Excellus BluePPO Signature Deduct 3 Drug Coverage Excluded Benefit Time Period: 03/01/2018-12/31/2018 Trinity Health - Syracuse HSA General Cost Sharing Expenses - Single $1,500 $2,500 $3,500 - Two Person $3,000 $5,000 $7,000 - Family $3,000 $5,000 $7,000 s that Apply to Aggregation - Single and Family Aggregation - In Network and Out of Network Medical plus drug The entire family annual deductible must be met before copay or coinsurance is applied for any individual family member. If the family deductible amount exceeds the out of pocket maximum per person cap, the individual cannot contribute more than the out of pocket maximum per person cap amount for the plan year. Family Domestic, In Network and Out of Network aggregate together Carryover Months No No No History Credit No No No 10% 20% 40% Annual Out of Pocket Maximum - Single $2,600 $5,000 $7,000 Annual Out of Pocket Maximum - Two Person $5,200 $10,000 $14,000 Annual Out of Pocket Maximum - Family $5,200 $10,000 $14,000 Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-of-pocket maximums exclude balances over allowable expense and noncovered services. Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-of-pocket maximums exclude balances over allowable expense and noncovered services. Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-of-pocket maximums exclude balances over allowable expense and noncovered services. 1 of 17 1205731-1 02/06/2018 08:48:52
Annual Out of Pocket Maximum - Per Person Cap s that Apply to Out of Pocket Maximum Annual Out of Pocket Maximum Aggregation - Single and Family Annual Out of Pocket Maximum Aggregation - In Network and Out of Network $2,600 $5,000 $7,000 The Out-of-Pocket Maximum Per Person Cap includes deductible, coinsurance, copays and prescription drugs. If a member under a family contract meets the Out-Of-Pocket Maximum Per Person Cap amount, the individual will no longer pay for covered services and claims will be paid at 100% of the allowable amount by the Health Plan for the remainder of the plan year. The remaining annual out-ofpocket maximum still needs to be met by any combination of family members on the contract before claims are paid at 100% for the whole family. Medical plus drug The entire Family Annual Out-of-Pocket Maximum must be met before family members receive covered services processed at 100% of the allowable amount for the remainder of the plan year. An individual member covered under a family plan may not exceed the Out-of- Pocket Maximum per person cap amount for that plan year, should the family Out-of- Pocket Maximum level exceed the Out-of- Pocket Maximum Per Person Cap. Family In Network and Out of Network aggregate together Office Visit Cost Shares Cost Share - Primary Care Cost Share - Specialist 10% 10% 20% 20% Plan Limits Limits Aggregation - In-network and Out of Network Annual Maximum Lifetime Benefit Maximum Kids Copay Age Limit Kids Copay Age Applies To Kids Copay Network Referrals Required In Network and Out of Network aggregate together Unlimited Unlimited Does Not Apply Does Not Apply N/A No 2 of 17 1205731-1 02/06/2018 08:48:52
Employer Funding Percentage HSA vs HRA Plan/Calendar Year Coordination of Benefits Prior Authorization Diabetic Preauthorization and Step Therapy Health Savings seed money. Amount prorated based oupon date of enrollment. $650/single $1,300/Family 50% HSA Calendar Year Benefits Made Whole Applies Applies Precertification PreCertification PreCertification Penalty Does Not Apply Does Not Apply Who is Type of Tiers Dependent Coverage Dependent Age End Period Domestic Partner Coverage 4 Tier (EE, 2P, EE/Children, FAM) Age to which all dependents (excluding spouse) are covered. 26 Age to which all dependents (excluding spouse) are covered. End of Year Additional Group Characteristics Total Employees 3200 Total Eligible 3200 Group Size Funding Arrangement FMHP Exempt Retiree Only ASC Hospital Blue No No 3 of 17 1205731-1 02/06/2018 08:48:52
Sovereign Nation Religious Group Grandfathered No No Allowable Expense Allowable Expense Facility in Area Facility Out of Area Professional Healthcare Provider In Area Professional Healthcare Provider Out of Area Emergency Facility in Area Negotiated Amount. Member's cost share is based on Charge if Lower than Negotiated Rate Amount, Blue Card Allowance or Charge Amount or Charge Amount, Blue Card Allowance or Charge Negotiated Amount. Member's cost share is based on Charge if Lower than Negotiated Rate We allow the lesser of 80 Percent of the Medicare Prospective Payment System or 100 Percent of Charge. If the service is not listed on the Medicare Prospective Payment System, we allow 75 Percent of Charge. We allow the lesser of 150 Percent of the Medicare Prospective Payment System, 100 Percent of Blue Card allowance or 100 Percent of Charge. If the service is not listed on the Medicare Prospective Payment System, we allow 75 Percent of Charge. We allow the lesser of 80 Percent of the Medicare Prospective Payment System or 100 Percent of Charge. If the service is not listed on the Medicare Prospective Payment System, we allow 75 Percent of Charge. We allow the lesser of 150 Percent of the Medicare Prospective Payment System, 100 Percent of Blue Card allowance or 100 Percent of Charge. If the service is not listed on the Medicare Prospective Payment System, we allow 75 Percent of Charge. We allow the lesser of 100 Percent of the Negotiated Amount or 100 Percent of Charge. 4 of 17 1205731-1 02/06/2018 08:48:52
Emergency Facility Out of Area Emergency Professional Healthcare Provider In Area Emergency Professional Healthcare Provider Out of Area Dialysis Facility in Area Dialysis Facility Out of Area Dialysis Professional Healthcare Provider In Area Dialysis Professional Healthcare Provider Out of Area Amount, Blue Card Allowance or Charge Amount or Charge Amount, Blue Card Allowance or Charge Negotiated Amount. Member's cost share is based on Charge if Lower than Negotiated Rate Amount, Blue Card Allowance or Charge Amount or Charge Amount, Blue Card Allowance or Charge We allow the lesser of 100 Percent of the Negotiated Amount, 100 Percent of Blue Card allowance or 100 Percent of Charge. We allow the lesser of 100 Percent of the Negotiated Amount or 100 Percent of Charge. We allow the lesser of 100 Percent of the Negotiated Amount, 100 Percent of Blue Card allowance or 100 Percent of Charge. Inpatient s Inpatient Facility Inpatient Hospital s Inpatient Hospital s 2nd Tier Mental Health Care Mental Health Care 2nd Tier Mental Health Residential Care Substance Use Detoxification Substance Use Rehabilitation Substance Use Residential Care Skilled Nursing Facility 10% 10% 10% 10% 10% 10% 10% 10% 10% $500 Copayment then 20% 20% 10% 20% 10% 10% 10% 10% $500 Copayment then 20% 120 Days per contract year Limits are combined Domestic, INN and OON. 5 of 17 1205731-1 02/06/2018 08:48:52
Physical Rehabilitation Maternity Care Routine Newborn Nursery Care Prosthetic - Implanted Devices Mastectomy Observation Stay 10% 10% 10% 10% 10% 10% $500 Copayment then 20% $500 Copayment then 20% 20% 20% 20% 20% 60 Days per plan year Limits are combined Domestic, INN and OON. Inpatient Professional s Inpatient Hospital Surgery Anesthesia In Hospital Physician Visits and Consults 20% 20% 20% Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. Outpatient Facility s Outpatient Facility s SurgiCenters and Freestanding Ambulatory Centers Surgical Care Colonoscopy Facility Diagnostic Preadmission Pre-Operative Testing Diagnostic X-ray 10% 10% 10% 10% 20% 20% 20% 20% Routine X-ray Advanced Imaging s Mammography Facility Diagnostic Diagnostic Laboratory and Pathology 10% 10% 10% 20% 20% 20% Routine Laboratory and Pathology Diagnostic Testing 10% 20% After $100 Co-pay INN and $200 Co-pay OON After $100 Co-pay INN and $200 Co-pay OON. First Diagnostic Colonoscopy will be covered in full regardless of age. Advanced Imaging s includes PET scans, MRI, nuclear medicine, and CAT scans. 6 of 17 1205731-1 02/06/2018 08:48:52
Radiation Therapy Chemotherapy Infusion Therapy Dialysis Injectable Drugs Mental Health Care Substance Use Care Autism Applied Behavior Analysis Substance Use Family Counseling Pulmonary Rehabilitation Cardiac Rehabilitation 10% 10% 10% 10% 10% 10% 10% 10% 10% 20% 20% 20% 10% 10% 20% 10% 20% 20% Is inclusive in the Home Care benefit and not covered as a separate benefit. Excludes vaccines, allergy injections & treatment of diabetes. Cost share is inclusive of services in which the injection is rendered with. Includes Partial Hospitalization Includes Partial Hospitalization 20 Visits per calendar year 36 Visits Per year Home and Hospice Care Home Care Home Care 10% 20% 120 Days per year Limits are combined Domestic, INN and OON. Hospice Care Hospice Care Inpatient Hospice Care Outpatient 0% 0% 0% 0% Family Bereavement Outpatient and Office Professional s Professional s 7 of 17 1205731-1 02/06/2018 08:48:52
Outpatient Hospital and Ambulatory Surgery Office Surgery Colonoscopy Professional Diagnostic Diagnostic X-ray Routine X-ray Advanced Imaging s Mammography Professional Diagnostic Diagnostic Laboratory and Pathology Routine Laboratory and Pathology Diagnostic Testing Radiation Therapy Chemotherapy Infusion Therapy Dialysis Injectable Drugs Mental Health Care Substance Use Treatment Maternity Care Autism Applied Behavior Analysis Additional Surgical Opinion 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% First Diagnostic Colonoscopy will be covered in full regardless of age. Advanced Imaging s includes PET scans, MRI, nuclear medicine, and Cat Scans. Is inclusive in the Home Care benefit and not covered as a separate benefit. Excludes vaccines, allergy injections & treatment of diabetes. Cost share is inclusive of services in which the injection is rendered with. 8 of 17 1205731-1 02/06/2018 08:48:52
Second Medical Opinion for Cancer Pulmonary Rehabilitation Cardiac Rehabilitation Office Visits - Diagnostic TeleMedicine Program Medications Administered in Office Eye Exams Diagnostic Hearing Evaluations Diagnostic Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine Adult Hearing Aids Pediatric Hearing Aid Age Limit Not Not 20% 20% 20% 20% Not 20% 20% 20% 20% 20% Not 36 Visits per year for the diagnosis and treatment of injury, disease and medical conditions. All professional provider specialties e.g. GYN, cardiac, orthopedists, etc. are included. This also includes eye exams or hearing exams for the diagnosis or treatment of illness or injury. Office visits may include house calls. Excludes injections for vaccines, allergy injections & treatment of diabetes. 20 Visits per year Allergy Testing includes injections and scratch and prick tests. Includes desensitization treatments (injections & serums). 1 Visit per year Limits are combined Domesitc, INN and OON. Does Not Apply Pediatric Hearing Aids Cochlear Implants Not 20% 20% Subject to $2,500 1 Purchase every 3 years Rehab and Habilitation Outpatient Facility 9 of 17 1205731-1 02/06/2018 08:48:52
Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation Physical Habilitation Occupational Habilitation Speech Habilitation 10% 10% 10% 10% 10% 10% 20% 20% 20% 20% 20% 20% 60 Visits per contract year occupational therapy. 60 Visits per contract year occupational therapy. 60 Visits per contract year occupational therapy. 60 visits combined for PT/OT/Speech Visits per contract year occupational therapy. Pre cert required 60 visits combined for PT/OT/Speech Visits per contract year occupational therapy. Pre cert required 60 visits combined for PT/OT/Speech Visits per contract year occupational therapy. Pre cert required Outpatient Professional s Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 20% 20% 20% 60 Visits per contract year occupational therapy. 60 Visits per contract year occupational therapy. 60 Visits per contract year occupational therapy. 10 of 17 1205731-1 02/06/2018 08:48:52
Physical Habilitation Occupational Habilitation Speech Habilitation 20% 20% 20% 60 visits combined for PT/OT/Speech Visits per contract year occupational therapy. Pre cert required 60 visits combined for PT/OT/Speech Visits per contract year occupational therapy. Pre cert required 60 visits combined for PT/OT/Speech Visits per contract year occupational therapy. Pre cert required Preventive s Preventive Professional s Meeting Federal Guidelines* Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Family Planning Pre/Post-Natal Care Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional Not Not 1 Exam per plan year Xrays, EKG and lab procedures performed as part of the health maintenance exam 100% DOM and Innet 1 Visit per year 1 Visit per year First base Mammogram between ages 35 and over CIF. First Diagnostic Colonoscopy will be covered in full regardless of age. Preventive Facility s Meeting Federal Guidelines* Cervical Cytology Preventative Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility 1 visit per year 1 visit per yaer First base Mammogram between ages 35 and over CIF. First Diagnostic Colonoscopy will be covered in full regardless of age. 11 of 17 1205731-1 02/06/2018 08:48:52
Preventive services in addition to those required under Federal Guidelines - Professional Prostate Cancer Screening Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional 1 visit per year 1 visit per year First base Mammogram between ages 35 and over CIF. First Diagnostic Colonoscopy will be covered in full regardless of age. Preventive services in addition to those required under Federal Guidelines - Facility Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility 1 visit per year First base Mammogram between ages 35 and over CIF. First Diagnostic Colonoscopy will be covered in full regardless of age. Other Benefits Additional Benefits Treatment of Diabetes Preventive N/A N/A N/A Treatment of Diabetes Insulin and Supplies Diabetic Education Diabetic Equipment 20% 20% 20% No coverage for Insulin and supplies through a pharmacy- covered through Carve-out Rx Vendor - CVS/Caremark Diabetic Retail Max Day Supply Diabetic Retail Copay for Max Day Supply Diabetic Mail Order Max Day Supply Diabetic Mail Order Copay for Max Day Supply Autism Assistive Communication Device Autologous Blood Banking Durable Medical Equipment (DME) Not Not Not Not 12 of 17 1205731-1 02/06/2018 08:48:52
Mastectomy Prosthesis Orthotics Foot Orthotics Prosthetic - External Benefit Prosthetic - Wigs External Benefit Medical Supplies Breast Pump Purchase or Rental Acupuncture Reproductive s Private Duty Nursing PUVA Treatment Nutritional Therapy Biofeedback Not Not Not PCP - Specialist - Not 20% 20% 20% 20% 20% 20% Not Not 20% Not Not Not One wig is allowed in a 365 day period. The maximum allowable amount is $500 1 Rental or Purchase per pregnancy 120 visits per calendar year PDN not covered in an inpatient hospital or any other health care facility Diagnoses Accidental Dental Dental Oral Surgery Temporomandibular Joint (TMJ) Nutritional Counseling Inherited Metabolic Disorder - PKU Infertility Care Organ and Bone Marrow Transplants Dental Surgery is covered for the removal of impacted teeth or multiple extractions only when a concurrent hazardous medical condition, such as a heart condition, exists. up to diagnosis. Artificial Insemination not covered No coverage for Cancer Treatment Centers of America. Transplants not covered out of network. 13 of 17 1205731-1 02/06/2018 08:48:52
Elective Sterilization - Female Elective Sterilization - Male Interruption of Pregnancy Not Not Not Not Not Not Emergency s ER Facility Facility Emergency Room Visit 10% 10% 10% Non emergency use of ER DOM- 10% subject to deductible Innet- 20% subject to deductible OON- 40% subject to deductible.prior Authorization may not apply to any Emergency services are covered worldwide if provided by a hispital facility. ER Professional Physician Emergency Room Visit 10% Non emergency use of ER DOM- 10% subject to deductible Innet- 20% subject to deductible OON- 40% subject to deductible.prior Authorization may not apply to any Emergency services are covered worldwide if provided by a hispital facility. Transportation Prehospital Emergency and Transportation - Ground or Water Air Ambulance Intra Hospital Transportation 10% 10% 10% 10% 10% 10% 10% 10% 10% DOM $1,500 deduct then 10% coinsurance. Innet $2,500 deduct then 10% coinsurance. OON $3,500 deduct then 10% coinsurance DOM $1,500 deduct then 10% coinsurance. Innet $2,500 deduct then 10% coinsurance. OON $3,500 deduct then 10% coinsurance DOM $1,500 deduct then 10% coinsurance. Innet $2,500 deduct then 10% coinsurance. OON $3,500 deduct then 10% coinsurance Urgent Care Urgent Care Center Facility Visit 10% 10% 10% DOM $1,500 deduct then 10% coinsurance. Innet $2,500 deduct then 10% coinsurance. OON $3,500 deduct then 10% coinsurance Urgent Care - Professional 14 of 17 1205731-1 02/06/2018 08:48:52
Physician Urgent Care Center Visit Physician Office Visit for Urgent Care 20% 10% DOM $1,500 deduct then 10% coinsurance. Innet $2,500 deduct then 10% coinsurance. OON $3,500 deduct then 10% coinsurance Total Health Management Programs Medical Management s Case Management Program Case Management Behavioral Health Program Disease Management Program Health Promotion Applies Applies Applies Applies Ancillary Benefits Vision Adult Eye Exams - Routine N/A Adult Eyewear - Routine Pediatric Vision Age Limit Does Not Apply Pediatric Eye Exams - Routine N/A Pediatric Eyewear - Routine Rx Benefits Rx Plan Rx Plan Drug Coverage Excluded Rx Benefits 15 of 17 1205731-1 02/06/2018 08:48:52
$0 Generics for Kids N/A N/A Generics for Kids Age Limit Does Not Apply Does not apply MAC Penalty N/A N/A Step Therapy N/A N/A Prior Authorization N/A N/A Oral Contraceptives N/A Mandatory MO for Maintenance Drugs N/A N/A Days Supply Per Retail Order 30 30 Days Supply Per Mail Order 90 90 Copays Per Mail Order Supply N/A N/A N/A N/A Family N/A N/A applies to N/A N/A Embedded Rx No No Annual benefit maximum N/A N/A Benefit maximum applies to N/A N/A OOP Maximum N/A N/A OOP Maximum Applies to N/A N/A Exclusions Exclusions 16 of 17 1205731-1 02/06/2018 08:48:52
Benefit Name Convalescent and Custodial Care Cosmetic s Dental s Experimental or Investigational Treatment Felony Participation Government Facility Medicare or Other Governmental Program Military No-Fault Automobile Insurance s Not Listed s with No Charge War Workers Compensation Excluded The group has reviewed the benefit grid 1205731-1 and accepts the benefits as indicated. Signature of Group Administrator: Date: 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 s coverage required by the Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive s Task Force list of items and services rated "A" or "B" that are covered pursuant to the Patient Protection and Affordable Care Act requirements. 17 of 17 1205731-1 02/06/2018 08:48:52