2018 Options Laborers' Coventry Laborers' Coventry Gold Laborers' Aetna Laborers' Basic Supplemental/Rx Monthly Cost Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by (a) (a) Monthly Premium None 2018 Subsidized $364.00 2018 - $302.00 2018 -.00 2018 - $231.00 Coverage Included Medical Drug Plan with full Must Use Certain Providers? Limitations No No No- Provider Yes - Advantra Network Approved Service, unless noted. Member must designate a PCP Yes - Gold Network (b) Approved Service, unless noted. Member must designate a PCP No- Provider Approved Service, unless noted; PART D drugs Out of Pocket Max $1500 maximum applies to all $2900.00 maximum Applies to $1,500.00 maximum Applies to No Limit No Limit N/A -covered Services all -Covered Services all -Covered Services Inpatient Hospital Care confinement, then $289 from the Part A Deductible; Copay 1-8; for Unlimited days. $310 a day each day for day(s) (Includes substance abuse 61st through the 90th day, $578 and rehabilitation) $250 per stay Inpatient Mental Health Care confinement, then $289 from the Part A Deductible; Copay 61st through the 90th day, $578 $2025 per stay $250 per stay Skilled Nursing Facility (In a All but $144.50 from the 21st day, days 1-20; $75 per Days 21- $20/day for days 1-20; $167 copay certified skilled up to the 100 day, for each benefit Co-pay Day 21-100 All costs after Day 100 100; 100 day limit per benefit days 21--100 nursing facility) period period 24 Hour Nurseline 24 hour Access to Nurseline 24 hour Access to Nurseline Home Health Care (Includes intermittent skilled nursing care, home health aide services and rehabilitation services, etc) No co-payments for all covered home health visits. No co-payments for covered home health visits. No co-payments for covered home health visits. Hospice You pay part of the cost for outpatient drugs and inpatient respite care. Balance not covered by Services are paid at 100% if you receive care from a certified hospice. Services are paid at 100% if you receive care from a certified hospice. Covered by Office Visit and/or Home Visit -approved $5 $20 Specialists Office Visit -approved $39 $20 Chiropractic Visits (manual manipulation of spine) -approved $20 $15 Podiatry $20 for all covered $39 -approved services Podiatry (Routine) per visit Maximum of 6 per $45 per visit Maximum of 6 per year year 1 of 5
2018 Options Laborers' Coventry Laborers' Coventry Gold Laborers' Aetna Laborers' Basic Supplemental/Rx Monthly Cost Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by (a) (a) Monthly Premium None 2018 Subsidized $364.00 2018 - $302.00 2018 -.00 2018 - $231.00 Coverage Included Medical Drug Plan with full Outpatient Mental Health Out Patient Substance Abuse Care Outpatient Surgery (Facility & Physician) Asst Surgery (Physician Chgs) Ambulance Emergency Room Urgent Care Center Out Patient Physical, Occupational or Speech Therapy Durable Medical Equipment Prosthetic Devices Diabetes Self Monitoring Training Diabetes Supplies Diagnostic X-Rays Diagnostic Laboratory then 35% of contracted Part B Deductible and 35% of -approved -approved -approved -approved -approved -approved -approved -approved -approved -approved -approved -approved -approved -approved $40 $20 $30 group;$40 individual $20 of the cost for each covered outpatient surgery visit including the facility $180-$280 copay at freestanding ASC; 20% outpatient services 20% of the cost for each covered outpatient surgery visit including the facility $300 $20, waived if admitted $100, waived if admitted $50, waived if admitted $65 $20 $40 $20 20% 20% 0% of the cost of 20% of the cost of co-payment co-payment copay for Lifescan monitor and supplies; 20% for non-lifescan; $25 x-ray; MRI/CT/PET-$150-300 all other diagnostic $20 20% $20 2 of 5
2018 Options Laborers' Coventry Laborers' Coventry Gold Laborers' Aetna Laborers' Basic Supplemental/Rx Monthly Cost Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by (a) (a) Monthly Premium None 2018 Subsidized $364.00 2018 - $302.00 2018 -.00 2018 - $231.00 Coverage Included Medical Drug Plan with full Radiation Therapy -approved 20% $20 Chemotherapy -approved 20% $20 copay Renal Dialysis -approved 20% $20 Cardiac Rehabilitation (Out Patient) -approved $40 $20 Transplant Services confinement, then $289 from the a day each day for day(s); $310 a day each day for day(s) (Hospital) 61st through the 90th day, $578 -approved Unlimited days. 1-8; Unlimited days. $250 per stay Transplant Services 20% of the cost of 0% co-payment (Physician) -approved Bone Mass Measurement -approved co-payment co-payment co-payment (every 24 months) Colorectal Screening Exams -approved co-payment co-payment co-payment Immunizations No co-payment co-payment co-payment co-payment Mammograms (Annual Screening) No co-payment co-payment co-payment co-payment Pap Smear No co-payment co-payment co-payment co-payment Pelvic Exams No co-payment co-payment co-payment co-payment No co-payment for approved lab Prostate Cancer Screening 20% of -approved services. 20% copay for other Exams related services co-payment co-payment co-payment Pharmacy (30 days) None 67% 33% Tier 1 - $3; Tier 2 $7; Tier 3-$47; Tier 4-$100; Tier 5-33% Specialty Drugs Select Care Generics--; Tier 1, Generics--$5; Tier 2, Preferred 3 of 5
2018 Options Laborers' Coventry Laborers' Coventry Gold Laborers' Aetna Laborers' Basic Supplemental/Rx Monthly Cost Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by (a) (a) Monthly Premium None 2018 Subsidized $364.00 2018 - $302.00 2018 -.00 2018 - $231.00 Coverage Included Medical Drug Plan with full Pharmacy - Mail Order (90 days) None 67% 33% Tier 1 - ; Tier 2-$16; Tier 3- $136; Tier 4-$300; Specialty N/A Select Care Generics--; Tier 1, Generics--$10; Tier 2, Preferred Pharmacy - Coverage Gap (Donut Hole) None 67% 33% From $3,750 total drug costs to $5000 true out-of-pocket drug costs: Tier 1 and Tier 2 covered through the gap. A discount on brand name drugs and generally pay no more than 44% of plan's costs for generics and 35% for brand. Select Care Generics--; Tier 1, Generics--$5; Tier 2, Preferred Pharmacy - Catastrophic None 67% drug costs 5% or $3.35 for covered generics, $8.35 for all others; whichever is higher. Hearing Exams Hearing Aids Hearing Diagnostic Dental Vision Exam after Cataract Surgery Vision Lens and Frames after Cataract Surgery One pair of eyeglasses with standard frames after cataract surgery that implants an intraocular lens per eye if done separately $50 for each approved Limited to $150 every three years from In-Network provider; $50 for each approved 2 oral exams; 2 cleaning, 1 x-ray annually. copay for covered comprehensive dental services $15 for each covered eye exam $15 for one pair of eyeglasses or surgery $39 for each approved, one exam every 12 months $500 allowance $39 for each approved up tof $250 for preventive services every year. for each covered eye exam for one pair of eyeglasses or surgery. Routine Covered at 100% 4 of 5
2018 Options Laborers' Coventry Laborers' Coventry Gold Laborers' Aetna Laborers' Basic Supplemental/Rx Monthly Cost Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by Part B - $TBD by (a) (a) Monthly Premium None 2018 Subsidized $364.00 2018 - $302.00 2018 -.00 2018 - $231.00 Coverage Included Medical Drug Plan with full Vision Contacts after Cataract Surgery One pair of contacts after cataract surgery that implants and intraocular lens per eye if done separately Routine Refraction Routine Glasses Annual Routine Physical Exam; Welcome to Exam Health/Wellness Education & Training Covered at 100% Transportation Fitness Benefit (SilverSneakers) $15 for one pair of eyeglasses or surgery $25.00 co-pay through Eye Med Managed Vision $15 copay for select frames ($100 Allowance) and lenses every two years through EyeMed Managed Vision copay for routine exam, limited Covered for Health Education Classes, Newsletter, Congestive Heart Program and Disease Management copay for each -covered smoking cessation counseling session. copay for each covered HIV screening. Non- covered eye exam not covered. Discounts available through EyeMed co-pay through Eye Med Managed Vision $150 allowance for contacts or glasses copay for routine exam, limited Covered for Health Education Classes, Newsletter, Congestive Heart Program and Disease Management copay for each -covered smoking cessation counseling session. copay for each covered HIV screening. No co-payment for each one way No co-payment for each one way trip, up to 24 trips to plan approved trip, up to 24 trips to plan approved location every year. location every year. copayment for one annual exam $70 reimbursement every 24 months copay for routine exam, limited Healthy Lifestyle Coaching, 1 phone call per week. 5 of 5