FLORIDA 2017 EHB BENCHMARK PLAN

Transcription

1 FLORIDA EHB BENCHMARK PLAN SUMMARY INFORMATION Plan Type Issuer Name Product Name Small Group Market Blue Cross and Blue Shield of Florida BlueOptions Plan Name BlueOptions Supplemented Categories (Supplementary Plan Type) Pediatric dental (FEDVIP) Pediatric vision (FEDVIP) Habilitation services (Federal Definition) Florida

2 BENEFITS AND LIMITS A B EHB C Is the Covered? D Quantitative Limit on Service? E Limit Quantity F Limit Unit G Exclusions Primary Care Visit to Treat an Injury or Illness Yes Covered No Specialist Visit Yes Covered No Other Practitioner Office Visit (Nurse, Physician Yes Covered No Assistant) Outpatient Facility Fee (e.g., Ambulatory Surgery Yes Covered No Center) Outpatient Surgery Physician/Surgical Services Yes Covered No Hospice Services Yes Covered No Routine Dental Services (Adult) No Covered No Infertility Treatment No Not Covered No Long-Term/Custodial Nursing Home Care No Not Covered No Private-Duty Nursing No Not Covered No Routine Eye Exam (Adult) No Covered No Urgent Care Centers or Facilities Yes Covered No Home Health Care Services Yes Covered Yes Day(s) per Part-time- Services limited to less than hours a day, less than hours a week. Intermittent- Services limited to each visit up to but not exceeding hours a day. H Explanations Excluded: Services rendered by an employee/operator of an adult congregate living facility, adult foster home, adult day care center, or a nursing facility. Emergency Room Services Yes Covered No Emergency Transportation/Ambulance Yes Covered No Inpatient Hospital Services (e.g., Hospital Stay) Yes Covered No Inpatient Physician and Surgical Services Yes Covered No Bariatric Surgery No Not Covered No Cosmetic Surgery No Not Covered No Skilled Nursing Facility Yes Covered Yes Day(s) per Prenatal and Postnatal Care Yes Covered No Delivery and All Inpatient Services for Maternity Care Yes Covered No Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded. Mental/Behavioral Health Outpatient Services Yes Covered Yes Visit(s) per Excludes services for psychological testing associated with the evaluation and diagnosis of learning disabilities or for mental retardation. Mental/Behavioral Health Inpatient Services Yes Covered Yes Day(s) per Exclusion of inpatient (overnight) mental health services received in a residential treatment facility. Substance Abuse Disorder Outpatient Services Yes Covered No Substance Abuse Disorder Inpatient Services Yes Covered No Exclusion of expenses for prolonged care and treatment of Substance Dependency in a specialized inpatient or residential treatment facility Generic Drugs Yes Covered No Preferred Brand Drugs Yes Covered No Non-Preferred Brand Drugs Yes Covered No Specialty Drugs Yes Covered No Florida

3 A B EHB C Is the Covered? D Quantitative Limit on Service? E Limit Quantity F Limit Unit G Exclusions H Explanations Outpatient Rehabilitation Services Yes Covered Yes Visit(s) per Combined limit for all outpatient therapy plus chiropractic. Habilitation Services Yes Covered No Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Chiropractic Care Yes Covered Yes Visit(s) per Combined limit for all outpatient therapy plus chiropractic. Durable Medical Equipment Yes Covered No Hearing Aids No Not Covered No Imaging (CT/PET Scans, MRIs) Yes Covered No Preventive Care/Screening/Immunization Yes Covered No Routine Foot Care No Not Covered No Acupuncture No Not Covered No Weight Loss Programs No Not Covered No Routine Eye Exam for Children Yes Covered No Eye Glasses for Children Yes Covered No Dental Check-Up for Children Yes Covered No Rehabilitative Speech Therapy Yes Covered Yes Visit(s) per Combined limit for all outpatient therapy plus chiropractic. Rehabilitative Occupational and Rehabilitative Physical Therapy Yes Covered Yes Visit(s) per If provided in an Inpatient setting, member must be able to actively participate in rehabilitative therapies and be able to tolerate at least hours per day of skilled Rehab services for at least days a week. Member s condition must be likely to significantly improve. Inpatient rehab limit is days. Well Baby Visits and Care Yes Covered No Laboratory Outpatient and Professional Services Yes Covered No X-rays and Diagnostic Imaging Yes Covered No Basic Dental Care - Child Yes Covered No Orthodontia - Child Yes Covered No Major Dental Care - Child Yes Covered No Basic Dental Care - Adult No Covered No Orthodontia - Adult No Not Covered No Major Dental Care Adult No Covered No Abortion for Which Public Funding is Prohibited No Covered No Elective abortions excluded. Transplant Yes Covered No Accidental Dental Yes Covered No Dialysis Yes Covered No Allergy Testing Yes Covered No Chemotherapy Yes Covered No Radiation Yes Covered No Diabetes Education Yes Covered No Prosthetic Devices Yes Covered No Infusion Therapy No Not Covered No Combined limit for all outpatient therapy plus chiropractic. Florida

4 A B EHB C Is the Covered? D Quantitative Limit on Service? E Limit Quantity F Limit Unit G Exclusions Treatment for Temporomandibular Joint Disorders Yes Covered No Services involving bones or joints of the jaw (e.g., Services to treat temporomandibular joint [TMJ] dysfunction) or facial region if, under accepted medical standards, such diagnostic Services are necessary to treat Conditions caused by congenital or developmental deformity, disease, or injury. H Explanations Payment for splints for the treatment of temporomandibular joint ("TMJ") dysfunction is limited to one splint in a six-month period unless a more frequent replacement is determined by us to be Medically Necessary. Nutritional Counseling Yes Covered No Diabetes coverage includes "nutrition counseling"; home health services include "nutritional guidance." Reconstructive Surgery Yes Covered No Only for Breast reconstruction following a Mastectomy. Florida

5 PRESCRIPTION DRUG EHB-BENCHMARK PLAN BENEFITS BY CATEGORY AND CLASS CATEGORY CLASS SUBMISSION COUNT Analgesics Nonsteroidal Anti-inflammatory Drugs Analgesics Opioid Analgesics, Long-acting Analgesics Opioid Analgesics, Short-acting Anesthetics Local Anesthetics Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving Anti-Addiction/ Substance Abuse Treatment Agents Opioid Dependence Treatments Anti-Addiction/ Substance Abuse Treatment Agents Opioid Reversal Agents Anti-Addiction/ Substance Abuse Treatment Agents Smoking Cessation Agents Aminoglycosides, Other Beta-lactam, Cephalosporins Beta-lactam, Other Beta-lactam, Penicillins Macrolides Quinolones Sulfonamides Tetracyclines Anticonvulsants Anticonvulsants, Other Anticonvulsants Calcium Channel Modifying Agents Anticonvulsants Gamma-aminobutyric Acid (GABA) Augmenting Agents Anticonvulsants Glutamate Reducing Agents Anticonvulsants Sodium Channel Agents Antidementia Agents Antidementia Agents, Other Antidementia Agents Cholinesterase Inhibitors Antidementia Agents N-methyl-D-aspartate (NMDA) Receptor Antagonist Antidepressants Antidepressants, Other Antidepressants Monoamine Oxidase Inhibitors Antidepressants SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors) Antidepressants Tricyclics Antiemetics Antiemetics, Other Antiemetics Emetogenic Therapy Adjuncts Antifungals Antigout Agents Anti-inflammatory Agents Glucocorticoids Anti-inflammatory Agents Nonsteroidal Anti-inflammatory Drugs Antimigraine Agents Ergot Alkaloids Florida

6 CATEGORY CLASS SUBMISSION COUNT Antimigraine Agents Prophylactic Antimigraine Agents Serotonin (-HT) b/d Receptor Agonists Antimyasthenic Agents Parasympathomimetics Antimycobacterials Antimycobacterials, Other Antimycobacterials Antituberculars Alkylating Agents Antiandrogens Antiangiogenic Agents Antiestrogens/Modifiers Antimetabolites, Other Aromatase Inhibitors, rd Generation Enzyme Inhibitors Molecular Target Inhibitors Monoclonal Antibodies Retinoids Antiparasitics Anthelmintics Antiparasitics Antiprotozoals Antiparasitics Pediculicides/Scabicides Antiparkinson Agents Anticholinergics Antiparkinson Agents Antiparkinson Agents, Other Antiparkinson Agents Dopamine Agonists Antiparkinson Agents Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors Antiparkinson Agents Monoamine Oxidase B (MAO-B) Inhibitors Antipsychotics st Generation/Typical Antipsychotics nd Generation/Atypical Antipsychotics Treatment-Resistant Antispasticity Agents Anti-cytomegalovirus (CMV) Agents Anti-hepatitis B (HBV) Agents Anti-hepatitis C (HCV) Agents Antiherpetic Agents Anti-HIV Agents, Integrase Inhibitors (INSTI) Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) Anti-HIV Agents, Other Anti-HIV Agents, Protease Inhibitors Anti-influenza Agents Florida

7 CATEGORY CLASS SUBMISSION COUNT Anxiolytics Anxiolytics, Other Anxiolytics Benzodiazepines Anxiolytics SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors) Bipolar Agents Bipolar Agents, Other Bipolar Agents Mood Stabilizers Blood Glucose Regulators Antidiabetic Agents Blood Glucose Regulators Glycemic Agents Blood Glucose Regulators Insulins Blood Products/Modifiers/ Volume Expanders Anticoagulants Blood Products/Modifiers/ Volume Expanders Blood Formation Modifiers Blood Products/Modifiers/ Volume Expanders Coagulants Blood Products/Modifiers/ Volume Expanders Platelet Modifying Agents Alpha-adrenergic Agonists Alpha-adrenergic Blocking Agents Angiotensin II Receptor Antagonists Angiotensin-converting Enzyme (ACE) Inhibitors Antiarrhythmics Beta-adrenergic Blocking Agents Calcium Channel Blocking Agents, Other Diuretics, Carbonic Anhydrase Inhibitors Diuretics, Loop Diuretics, Potassium-sparing Diuretics, Thiazide Dyslipidemics, Fibric Acid Derivatives Dyslipidemics, HMG CoA Reductase Inhibitors Dyslipidemics, Other Vasodilators, Direct-acting Arterial Vasodilators, Direct-acting Arterial/Venous Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines Attention Deficit Hyperactivity Disorder Agents, Amphetamines Central Nervous System, Other Fibromyalgia Agents Multiple Sclerosis Agents Dental and Oral Agents Dermatological Agents Enzyme Replacement/ Modifiers Antispasmodics, Gastrointestinal Florida

8 CATEGORY CLASS SUBMISSION COUNT, Other Histamine (H) Receptor Antagonists Irritable Bowel Syndrome Agents Laxatives Protectants Proton Pump Inhibitors Genitourinary Agents Antispasmodics, Urinary Genitourinary Agents Benign Prostatic Hypertrophy Agents Genitourinary Agents Genitourinary Agents, Other Genitourinary Agents Phosphate Binders Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) Anabolic Steroids Androgens Estrogens Progesterone Agonists/Antagonists Progestins Selective Estrogen Receptor Modifying Agents Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents Immunological Agents Angioedema (HAE) Agents Immunological Agents Immune Suppressants Immunological Agents Immunizing Agents, Passive Immunological Agents Immunomodulators Inflammatory Bowel Disease Agents Aminosalicylates Inflammatory Bowel Disease Agents Glucocorticoids Inflammatory Bowel Disease Agents Sulfonamides Metabolic Bone Disease Agents Ophthalmic Prostaglandin and Prostamide Analogs, Other Ophthalmic Anti-allergy Agents Ophthalmic Antiglaucoma Agents Ophthalmic Anti-inflammatories Otic Agents Florida

9 CATEGORY CLASS SUBMISSION COUNT Antihistamines Anti-inflammatories, Inhaled Corticosteroids Antileukotrienes Bronchodilators, Anticholinergic Bronchodilators, Sympathomimetic Cystic Fibrosis Agents Mast Cell Stabilizers Phosphodiesterase Inhibitors, Airways Disease Pulmonary Antihypertensives Respiratory Tract Agents, Other Skeletal Muscle Relaxants Sleep Disorder Agents GABA Receptor Modulators Sleep Disorder Agents Sleep Disorders, Other Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Modifiers Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Replacement Therapeutic Nutrients/ Minerals/ Electrolytes Vitamins Florida