2018 HDHP. Denver Health Medical Plan, Inc. Career Service Employees (CSE) and Denver Employee Retirement Plan (DERP) HighPoint Denver Plus Network

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1 2018 HDHP Denver Health Medical Plan, Inc. Career Service Employees (CSE) and Denver Employee Retirement Plan (DERP) HighPoint Denver Plus Network HighPoint Denver Cofinity Network Out of Network Deductible Individual Family $1,350 per calendar year. $2,700 per calendar year. Applicable to medical care & prescription drug benefits; family deductible includes employee & one or more enrolled family members, no coverage may be paid for any family member unless the family deductible is met. Out-of-Pocket Maximum Individual Family Services received in either tier will accumulate toward this amount. $2,700 per calendar year. $5,400 per calendar year. The out-of-pocket maximum includes the annual deductible, coinsurance and copays. It does not include monthly premiums. Lifetime Maximum Applicable to medical care & prescription drug benefits; family out-of-pocket maximum includes employee & one or more enrolled family members, maximum is not met for any family member unless the family out-of-pocket maximum is met. Services received in either tier will accumulate toward this amount. No lifetime maximum. No lifetime maximum. Covered Providers Medical Office Visits Primary Care Providers (Family Medicine, Internal Medicine and Pediatrics) Specialist Denver Health and Hospital Authority, University of Colorado Hospital, Colorado Pediatric Partners and Children s Hospital Colorado providers and facilities. Columbine network for chiropractic. See online provider directory for a complete list of current providers: find-doctor. Cofinity network providers and facilities. Columbine network for chiropractic. See online provider directory for a complete list of current providers:

2 Preventive Services Children Adults No copayment (100% covered). Preventive Rx is covered at 100%, deductible does not apply. No copayment (100% covered). Preventive Rx is covered at 100%, deductible does not apply. This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF). This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF). Annual well visit, well woman exams, well baby care, prenatal visits; colonoscopy, mammogram. See USPSTF list on our website at Annual well visit, well woman exams, well baby care, prenatal visits; colonoscopy, mammogram. See USPSTF list on our website at Maternity Prenatal and Postnatal Care Visits considered preventive are $0. Cost sharing may apply for additional services. Visits considered preventive are $0. Cost sharing may apply for additional services. Delivery and Inpatient Prescription Drugs Deductible will apply, except for preventive drugs. Deductible will apply, except for preventive drugs. After deductible is met: Denver Health Pharmacy(30-day supply) Preferred Generics: $10 copay Generics & Preferred Brand: $15 copay Non-Preferred Brand: $30 copay Specialty: $30 copay Denver Health Pharmacy or Denver Health Pharmacy by Mail (90-day supply) Generics & Preferred Brand: $30 copay (30-day supply) Generics & Preferred Brand: $40 copay Specialty: $60 copay After deductible is met: (30-day supply) Generics & Preferred Brand: $40 copay Specialty: $60 copay (90-day supply) Preferred Generics: $40 copay Generics & Preferred Brand: $80 copay Non-Preferred Brand: $120 copay For drugs on our approved formulary list, call Member Services at (303) (90-day supply) Preferred Generics: $40 copay Generics & Preferred Brand: $80 copay Non-Preferred Brand: $120 copay For drugs on our approved formulary list, call Member Services at (303)

3 Inpatient Hospital Outpatient/Ambulatory Surgery Diagnostics Laboratory and Radiology Laboratory, X-ray MRI and PET/CT scans Maximum on surgical treatment of morbid obesity of once per lifetime. Other Diagnostic and Therapeutic Services Sleep study Maximum on surgical treatment of morbid obesity of once per lifetime. Radiation therapy Infusion therapy (includes chemotherapy) Injections Renal Dialysis Emergency Care Urgent Care Ambulance will apply (immunizations, allergy shots and any other injection given by a nurse is $0). 20% coinsurance will apply (immunizations, allergy shots and any other injection given by a nurse is $0).

4 Behavioral Health, Mental Health Care and Substance Abuse Outpatient Inpatient Therapies Rehabilitative: Physical, Occupational, and Speech Therapy Habilitative: Physical, Occupational, and Speech Therapy Pulmonary Rehabilitation Cardiac Rehabilitation Durable Medical Equipment Hearing Aids Adults (18 years of age and over) Children (under 18 years of age) Prosthetics Orthotics (Shoe) HighPoint Denver Cofinity Network Out of Network Medically-necessary hearing aids prescribed by a DHMP Medical Care Network provider are covered every five years in network. For adults age 18 and over, once the deductible is met, there is a $1,500 benefit maximum every 5 years. Charges exceeding the $1,500 hearing aid maximum benefit, are the responsibility of the member. Cochlear Implants: the device is covered at 100%, applicable inpatient/outpatient surgery charges Children under age 18 are covered at 100%, deductible does not apply and there is no maximum benefit. Hearing screens and fittings for hearing aids are covered under office visits and applicable cost sharing applies. Hearing aids no longer apply to the annual DME limit. Cochlear implants are covered for children under age 18. Once deductible is met, the device is covered at 100%, applicable inpatient/outpatient surgery charges No maximum benefit. Medically-necessary hearing aids prescribed by a DHMP Medical Care Network provider are covered every five years in network. For adults age 18 and over, once the deductible is met, there is a $1,500 benefit maximum every 5 years. Charges exceeding the $1,500 hearing aid maximum benefit, are the responsibility of the member. Cochlear Implants: the device is covered at 100%, applicable inpatient/outpatient surgery charges Children under age 18 are covered at 100%, deductible does not apply and there is no maximum benefit. Hearing screens and fittings for hearing aids are covered under office visits and applicable cost sharing applies. Hearing aids no longer apply to the annual DME limit. Cochlear implants are covered for children under age 18. Once deductible is met, the device is covered at 100%, applicable inpatient/outpatient surgery charges No maximum benefit. Once the deductible is met, medically necessary orthotics are reimbursed up to $100 per calendar year.

5 Oxygen/Oxygen Equipment Oxygen Equipment Transplants Home Health Care Hospice Care Skilled Nursing Facility Dental Care Deductible then 100% covered. will apply; no maximum benefit. Only covered at authorized facilities. Coverage no less extensive than for other physical illness. Covered transplants include: cornea, kidney, kidney-pancreas, heart, lung, heartlung, liver and bone marrow for Hodgkin s, aplastic anemia, leukemia, immunodeficiency disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer and Wiskott- Aldrich Syndrome only. Peripheral stem cell support is a covered benefit for the same conditions listed above for bone marrow transplants. will apply for prescribed medically necessary skilled home health services. Maximum benefit is 100 days per calendar year at authorized facility. Not covered except for fluoride varnish at PCP visit. Deductible then 100% covered. 20% coinsurance will apply; no maximum benefit. Only covered at authorized facilities. Coverage no less extensive than for other physical illness. Covered transplants include: cornea, kidney, kidney-pancreas, heart, lung, heartlung, liver and bone marrow for Hodgkin s, aplastic anemia, leukemia, immunodeficiency disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer and Wiskott- Aldrich Syndrome only. Peripheral stem cell support is a covered benefit for the same conditions listed above for bone marrow transplants. 20% coinsurance will apply for prescribed medically necessary skilled home health services. Maximum benefit is 100 days per calendar year at authorized facility. Vision Care Chiropractic Maximum 20 visits per calendar year. Services must be provided by Columbine Chiropractic in order to be covered. Maximum 20 visits per calendar year. Services must be provided by Columbine Chiropractic in order to be covered. Note: Acupuncture and massage are not plan benefits but DHMP offers discount programs. The acupuncture discount program is through Columbine Chiropractic. See website for provider listing. DHMP will not pay for acupuncture received at a Columbine Chiropractic office. Member must pay through discount program. DHMP also offers a massage discount through Massage Envy and Massage Heights. See website for details: www. denverhealthmedicalplan.org/premium-perks.

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