Physicians Plus Insurance Corporation Coverage Period: 01/01/ /31/2016

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1 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $0 See the chart starting on page 2 for other costs for services this plan covers. Yes. $5,000 Family. Examples include Inpatient Hospital Services, Outpatient Surgical Services and Skilled Nursing. Yes. $6,000 Member/ $12,000 Family Premiums, balance-billed charges, and health care this plan doesn t cover. No Yes. For a list of in-network providers, see or call or Yes. Out-of-network specialists require prior written approval from Physicians Plus. Yes You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay for these expenses, they don t count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use out-of-network providers for some services. Plans use the term in-network, preferred or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission or prior authorization before you see the specialist. Some of the services this plan doesn t cover are listed on page 6. See your policy or plan document for additional information about excluded services. 1 of 12

2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percentage of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need In-network Out-of-network Primary care visit to treat an injury or illness $40 copay/visit None Specialist visit $80 copay/visit None Other practitioner office visit Primary: $40 copay/visit Specialty: $80 copay/visit None Preventive care/screening/immunization No Charge Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Limitations & Exceptions Full coverage only for preventive services (defined by Health Care Reform) Genetic testing requires prior authorization. None 2 of 12

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery Services You May Need Preferred Value Generic drugs Preferred Generic drugs Preferred Brands Preferred Specialty, Brands and Generic Drugs Non-Preferred Specialty Brands and Generic drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees In-network $10 copay/ prescription $30 copay/ prescription $75 copay/ prescription 50% / prescription 50% / prescription Out-of-network Limitations & Exceptions Most medications available for three month supply; some limited to less depending upon formulary status. Most medications available for three month supply; some limited to less depending upon formulary status. Most medications available for three month supply; some limited to less depending upon formulary status. Most medications available for three month supply; some limited to less depending upon formulary status. May require prior authorization and filling within the Specialty Pharmacy Network. May require prior authorization and filling within the Specialty Pharmacy Network. Coverage is limited to medically necessary services. Coverage is limited to medically necessary services. 3 of 12

4 Common Medical Event If you need immediate medical attention If you have a hospital stay Services You May Need Emergency room services Emergency medical transportation In-network $250 copay/visit then $2,500 Member/ $5,000 Family deductible then 20% Out-of-network $250 copay/visit then $2,500 Member/ $5,000 Family deductible then 20% Urgent care $100 copay/visit None Facility fee (e.g., hospital room) Physician/surgeon fee Limitations & Exceptions Coverage is limited to emergency care. Copay is waived if admitted inpatient. Coverage is limited to emergency care. Prior authorization required. Prior authorization required. 4 of 12

5 Common Medical Event If you have mental health, behavioral health or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need In-network Out-of-network Mental/Behavioral health outpatient services $40 copay/visit Mental/Behavioral health inpatient services Substance use disorder outpatient services $40 copay/visit Substance use disorder inpatient services Limitations & Exceptions For provider and benefit information, call (608) Prior authorization required. For provider and benefit information, call (608) Prior authorization required. Prenatal and postnatal care No Charge None Delivery and all inpatient services Prior authorization required. Home health care Rehabilitation services Habilitation services Coverage is limited to 60 combined visits annually. Prior authorization required. Policy pays up to 50 combined rehabilitation and habilitation therapy visits annually. Prior authorization required. Policy pays up to 50 combined rehabilitation and habilitation therapy visits annually. Prior authorization required. 5 of 12

6 Common Medical Event If your child needs dental or eye care Services You May Need Skilled nursing care Durable medical equipment Hospice service Eye exam Glasses In-network Primary: $40 Specialty: $80 copay/visit Basic model: No charge (up to age 18) Out-of-network Dental check-up Limitations & Exceptions Coverage is limited to 30 days annually. Prior authorization required. Prior authorization required for items over $750. Prior authorization required. Limited to one routine exam annually. Other exams covered as medically necessary. One basic model covered annually for children to age 18. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric Surgery Cosmetic Surgery Dental Care (Adult) Dental Care (Child) Glasses, Lenses and Frames (Adult) Infertility Treatment Long Term Care Non-Emergency care when traveling outside the United States Private Duty Nursing Routine Foot Care Weight Loss Programs 6 of 12

7 Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic Care Hearing Aids (Limited) Routine eye care Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area For more information on your rights to continue coverage, contact Physicians Plus Insurance Corporation at or You may also contact your state insurance department at the Wisconsin Office of the Commissioner of Insurance at or or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, coverage or assistance, please contact: Physicians Plus Insurance Corporation at or You may also contact the Wisconsin Office of the Commissioner of Insurance at or or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. 7 of 12

8 Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al ( ) Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa ( ) Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 ( ) Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' ( ) To see examples of how this plan might cover costs for a sample medical situation, see the next page. 8 of 12

9 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $3,920 Patient pays $3,620 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $2,500 Copays $60 Coinsurance $910 Limits or exclusions $150 Total $3,620 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $2,260 Patient pays $3,140 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $2,500 Copays $400 Coinsurance $160 Limits or exclusions $80 Total $3,140 9 of 12

10 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 10 of 12

11 SUMMARY OF BENEFITS Plan Name: 2016 HMO Silver Medical Plan: FY402520AC 2500D 20 COINS OV 40 Certificate: 2016 Individual HMO ACA Pharmacy Plan: AY13755M6000TM Important: All Items with an asterisk (*) require prior authorization from Physicians Plus for coverage. Questions? Call Member Services at (608) or (800) Benefit Overview In-Network s, You Pay Notes Per Member Per Family Medical Deductible $2,500 $5,000 Medical Coinsurance 20% 20% Overall Maximum Out-of-Pocket (MOOP) $6,000 $12,000 Includes Deductible, Copays and Coinsurance Office Visits In-Network s, You Pay Notes Preventive $0 Only for preventive services defined by Health Care Reform Office Visit, Primary Care $40 Copay Includes PCP, Chiropractic and OB/GYN visits Office Visit, Specialty Care $80 Copay Immediate/Urgent Care $100 Copay Behavioral Health/Alcohol and Other Drug For provider and benefit information, call $40 Copay Abuse (BH/AODA) Behavioral Health Management at (608) Hearing/Vision Exam, Primary Care $40 Copay Examples: PCP hearing exam/optometry Hearing/Vision Exam, Specialty Care $80 Copay Examples: Audiology, ENT/Ophthalmology Other Medical Services In-Network s, You Pay Notes Office Surgery Diagnostic Testing, Labs and X-rays *Genetic Testing requires prior authorization Allergy Testing and Injections High-Tech Radiology Includes MRI, MRA, CT/CAT, PET scans and nuclear medicine scans Sleep Study (Home or Facility) *Durable Medical Equipment (DME) and Supplies Items over $750 require prior authorization Hearing Aids One basic aid per ear every 36 months Oral Surgery *Orthognathic Surgery requires prior authorization Coverage is 50 combined visits per calendar year *Therapies for physical, occupational, speech, habilitative, rehabilitative and home therapy *Home Health Services Coverage is limited to 60 visits per calendar year Home Hospice Cardiac Rehabilitation Coverage is limited to 36 visits per cardiac event Radiation Therapy Infusion Therapy *Certain infusions require prior authorization Emergency Services In-Network s, You Pay Notes Emergency Room (ER) $250 Copay then Deductible then 20% Coinsurance Coverage is limited to emergency care Ambulance, Ground Coverage is limited to emergency care Ambulance, Air Coverage is limited to emergency care This is a summary of the benefit plan and is not representative of all details of the plan. Please consult the Medical Certificate of Coverage for complete descriptions of the services, supplies, limits, exclusions and other terms and requirements of coverage. The Medical Certificate of Coverage and directory of network providers is available at P

12 SUMMARY OF BENEFITS Plan Name: 2016 HMO Silver Medical Plan: FY402520AC 2500D 20 COINS OV 40 Certificate: 2016 Individual HMO ACA Pharmacy Plan: AY13755M6000TM Important: All Items with an asterisk (*) require prior authorization from Physicians Plus for coverage. Questions? Call Member Services at (608) or (800) Inpatient Services In-Network s, You Pay Notes *Surgeries/Hospital Stays/Hospice/ Other Inpatient Services *Behavioral Health/Alcohol and Other Drug Abuse (BH/AODA) Labor and Delivery Please notify us within 48 hours *Skilled Nursing Facility Coverage is limited to 30 days per calendar year *Transplant Services Cost Depends on Type of Service Outpatient & Surgery Center In-Network s, You Pay Notes Surgeries/Procedures/Ancillary/ *Certain surgeries require prior authorization; see Facility Medical Certificate for details Colonoscopy Pharmacy Benefit Overview Formulary Name Five Tier Premier Pharmacy Network Standard Retail with Mail Order and Specialty Pharmacy Limits Prior authorization, quantity limits, step therapy, age restrictions and other limits may apply Prescription Drugs, Insulin & Mail Order Benefit: You You pay, for a 30-day supply You pay, for a 90-day supply Disposable Diabetic Supplies¹ pay, for a 90-day supply ACA Preventive Medications $0 $0 $0 Tier 1: $ Preferred Value Generics $10 Copay $30 Copay $25 Copay Tier 2: $$ Preferred Generics $30 Copay $90 Copay $75 Copay Tier 3: $$$ Preferred Brands $75 Copay $225 Copay $ Copay Tier 4: $$$$ Preferred Specialty, Brands and Generics 1 50% Coinsurance Tier 5: $$$$$ Non-Preferred Generics, Brands and 50% Coinsurance 50% Coinsurance 50% Coinsurance Specialty 1 Formulary Insulin, Preferred $75 Copay $225 Copay $ Copay Formulary Insulin, Non-Preferred Formulary Disposable Diabetic Supplies, Preferred 20% Coinsurance 20% Coinsurance 20% Coinsurance 1 Preferred and Non-Preferred Specialty medications limited to a one-month supply. May require filling within the Physicians Plus Specialty Pharmacy Network. Refer to your Formulary documents for more information. Select medications, insulin and supplies may require prior authorization (PA) through the PA exception process for coverage and application to the Deductible and MOOP. If a PA is denied or not obtained, the member will be responsible for the full cost of the drug. For a list of formulary drugs, tier ($) placement, prior authorization requirements and other limitations that may apply, please refer to your formulary at Please contact Pharmacy Services at (608) or (800) with questions or comments. This is a summary of the benefit plan and is not representative of all details of the plan. Please consult the Medical Certificate of Coverage for complete descriptions of the services, supplies, limits, exclusions and other terms and requirements of coverage. The Medical Certificate of Coverage and directory of network providers is available at P

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