Benefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information
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1 Excellus BluePPO Benefit Time Period: 01/01/ /31/2016 COLGATE UNIVERSITY Cost Sharing Expenses Deductible - Single $250 $750 Deductible - Family $750 $2,250 0% 30% Annual Out of Pocket Maximum - Single $4,600 $1,750 Annual Out of Pocket Maximum - Family $9,200 $5,250 Office Visit Cost Shares Each individual does not exceed the single deductible. 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. Cost Share - Primary Care Cost Share - Specialist Cost Share - Sick Kids Plan Limits $20 Copayment $20 Copayment Plan/Calendar Year Who is Covered Calendar Year Benefits Domestic Partner Coverage Inpatient Facility Inpatient Hospital Services Substance Use Detoxification Skilled Nursing Facility Maternity Care Yes 45 Days per year 60 Days per year 1 of /22/ :58:41
2 Inpatient Professional Services Inpatient Hospital Surgery Anesthesia Outpatient Facility Services Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. SurgiCenters and Freestanding Ambulatory Centers Surgical Care Diagnostic X-ray Diagnostic Laboratory and Pathology 0% 0% 0% Infusion Therapy Inclusive of Primary Service Inclusive of Primary Service Dialysis Substance Use Care Home Care Advanced Imaging Services includes PET scans, MRI, nuclear medicine, and CAT scans. Is inclusive in the Home Care benefit and not covered as a separate benefit. Includes Partial Hospitalization Includes Partial Hospitalization Home Care Hospice Care $50 Copayment 25% Subject to $50 Deductible Hospice Care Inpatient Professional Services Office Surgery Diagnostic X-ray Diagnostic Laboratory and Pathology Infusion Therapy Inclusive of Primary Service Inclusive of Primary Service Is inclusive in the Home Care benefit and not covered as a separate benefit. Dialysis Maternity Care Chiropractic Care PCP / Specialist - PCP / Specialist - PCP / Specialist - 2 of /22/ :58:41
3 Allergy Testing Allergy Treatment Including Serum PCP - $20 Copayment Specialist - PCP / Specialist - Hearing Evaluations Routine PCP / Specialist - Not Covered Not Covered Not Covered Outpatient Facility Allergy Testing includes injections and scratch and prick tests. Includes desensitization treatments (injections & serums). Occupational Rehabilitation Speech Rehabilitation Outpatient Professional Services 0% 0% 0% Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. Occupational Rehabilitation Speech Rehabilitation Outpatient Facility and Professional Provider Includes aggregate of visits for INN and OON and professional and facility covered services for physical, speech, and occupational therapy. Adult Physical Examination PCP / Specialist - Adult Immunizations PCP / Specialist - Not Covered Well Child Visits and Immunizations PCP / Specialist - Routine GYN Visit Cervical Cytology Preventative Prostate Cancer Screenings Mammography Preventive Facility Mammography Preventive Professional Bone Density Testing Facility Bone Density Testing Professional Colonoscopy Screening Facility Colonoscopy Screening Professional Pre/Post-Natal Care PCP / Specialist - PCP / Specialist - PCP / Specialist - PCP / Specialist - PCP / Specialist - PCP / Specialist - 3 of /22/ :58:41
4 Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Equipment Durable Medical Equipment (DME) Medical Supplies Acupuncture PCP / Specialist - $20 Copayment PCP / Specialist - $20 Copayment PCP / Specialist - 20% PCP / Specialist - 20% PCP / Specialist - 50% 50% Private Duty Nursing PCP / Specialist - Not Covered Not Covered Not Covered ER Facility Limited to a 30 day supply for retail pharmacy or a 90 day supply for mail order pharmacy. 10 Visits Per Contract Year OON: Deductible, then 50% OP Facility Emergency Room Visit $100 Copayment $100 Copayment Transportation Prior Authorization may not apply to any emergency care services. Emergency services are covered worldwide if provided by a hospital facility. Prehospital Emergency Services Transportation Urgent Care Facility Urgent Care Center Facility Visit Vision Adult Eye Exams - Routine Adult Eyewear - Routine Not Covered Not Covered Not Covered Pediatric Eye Exams - Routine Pediatric Eyewear - Routine Not Covered Not Covered Not Covered Rx Plan Rx Plan Rx Benefits Days Supply Per Retail Order 30 Days Supply Per Mail Order 90 Copays Per Mail Order Supply 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 Services coverage required by the Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive Services Task Force list of items and services rated "A" or "B" that are covered pursuant to the Patient Protection and Affordable Care Act requirements. 4 of /22/ :58:41
5 Get the most value from your pharmacy benefit. Go generic Generic drugs usually have a lower copay. Many brand-name drugs have FDA-approved generics that are safe and effective. Ask your doctor if there is a generic medicine for you. Shop around Use the website and mobile app to compare costs before you fill a prescription. Stay in-network Network pharmacies offer the best value. Use the website or mobile app to find a nearby network pharmacy. Get delivery Home delivery of long-term medicine usually costs less than going to a retail pharmacy. Avoid lines, save gas and let us remember the refills for you. BriovaRx Specialty Pharmacy Highly personalized service for complex conditions including cancer, rheumatoid arthritis, Multiple Sclerosis and more. Visit BriovaRx.com Diabetic support program Your plan offers free support and low cost supplies for diabetes management. Visit libertymedical.com/catamaran/home YOUR HEALTH is in YOUR HANDS Every day you make dozens of choices that affect your health. Our online and mobile tools help make some of those choices easier. Use these tools to: Find the lowest copay for your medications Order refills of your mail order prescriptions Set medication reminders Always have a list of your current medications available Manage prescriptions for family members Locate a pharmacy near you Get the App Scan the QR code or search for OptumRx/ CatamaranRx at the Apple App Store or the Google Play Store. Questions? Get help 24/7. Go online or call member services find the website and phone number on your ID card. optumrx.com/mycatamaranrx
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