Excellus BluePPO Signature Deduct 3

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Malcolm Hill
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1 Excellus BluePPO Signature Deduct 3 Drug Coverage Excluded Benefit Time Period: 01/01/ /31/2017 Trinity Health - Syracuse HSA General Cost Sharing Expenses - Single Domestic - $1,300 $2,500 $3,500 - Family Domestic - $2,600 $5,000 $7,000 20% 40% Annual Out of Pocket Maximum - Single Domestic - $2,600 $5,000 $7,000 Annual Out of Pocket Maximum - Family Domestic - $5,200 $10,000 $14,000 Annual Out of Pocket Maximum - Per Person Cap Domestic - $2,600 $5,000 $7,000 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. 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. Office Visit Cost Shares Cost Share - Primary Care Cost Share - Specialist 20% 20% 40% 40% Plan Limits Plan/Calendar Year Diabetic Preauthorization and Step Therapy Calendar Year Benefits Yes 1 of /20/ :27:01

2 Who is Domestic Partner Coverage Inpatient s Inpatient Facility Inpatient Hospital s Mental Health Care Substance Use Detoxification Skilled Nursing Facility Physical Rehabilitation Maternity Care $500 Copayment then 20% 10% 10% $500 Copayment then 20% $500 Copayment then 20% $500 Copayment then 20% 40% 40% 40% 40% 40% 40% 120 Days per contract year Limits are combined Domestic, INN and OON. 60 Days per year Limits are combined Domestic, INN and OON. Inpatient Professional s Inpatient Hospital Surgery Anesthesia 10% 10% 20% 20% 40% 40% 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 Diagnostic X-ray Diagnostic Laboratory and Pathology 20% 20% 20% 40% 40% 40% After $100 Co-pay INN and $200 Co-pay OON 2 of /20/ :27:01

3 Radiation Therapy Chemotherapy Infusion Therapy Dialysis Mental Health Care Substance Use Care Domestic - Inclusive of Primary 20% 20% 20% 10% 10% 40% 40% 40% 40% 40% Is inclusive in the Home Care benefit and not covered as a separate benefit. Includes Partial Hospitalization Includes Partial Hospitalization Home and Hospice Care Home Care Home Care 20% 40% 120 Days per year Limits are combined Domestic, INN and OON. Hospice Care Hospice Care Inpatient Domestic - 0% 0% 40% Outpatient and Office Professional s Professional s Office Surgery Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy 10% 10% 10% 10% 10% 20% 20% 20% 20% 20% 40% 40% 40% 40% 40% 3 of /20/ :27:01

4 Infusion Therapy Dialysis Mental Health Care Maternity Care TeleMedicine Program Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine 10% 10% 10% Not 10% 10% 10% 20% 10% 20% Not 20% 20% 20% 40% 40% 40% Not 40% 40% 40% 40% Is inclusive in the Home Care benefit and not covered as a separate benefit. Not 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. Rehab and Habilitation Outpatient Facility Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 20% 20% 20% 40% 40% 40% occupational therapy. occupational therapy. occupational therapy. Not for learning disabilities and congenital defects unless following surgery. 4 of /20/ :27:01

5 Outpatient Professional s Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 10% 10% 10% 20% 20% 20% 40% 40% 40% occupational therapy. occupational therapy. occupational therapy. Not for learning disabilities and congenital defects unless following surgery. Preventive s Preventive Professional s Meeting Federal Guidelines* Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Pre/Post-Natal Care Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional 40% 40% 40% 40% 40% 40% 40% 40% 1 Exam per 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 40% 40% 40% 40% 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. 5 of /20/ :27:01

6 Preventive services in addition to those required under Federal Guidelines - Professional Prostate Cancer Screening Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional 10% 20% 40% 40% 40% 40% 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 20% 40% 40% 40% 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 Insulin and Supplies Diabetic Equipment Durable Medical Equipment (DME) Medical Supplies Acupuncture Private Duty Nursing 10% 10% 10% 10% Not 10% 20% 20% 10% 20% Not 20% 40% 40% 40% 40% Not 40% No coverage for Insulin and supplies through a pharmacy- covered through Carve-out Rx Vendor - CVS/Caremark Not 120 visits per calendar year PDN not covered in an inpatient hospital or any other health care facility 6 of /20/ :27:01

7 Emergency s ER Facility Facility Emergency Room Visit 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. Transportation Prehospital Emergency and Transportation - Ground or Water 20% 20% DOM $1,300 deduct then 10% coinsurance. Innet $2,500 deduct then 20% coinsurance. OON $3,500 deduct then 20% coinsurance Urgent Care Urgent Care Center Facility Visit 10% 10% DOM $1,300 deduct then 10% coinsurance. Innet $2,500 deduct then 10% coinsurance. OON $3,500 deduct then 10% coinsurance Ancillary Benefits Vision Adult Eye Exams - Routine Domestic - Not Not Not Not Adult Eyewear - Routine Domestic - Not Not Not Not Pediatric Eye Exams - Routine Domestic - Not Not Not Not Pediatric Eyewear - Routine Domestic - Not Not Not Not Rx Benefits Rx Plan Rx Plan Drug Coverage Excluded 7 of /20/ :27:01

8 Rx Benefits Days Supply Per Retail Order Domestic Days Supply Per Mail Order Domestic Copays Per Mail Order Supply Domestic - NA NA 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. 8 of /20/ :27:01

Excellus BluePPO Signature Hybrid 5

Excellus BluePPO Signature Hybrid 5 Drug Coverage Excluded Benefit Time Period: 01/01/2017-12/31/2017 Trinity Health - Syracuse Essential General Cost Sharing Expenses - Single Domestic - $1,000 $2,500