Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017

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1 HOSPITAL INPATIENT SERVICES Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017 About this chart: This chart is to be used as a guide only and does not contain all details or exclusions. Actual benefits will be governed by the terms and conditions of the master contract. All benefits are subject to change due to Healthcare Reform Legislation. Anesthesia 50% 100% (acute inpatient rehabilitation not covered) Diagnostic Lab Work and X-rays, Hospital Services, Medical/ Surgical Physician Services, Operating Room Expenses, Physical and Rehabilitation Therapy, and Room, Board, and General Nursing Services Organ Transplant for nonexperimental transplants; pre-authorization 50% ; preauthorization 50% for non-experimental transplants; preauthorization 100%, 365 inpatient days (acute inpatient rehabilitation not covered); pre-authorization for nonexperimental kidney, bone marrow, and cornea transplants; for liver, heart, heart-lung, or pancreas, pre-authorization 100% for kidney, bone marrow, and cornea transplants; for liver, heart, heart-lung, or pancreas, pre-authorization 80% (acute inpatient rehabilitation not covered) $100 deductible per admission, then plan pays 80% up to $1,500 out of pocket maximum per admission, then 100%, 365 inpatient days (acute inpatient rehabilitation not covered); pre-authorization 80% to $1,500, then 100% allowed benefit for nonexperimental transplants; pre-authorization with a maximum of $1 million per transplant HOSPITAL OUTPATIENT SERVICES Chemotherapy $10 copay per visit $10 copay per visit, 50% $10 copay per visit 100% 80% Colonoscopy 50% 100% 80% Diagnostic Lab Work and X-rays 50% 100% 80%

2 HOSPITAL OUTPATIENT SERVICES (continued) Outpatient Surgery 50% 100% 80% Physical & Rehabilitation Therapy $10 copay per visit; combined maximum 60 visits per injury or illness per year for short term care $10 copay per visit; 50%, combined maximum 60 visits per injury or illness per year for short term care $10 copay per visit, 90 visits per therapy type per injury, incident, or condition per year 100% for 100 visits per calendar year for physical, speech, and occupational therapies combined; pre-certification after first 10 visits 80% for 100 visits per calendar year for physical, speech, and occupational therapies combined; pre-certification after first 10 visits Pre-admission Testing 50% $10 copay per visit 100% 80% Radiation Therapy $10 copay per visit office only; facility paid in full $10 copay per visit, 50% of $10 copay per visit 100% 80% COMMON AND PREVENTIVE SERVICES Doctor s Office Visits $5 copay per visit $5 copay per visit, 50% of $5 copay per visit $5 copay per visit $5 copay per visit then 80% of Specialist Office Visits $10 copay per visit $10 copay per visit, 50% of $10 copay per visit $10 copay per visit 80% of Routine GYN Examinations (one per year) $10 copay per visit, 50% of 100% $5 copay per visit then 80% Chlamydia Screening 50% 100% 80% Hearing Exams (PCP) $5 copay per visit (PCP), (screening only) 50% $5 copay for hearing exam (PCP) Hearing screening for newborns covered in full as preventive care services Immunizations 50% when done in conjunction with an office visit $5 copay per visit then 100% with medical diagnosis; one exam every 36 months (routine exams excluded) Included in well baby visits Hepatitis B vaccination covered in full $5 copay per visit then 80% with medical diagnosis; one exam every 36 months (routine exams excluded) Included in well baby visits Hepatitis B vaccination covered in full 2

3 COMMON AND PREVENTIVE SERVICES (continued) Mammography 50% 100% 80% Prostate Screening 50% 100% 80% Routine Physical ; one per year $5 copay per visit; 50% ; one per year Well Baby Care $5 copay per visit, 50% EMERGENCY TREATMENT Ambulance Service Emergency Room, if emergency admitted) 50%, if emergency only admitted) ; limit one per year 100% ; limit one per year $5 copay per visit, 80% 100% $5 copay per visit, 80%, if medically necessary admitted) 100% (air transport not covered) admitted) then 100% Urgent Care Facility $10 copay per visit $10 copay per visit $10 copay per visit $10 copay; 100% allowed benefit MATERNITY Pre- and Post-Natal Care $10 copay for initial visit to determine pregnancy, then 50% $10 copay for initial visit to determine pregnancy, then covered in full 100% (air transport not covered) admitted) then 100% $10 copay; 80% allowed benefit 100% 80% Delivery (inpatient) 50% 100% 80% Newborn Care (inpatient) 50% 100%, 80%, initial initial visit visit 3

4 MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS INPATIENT Alcohol and Substance Abuse Care Mental Health Benefits 50% ; preauthorization 50% ; preauthorization MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS OUTPATIENT Alcohol and Substance Abuse Care (office only) Alcohol and Substance Abuse Care (all other outpatient services) 100% ; precertification 100% ; precertification $100 deductible per admission, then 80% up to $1,500 inpatient out-ofpocket limit maximum per admission then 100%, 365 inpatient days; precertification $100 deductible per admission, then 80% up to $1,500 inpatient out-ofpocket limit maximum per admission, then 100%, 365 inpatient days; precertification $5 copay per visit 50% $5 copay per visit; preauthorization $5 copay per visit 80% 50% $5 copay per visit 100% 80% 4

5 MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS OUTPATIENT (continued) Mental Health Benefits (office only) Mental Health Benefits (all other outpatient services) OTHER SERVICES AND SUPPLIES $5 copay per visit 50% $5 copay per visit (no preauthorization for outpatient mental health) $5 copay 80% 50% $5 copay per visit 100% 80% Allergy Serum 50% Covered under prescription drug plan Diabetic Supplies 50%,, including 100%, including lancets, test lancets, test strips, including lancets, test strips, and glucometers disposable insulin needles, strips, and glucometers and glucometers Insulin Insulin and needles covered in full under prescription drug plan after copay Family Planning and Fertility Testing $10 copay per visit; office visits and diagnostics covered as any other service $10 copay per visit; 50% $10 copay per visit for family planning and fertility testing; 50% for other fertility services; IVF limited to 3 attempts per live birth and $100,000 maximum benefit per lifetime 100% In-vitro fertilization and related outpatient services are covered with the following restrictions: Limited to 3 attempts per live birth Coverage is provided same as physician office services, professional fees, outpatient diagnostic, and therapeutic services Artificial insemination is covered; maximum of 6 cycles per live birth Limited to $100,000 per lifetime Pre-authorization Covered under prescription drug plan 100%, including lancets, test strips, and glucometers 80% 5

6 OTHER SERVICES AND SUPPLIES (continued) Home Health Care Private Duty Nursing (outpatient only) Durable Medical Supplies (such as crutches and wheelchairs) after prior plan approval for skilled care when medically necessary; prior plan approval after prior plan approval Hospice Care (inpatient) limited to 30 days Hospice Care (outpatient) (in lieu of hospitalization) Podiatry Services (nonroutine) Covered as any other office visit Prosthetic Devices (such as artificial limbs) Second Surgical Opinions after prior plan approval 90 days of unlimited visits; 50% after prior plan approval 50% ; prior plan approval 50% ; preauthorization for skilled care when medically necessary; prior plan approval 90 days of unlimited visits; 100% with pre-authorization Mandatory pre-certification and medical necessity; 100% 90 days of unlimited visits; 100% with pre-authorization Mandatory pre-certification and medical necessity; 80% 100% 80% 50% 100% ; preauthorization 50% ; preauthorization (in lieu of hospitalization) $10 copay per visit, 50% $10 copay per visit $10 copay per visit, 50% (in lieu of hospitalization) 50% ; prior authorization, except artificial limbs and artificial eyes; Artificial limbs and artificial eyes $5 per device; prior authorization 100% ; preauthorization $10 copay per visit 100% $10 copay per visit 100% 100% ; preauthorization 100% ; preauthorization 80% 100% allowed amount 100% allowed amount 100% 6

7 OTHER PLAN FEATURES Annual Deductible (plan year) Yearly Out-of-Pocket Maximum (excluding mental and nervous coverage) Lifetime Maximum Benefit Are referrals in this plan? Dependent Eligibility N/A N/A N/A N/A N/A Individual: $6,350 Family: $12,700 N/A Individual: $1,100 Family: $3,600 Includes mental and nervous coverage. The following services do not apply to out-of-pocket maximum: Outpatient drugs, supplies, and supplements, including blood, blood products, and medical foods Inpatient and outpatient infertility services Individual: $6,350 Family: $12,700 Unlimited Unlimited Unlimited Unlimited Unlimited No No Referrals from PCPs are except: standing referrals for certain conditions; no referrals for Outpatient Mental Health, OB/GYN, and eye refraction provided by an Optometrist No N/A No Please note: If you plan to travel overseas, call your health plan for coverage information. 7

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