BluePoint 3 Benefit Time Period: 06/01/2015-05/31/2016 Broome County - Red HMO Plan General Information Cost Sharing Expenses Deductible - Single $0 Deductible - Two Person $0 Deductible - Family $0 Services that Apply to Deductible Deductible Aggregation - Single and Family Deductible Aggregation - In Network and Out of Network Medical Only Individual In Network & Out of Network aggregate together Deductible Carryover Months History Credit Coinsurance 0% Annual Out of Pocket Maximum - Single $4,425 $4,425 Annual Out of Pocket Maximum - Two Person $8,845 $8,845 Out-of-pocket maximums accumulate the coinsurance amount, medical copays, and include the deductible, if applicable. Annual Out of Pocket Maximum - Family $8,845 $8,845 Services that Apply to Out of Pocket Maximum Annual Out of Pocket Maximum Aggregation - Single and Family Annual Out of Pocket Maximum Aggregation - In Network and Out of Network Medical Only Individual In Network & Out of Network aggregate together Office Visit Cost Shares Cost Share - Primary Care $15 Cost Share - Specialist $15 Plan Limits Limits Aggregation - In-network and Out of Network In Network & Out of Network aggregate together Annual Maximum Lifetime Benefit Maximum Unlimited Unlimited 1 of 11 577759-1 06/24/2015 03:15:26
Kids Copay Age Limit Kids Copay Age Applies To Kids Copay Network Referrals Required Does t Apply Does t Apply ne Employer Deductible Funding Percentage 0% HSA vs HRA Plan/Calendar Year Coordination of Benefits Prior Authorization PreCertification PreCertification Penalty Does t Apply Calendar Year Benefits Made Whole Applies Does t Apply Does t Apply Who is Type of Tiers Dependent Coverage Dependent Age End Period Domestic Partner Coverage 2 Tier (EE / FAM) Age to which all dependents (excluding spouse) are covered Dependent To Age 26 Age to which all dependents (excluding spouse) are covered End of Month Additional Group Characteristics Total Employees Total Eligible Group Size Funding Arrangement Retiree Only Sovereign Nation Religious Group Grandfathered ASC 2 of 11 577759-1 06/24/2015 03:15:26
Inpatient Services Inpatient Facility Inpatient Hospital Services in Mental Health Care in 30 Days per year Mental Health Residential Care in 30 Days per year Substance Use Detoxification in 7 Days per year Substance Use Rehabilitation Substance Use Residential Care Skilled Nursing Facility in 45 Days per year Physical Rehabilitation in 60 Days per year Maternity Care in Routine Newborn Nursery Care in Prosthetic - Implanted Devices in Subject to 20% when not rendered in an inpatient setting Mastectomy in Observation Stay in Inpatient Professional Services Inpatient Hospital Surgery Anesthesia In Hospital Physician Visits and Consults Outpatient Facility Services Outpatient Facility Services SurgiCenters and Freestanding Ambulatory Centers Surgical Care $15 Preadmission Pre-Operative Testing in Diagnostic X-ray in Routine X-ray in Advanced Imaging Services in Diagnostic Laboratory and Pathology in Routine Laboratory and Pathology in 3 of 11 577759-1 06/24/2015 03:15:26
Diagnostic Testing in Radiation Therapy $15 Chemotherapy $15 Infusion Therapy Inclusive of Primary Service Is inclusive in the Home Care Benefit and not covered as a separate benefit. Dialysis $15 Injectable Drugs Inclusive of Primary Service Excludes vaccines, allergy injections & treatment of diabetes. Cost share is inclusive of services in which the injection is rendered with. Mental Health Care $15 20 Visits per calendar year Substance Use Care $15 Autism Applied Behavior Analysis Substance Use Family Counseling $15 This benefit is included in the 60 visits per year for Substance Use Care. Pulmonary Rehabilitation $15 Cardiac Rehabilitation $15 Home and Hospice Care Home Care Home Care in Hospice Care Hospice Care Inpatient in 210 Days Per Lifetime Hospice Care Outpatient in 210 Days Per Lifetime Family Bereavement in 5 Visits per year Outpatient and Office Professional Services Professional Services Outpatient Hospital and Ambulatory Surgery Office Surgery Diagnostic X-ray Routine X-ray 4 of 11 577759-1 06/24/2015 03:15:26
Advanced Imaging Services Diagnostic Laboratory and Pathology Routine Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Dialysis Injectable Drugs Mental Health Care Substance Use Treatment Maternity Care Autism Applied Behavior Analysis Additional Surgical Opinion Second Medical Opinion for Cancer Pulmonary Rehabilitation Office Visits - Diagnostic Medications Administered in Office Eye Exams Diagnostic Hearing Evaluations Diagnostic Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine Adult Hearing Aids PCP / Specialist - Inclusive of Primary Service PCP / Specialist - Inclusive of Primary Service PCP / Specialist - t PCP / Specialist - t PCP / Specialist - t Is inclusive in the Home Care benefit and not covered as a separate benefit. Excludes vaccines, allergy injections & treatment of diabetes. Cost share is inclusive of services in which the injection is rendered with. 20 Visits per Calendar Year 60 visit max per calendar year $15 for initial visit, remainder in Pediatric Hearing Aid Age Limit Does t Apply Pediatric Hearing Aids Cochlear Implants PCP / Specialist - t Subject to 20% when not rendered in an inpatient setting 5 of 11 577759-1 06/24/2015 03:15:26
Rehab and Habilitation Outpatient Facility Physical Rehabilitation $15 Occupational Rehabilitation $15 Speech Rehabilitation $15 Physical Habilitation $15 Occupational Habilitation $15 Speech Habilitation $15 Outpatient Professional Services Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation Physical Habilitation Occupational Habilitation Speech Habilitation Preventive Services Outpatient Facility and Professional Provider Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Cervical Cytology Preventative in 1 Exam per year includes associated labs and x-rays and appropriate routine immunizations 6 of 11 577759-1 06/24/2015 03:15:26
Prostate Cancer Screenings Mammography Preventive Facility in Mammography Preventive Professional Bone Density Testing Facility in Bone Density Testing Professional Colonoscopy Screening Facility in Colonoscopy Screening Professional Family Planning Pre/Post-Natal Care All Routine in. Other Benefits Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Education Diabetic Equipment Autism Assistive Communication Device Autologous Blood Banking Durable Medical Equipment (DME) Mastectomy Prosthesis Orthotics Foot Orthotics Prosthetic - External Benefit Prosthetic - Wigs External Benefit Medical Supplies Acupuncture Private Duty Nursing PCP / Specialist - t PCP / Specialist - t PCP / Specialist - 20% Coinsurance PCP / Specialist - 20% Coinsurance PCP / Specialist - 20% Coinsurance PCP / Specialist - t PCP / Specialist - 20% Coinsurance PCP / Specialist - t PCP / Specialist - 20% Coinsurance PCP / Specialist - t PCP / Specialist - t 20% or $15, whichever is Less 20% or $15, whichever is Less 7 of 11 577759-1 06/24/2015 03:15:26
Diagnoses Accidental Dental PCP / Specialist - Included Dental Oral Surgery PCP / Specialist - Included Temporomandibular Joint (TMJ) PCP / Specialist - t Nutritional Counseling PCP / Specialist - Included Nutritional Counseling is covered in full Inherited Metabolic Disorder - PKU PCP / Specialist - Included Infertility Care PCP / Specialist - Included Organ and Bone Marrow Transplants PCP / Specialist - Included Elective Sterilization PCP / Specialist - Included Interruption of Pregnancy PCP / Specialist - Included Custom Professional Smoking Cessation Emergency Services ER Facility OP Facility Emergency Room Visit $50 $50 ER Professional Physician Emergency Room Visit in Transportation Prehospital Emergency Services Transportation in in Air Ambulance Water Ambulance Urgent Care Facility Urgent Care Center Facility Visit $50 8 of 11 577759-1 06/24/2015 03:15:26
Urgent Care Professional Physician Urgent Care Center Visit Physician Office Visit for Urgent Care Total Health Management Programs Medical Management Services Case Management Program Case Management Behavioral Health Program Disease Management Program Health Promotion Incentive Programs Benefit Name Applies Additional Information Gym Membership Reimbursement Exercise Rewards HealthyRewards/ActiveRewards BlueHealthyDollars/UniveraFit Dollars Blue4U Other Incentive Plan Earn up to $600 per family per contract year for fitness facility memberships in this offline program by tracking 50 visits in a 6-month period. The program also includes free online tools to help in meeting wellness goals. Vision and Dental Vision Adult Eye Exams - Routine $15 1 Exam every 2 years Adult Eyewear - Routine Pediatric Vision Age Limit Does t Apply Pediatric Eye Exams - Routine $15 1 Exam every 2 years Pediatric Eyewear - Routine 9 of 11 577759-1 06/24/2015 03:15:26
Dental Adult Dental Pediatric Dental Age Limit 19 Pediatric Dental - Emergency Care Pediatric Dental - Preventive $15 Periodic exams, x-rays, cleanings, fluoride treatments. and sealants - Children up to age 19 Pediatric Dental - Routine Pediatric Dental - Endodontic Pediatric Dental - Prosthodontics Pediatric Dental - Orthodontics Exclusions Exclusions Benefit Name Convalescent and Custodial Care Cosmetic Services Dental Services Experimental or Investigational Treatment Felony Participation Government Facility Medicare or Other Governmental Program Military Service -Fault Automobile Insurance Services t Listed Services with Charge War Workers Compensation Excluded Rx Benefits Rx Plan Rx Plan DRUG COVERAGE EXCLUDED 10 of 11 577759-1 06/24/2015 03:15:26
Rx Benefits $0 Generics for Kids Generics for Kids Age Limit MAC Penalty Step Therapy Prior Authorization Oral Contraceptives Mandatory MO for Maintenance Drugs Days Supply Per Retail Order Days Supply Per Mail Order Copays Per Mail Order Supply Deductible Family Deductible Deductible applies to Embedded Rx Annual benefit maximum Benefit maximum applies to OOP Maximum OOP Maximum Applies to Does not apply Subject to Deductible Subject to Deductible The group has reviewed the benefit grid 577759-1 and accepts the benefits as indicated. Signature of Group Administrator: Date: This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined by theterms 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. 11 of 11 577759-1 06/24/2015 03:15:26