facility Emergency Dental Care: after after In an Emergency Room $100/visit $100/visit $100/visit In a doctor s or dentist s office $30/visit $30/visit In a hospital or outpatient surgical facility Temporomandibular Joint Dysfunction (TMJ) * (TMJ must be related to a specific medical condition, conservative treatment requirement for five months) In a doctor s or dentist s office $30/visit $30/visit In a hospital or outpatient surgical facility Other Services Home Health Care * Hospice Services * (life expectancy up to six months) Durable Medical Equipment* (some items require Prior Approval) Wigs (Scalp Hair Prostheses)* for hair loss due to treatment of any form of cancer or leukemia (the Plan covers one prosthesis per Calendar Year) after after after after after after after $0 after Prosthetic Devices * Ambulance and Transportation Services* (non-emergency transportation requires Prior Approval) Reconstructive or Restorative Surgery* In a doctor s office after after after $0 $30/visit after after after * Essential Health s (EHB) as defined by the Affordable Care Act (ACA) Page 4 of 8
In an outpatient surgical facility Kidney Dialysis* Nutritional Support ($5,000 maximum per Calendar Year for low protein food products) Cardiac Rehabilitation* Speech, Hearing and Language Disorders * (Prior Approval is required for speech therapy services after the initial evaluation) Hearing Aids (Covered with Prior Approval for Members age 21 and under. The Plan covers the cost of one hearing aid per hearing-impaired ear, every 36 months, up to a maximum of $2,000 for each hearing aid.) Human Organ Transplants and Bone Marrow Transplants * (without Prior Approval, payments you make to for and Coinsurance do not count toward your or Coinsurance amounts) $20/visit $0 up to $2,000 per device per ear (Member is responsible for all costs beyond maximum) Behavioral Health (Includes Mental Health and Substance Use Disorder) after after after after $20/visit $0 up to $2,000 per device per ear (Member is responsible for all costs beyond maximum) after Inpatient Services* $0 Outpatient Services:* In a doctor s office $20/visit $20/visit In the hospital outpatient department Additional Services Chiropractic Care (Limited to 12 visits per Calendar Year. After your first visit to an In-Plan Provider, your chiropractor must get authorization for services to be covered by OptumHealth Care Solutions. OptumHealth Care Solutions will work with your In-Plan chiropractor to determine the appropriate level of Covered Services to treat your condition.) $25/visit $25/visit after after after after after after after after after after after * Essential Health s (EHB) as defined by the Affordable Care Act (ACA) Page 5 of 8
Asthma Support Program 1 (asthma-related medications, inhalers and epinephrine injectors, spacers/chambers, nebulizers and peak flow meters) Diabetes Support Program 1 (diabetes-related prescriptions and supplies including insulin, oral medications, syringes and test strips, and glucometers) $0 $0 1 The prescription portion of this program is provided through Trinity Health (administered by CVS/Caremark) Prescription Drugs Administered directly by CVS Caremark CVS CAREMARK MEMBER SERVICES 1-877-876-6877 Retail 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name 100% after $10 copay 20% with $30 minimum and $80 maximum 40% with $60 minimum and $100 maximum Mail Order 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name 100% after $25 copay 20% with $75 minimum and $200 maximum 40% with $150 minimum and $250 maximum 50% coinsurance for infertility drugs dispensed through pharmacy (no maximum) If the brand drug has a specific equivalent generic drug available and the plan participant receives the brand, then in addition to the copay, the plan participant must also pay the difference between the ingredient cost of the brand drug and the generic drug. Specialty medications must be filled through the CVS Caremark Specialty program; prescriptions limited to a 30 day supply. Mandatory Maintenance is required for each maintenance medication after an initial retail prescription and two refills. Coverage of Preventive Services Medications (under the Patient Protection and Affordable Care Act (No copay): Prescription required - Iron supplements (Ages 6 months through 12 months), Oral Fluorides (Ages 5 and younger), Aspirin (ages 50-59 males, ages 12-59 females), Folic Acid (women age 55 and younger), Immunizations, Vitamin D (Ages 65+), Bowel Preparation Medications Prescription only (ages 50 through 74), and Breast Cancer Drugs (female age 35+) Prescription required (total 168-day supply) - Tobacco Cessation - Nicotine replacement products, including Nicotine patch, gum & lozenges. Also covers generic Zyban or Chantix Exclusions: Cosmetic medication Anti-wrinkle agents, Hair growth / removal, etc Erectile Dysfunction (ED) Medications Non-Sedating Antihistamine (NSA) Drugs Compound pain patches and bulk powders Hypoactive Sexual Desire Disorder (Addyi) * Essential Health s (EHB) as defined by the Affordable Care Act (ACA) Page 6 of 8
The following is a list of the drugs that need prior authorization to be covered (not intended to be an allinclusive list): (Your physician must call 1-800-626-3046 to obtain approval for a period of up to one year) Topical acne Oral contraceptives Compounds $300 an greater Specialty medications Anti-obesity agents Narcolepsy Anabolic steroids * Essential Health s (EHB) as defined by the Affordable Care Act (ACA) Page 7 of 8
The following is a list of most but not all of the drugs that have a quantity limit imposed: Flu medication Migraine medication Due to the large number of available medicines, this list is not all inclusive. Please note that this list does not guarantee coverage and is subject to change. Your prescription benefit plan may not cover certain products or categories, regardless of their appearance on this list. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. For a complete description of benefits please see the applicable summary plan descriptions. If there is a discrepancy between this summary and any applicable plan document, the plan document will control. More information is available through Caremark.com to help you manage your prescription drug program. You will be able to locate a pharmacy, order mail service refills, track mail service orders, and ask questions. For additional information contact Caremark at 800-966-5772. NOTE: Sisters of Providence Health System provides an Asthma & Diabetes program (please contact the SPHS s Office at 413.748.9620 to learn more) * Essential Health s (EHB) as defined by the Affordable Care Act (ACA) Page 8 of 8