Benefit Name Domestic In Network Out of Network. Benefit Name Domestic In Network Out of Network. 30% Coinsurance Subject to Deductible
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1 Excellus BluePPO $5/$45/$90 Integrated Rx Benefit Time Period: 01/01/ /31/2019 Thompson Health General Cost Sharing Expenses Deductible - Single $1,350 $1,350 $2,700 Deductible - Family $2,700 $2,700 $5,400 Deductible applies to annual OOP maximum. Integrated Rx applies to deductible and OOP maximum. The family deductible is met for all when one or more people on the contract meet the total family deductible. Family equals 2 or more people. Deductible applies to annual OOP maximum. Integrated Rx applies to deductible and OOP maximum. 20% 30% 40% Annual Out of Pocket Maximum - Single $3,000 $3,000 $6,000 Annual Out of Pocket Maximum - Family $6,000 $6,000 $12,000 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. Office Visit Cost Shares Cost Share - Primary Care Cost Share - Specialist 20% 20% 30% 30% 10% subject to deductible for Thompson Health Primary Care Physicians. Plan Limits Plan/Calendar Year Diabetic Preauthorization and Step Therapy Calendar Year Benefits No Who is Domestic Partner Coverage 1 of 8
2 Inpatient s Inpatient Facility Inpatient Hospital s Mental Health Care Substance Use Detoxification Skilled Nursing Facility Physical Rehabilitation Maternity Care 20% 20% 20% 20% 20% 20% 30% 20% 20% 20% 20% 30% 45 Days per year 20% subject to deductible for Thompson Health Providers. Limits are combined INN and OON. 60 Days per year Limits are combined INN and OON. Inpatient Professional s Inpatient Hospital Surgery Anesthesia 30% 30% Assistant surgeon covered only when medically necessary. 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 Radiation Therapy Chemotherapy Infusion Therapy 20% 20% 20% 20% 20% 20% 30% 30% 30% 30% 10% subject to deductible for Thompson Hospital. 10% subject to deductible for Thompson Health Providers. See Advanced Imaging s for PET scans, MRI, nuclear medicine and CAT scans. See Advanced Imaging s for PET scans, MRI, nuclear medicine, and CAT scans. 10% coinsurance subject to deductible for Thompson Health Providers. 10% subject to deductible for Thompson Health Providers. Is inclusive in the Home Care benefit and not covered as a separate benefit. 2 of 8
3 Dialysis Mental Health Care Substance Use Care 20% 20% 20% 20% 20% 20% Includes Partial Hospitalization Includes Partial Hospitalization Home and Hospice Care Home Care Home Care 20% 30% 40 visits per year Limits are combined INN and OON. Hospice Care Hospice Care Inpatient 20% 30% Outpatient and Office Professional s Professional s Office Surgery Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Dialysis Mental Health Care 30% 30% 30% 30% 30% Assistant surgeon covered only when medically necessary. 10% subject to deductible for Thompson Health Providers. See Advanced Imaging s for PET scans, MRI, nuclear medicine, and Cat Scans. 10% subject to deductible for Thompson Health Providers. Is inclusive in the Home Care benefit and not covered as a separate benefit. 3 of 8
4 Maternity Care TeleMedicine Program Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine Not Not 30% 30% Not Not 10% subject to deductible for Thompson Health Providers. Allergy Testing includes injections and scratch and prick tests. 10% subject to deductible for Thompson Health Providers. Includes desensitization treatments (injections & serums). 1 Exam per year 1 Exam per year. Limits are combined INN and OON. Rehab and Habilitation Outpatient Facility Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 20% 20% 20% 20% 20% 20% Outpatient Professional s 4 of 8
5 Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation 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 1 Exam per year Preventive Facility s Meeting Federal Guidelines* Cervical Cytology Preventative Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility Preventive services in addition to those required under Federal Guidelines - Professional 5 of 8
6 Prostate Cancer Screening 30% Mammography Screening Professional Colonoscopy Screening Professional 30% Bone Density Screening Professional 30% Preventive services in addition to those required under Federal Guidelines - Facility Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility 20% 20% 20% 30% Other Benefits Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Equipment Durable Medical Equipment (DME) Medical Supplies Acupuncture Limited to a 90 day supply for retail pharmacy or a 90 day supply for mail order pharmacy. 10 per year Limits combined INN and OON. Private Duty Nursing Not Not Not Not Emergency s ER Facility 6 of 8
7 Facility Emergency Room Visit 20% 20% 20% 20% subject to deductible for Thompson Health Providers. Prior Authorization may not apply to any emergency care services. Emergency services are covered worldwide if provided by a hospital facility. Transportation Prehospital Emergency and Transportation - Ground or Water 20% 20% 20% 20% subject to deductible for Thompson Health Providers. Urgent Care Urgent Care Center Facility Visit 20% 20% 10% subject to deductible for Thompson Health Providers. Ancillary Benefits Vision Adult Eye Exams - Routine 20% 20% 1 exam per year Limits are combined INN and OON. Adult Eyewear - Routine N/A Not Not Not Pediatric Eye Exams - Routine 20% 20% 1 exam per year Limits are combined INN and OON. Pediatric Eyewear - Routine N/A Not Not Not Rx Benefits Rx Plan Rx Plan $5/$45/$90 Integrated Rx Rx Benefits 7 of 8
8 Days Supply Per Retail Order Days Supply Per Mail Order Copays Per Mail Order Supply 2 2 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 8
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