WHO IS COVERED Enrollment Requirement Members must be enrolled in both Medicare Parts A and B Members must be enrolled in both Medicare Parts A and B Type of Tier Single only Single only Dependent/Student Coverage Not applicable Not applicable Domestic Partner Coverage Not applicable Not applicable COST SHARING EXPENSES Deductible See specific Benefit Type $50 per member Copay See specific Benefit Type N/A Coinsurance See specific Benefit Type Plan pays 80% of until deductible and totals $550 in a calendar year. Components on 50% benefits are not applied to the annual out of pocket maximum. Annual Out-of-Pocket Maximum None $550 per member Deductible Carryover N/A Expenses incurred during the last 3 months of a calendar year and applied to that year's deductible can also be counted toward the deductible for following year Lifetime Benefit Maximum Federal Mandate HOSPITAL INPATIENT SERVICES Inpatient Hospital Services State Mandate for Biologically based Mental Illness & Children with Serious Emotional Disturbance None covers daily copay for 61st to 90th day of each Benefit Period. Lifetime Reserve copay for 60 days. When Medicare exhausts, plan pays 100% of Allowed Expense up to 365 days per lifetime. Plan covers Medicare Part B deductible, for partial hospitalization. Inclusive in Mental Health or Inpatient benefit as determined by Medicare. None ($2,000,000 lifetime limited removed 1/1/11) Medicare Part A inpatient deductible and hospital covered for days 61- After 120 days are exhausted, services are covered at 80%, subject to the deductible. Private room covered when medically necessary Medicare Part A inpatient deductible and hospital covered for days 61- After 120 days are exhausted, services are covered at 80%, subject to the deductible. Private room covered when medically necessary Residential Treatment unless Medicare covers. Detoxification Federal Mandate Chemical Dependence and Abuse Rehabilitation Medicare A Deductible covered, plan Covers Medicare Part A inpatient deductible, hospital days 61- Covers Medicare Part A inpatient Deductible, hospital days 61- November 2012 Page 1
Skilled Nursing Facility Physical Rehabilitation Internal Prosthetics Observation Stay HOSPITAL OUTPATIENT SERVICES Surgical Care including Surgicenters & Freestanding Facilities Pre-admission/Pre-Operative Testing Diagnostic Imaging, X-ray, CAT, MRI Routine Imaging, X-ray, CAT, MRI Benefit Type Diagnostic Laboratory and Routine Laboratory and Radiation Therapy Chemotherapy Dialysis (all forms) Mammogram Cervical Cytology - Pap Smear only Medicare Part A deductible covered; daily copay for days 21st to 100th day covered. There is a limit of 100 days of in each benefit period. Covers Medicare Part A deductible and copay Medicare Part B deductible, copay or or copay applies Covers Medicare B deductible and copay or. Covers Medicare SNF for days 21-100 and full coverage for days 101-120. Also covers 80% of semi-private room charges beyond 120 days, in a Medicare approved Skilled Nursing Facility, subject to the deductible. Custodial care is not covered Covers Medicare Part A deductible & daily copays for 61 st to 90 th day of each benefit period Covers Medicare Part A deductible and Periodic routine mammograms - Covers Medicare Part B deductible and 80% of the difference between the Medicare payment and the Blue Shield Schedule of Allowances. November 2012 Page 2
State Mandate for Biologically based Mental Illness & Children with Serious Emotional Disturbances Chemical Dependency Covered Therapies Includes Physical, Speech, and Occupational Therapy Pulmonary Rehabilitation Cardiac Rehabilitation Injectable Drugs Excludes vaccines, allergy injections & treatment of diabetes Home Care Hospice Care PHYSICIAN SERVICES Inpatient Hospital Surgery Outpatient Hospital & Ambulatory Surgery Office Surgery Covered Therapies Includes Physical, Speech, and Occupational Therapy Anesthesia Includes Inpatient, Outpatient, Office Visits and maternity Additional Surgical Opinion Plan covers Medicare Part B deductible and Inclusive in Mental Health Outpatient or Office benefit as determined by Medicare. Covers Durable Medical Equipment as part of Home Care and Medicare Parts A or B Coinsurance Covers Medicare Part A copay for outpatient prescription drugs and Medicare Part A for respite care. Covered in full for same number of Medicare approved days Covered in full for same number of Medicare approved days Covers Medicare Part B Deductible and November 2012 Page 3
Second Medical Opinion In-Hospital Physician Visits Physician s Office Preventative Services Routine Physical Examinations Adult Immunizations PHYSICIAN OFFICE - OTHER SERVICES Diagnostic Laboratory and Routine Laboratory and Eye Exams - Diagnostic Covers Medicare B deductible, copay or (Medicare Part B covers a once per lifetime preventive exam within the first 6 months of enrollment) unless Medicare deductible, (Medicare Part B covers a once per lifetime preventive exam within the first 6 months of enrollment) unless Medicare deductible, unless Medicare deductible, Eye Exams Routine Hearing Evaluations Diagnostic Plan covers Medicare Part B deductible and Hearing Evaluations Routine unless Medicare deductible, Hearing Aids unless Medicare deductible, Covered subject to deductible and, 2 per lifetime Diagnostic Office Visits Includes all diagnostic physician visits e.g. GYN, cardiac, orthopedists, etc. Office & Outpatient Consultations Diagnostic Imaging Services, X- ray, CAT, MRI, etc. Routine Imaging Services, X-ray, CAT, MRI, etc. Radiation Therapy Chemotherapy Dialysis (all forms) State Mandate Mammogram unless Medicare deductible, November 2012 Page 4
Routine GYN Visits Prostate Cancer Screenings Allergy Testing Allergy Treatment Includes Serum and Injections State Mandate for Biologically based Mental Illness & Children with Serious Emotional Disturbances Chiropractic Care Inpatient Consultations Infertility Care Bone Density Testing Benefit Type Injectable Drugs Excludes vaccines, allergy injections & treatment of diabetes ADDITIONAL BENEFITS Prescription Drug Treatment of Diabetes Insulin & Supplies Plan covers Medicare B deductible and for office exam. Pap smear covered in full under Medicare Part B Plan covers Medicare B deductible and unless Medicare deductible, unless Medicare deductible, Inclusive in Mental Health or Office benefit as determined by Medicare. Not Covered unless Medicare deductible, Drug benefit for 2013 remains same as 2012 Plan covers Medicare Part B deductible and for supplies. (Insulin covered under prescription drug benefit) for office exam. Pap smear covered in full under Medicare Part B Drug coverage is offered through either Excellus or an alternate vendor for supplies. (Insulin covered under prescription drug benefit) Diabetic Education November 2012 Page 5
Diabetic Equipment Mastectomy Prosthesis Durable Medical Equipment (DME) External Prosthetics/ Orthotics Foot orthotics excluded Foot Orthotics Covered under DME benefit Items not covered in whole by Medicare are covered at 100%, subject to deductible, when ordered by your physician and obtained from a participating provider. If obtained from a non-participating provider, DME will be covered at 50% of the charge, subject to the deductible. Medical Supplies Air Ambulance Service Prehospital Emergency Services/Transportation Nutritional Therapy Medicare Blood Deductible Covers Medicare Part A deductible and Medicare Part B deductible and Private Duty Nursing Covered at 80% of charges up to $100 per day for 30 days per contract year. (Coverage will be provided for Medically Necessary private duty nursing as an inpatient or in a member s home) Non-Assigned Provider Excess When Medicare pays a percentage of the Charges - Medicare B only Medicare Approved Amount for a Applies if a provider does not covered Part B service, the plan will pay accept Medicare s assignment 100% of the balance. Plan also pays the difference between the Medicare Approved Amount for Part B services and actual charges billed by provider (not to exceed charge limitations established by Medicare programs). EMERGENCY SERVICES Facility Emergency Room November 2012 Page 6
Physician s Hospital Emergency Room Visit Foreign Country Emergency Care Facility & Physician combined Freestanding Urgent Care Center Emergency & non-emergency services Physician s Freestanding Urgent Care Center Visit Emergency & non-emergency services $250 deductible, then plan pays 80% of charges up to $50,000 lifetime maximum if not covered by Medicare. (See standard Emergency Benefit Types when Medicare covers.) Covers Medicare B deductible and copay or This is not a contract. It is intended to highlight the coverage of this program. Benefits are determined by the terms of the contract. All benefits are subject to medical necessity. All day and visit limits are combined limits for both in and out of network benefit. November 2012 Page 7