Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2015

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1 Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2015 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. HOSPITAL INPATIENT SERVICES 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 HOSPITAL OUTPATIENT SERVICES for nonexperimental transplants; pre-authorization 50% ; preauthorization 50% for non-experimental transplants; preauthorization Chemotherapy $10 copay per visit $10 copay per visit, 50% 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 100% for kidney, bone marrow, and cornea transplants; for liver, heart, heart-lung, or pancreas, pre-authorization with a maximum of $1 million per transplant $10 copay per visit 100% 80% Colonoscopy 50% 100% 80% Diagnostic Lab Work and 50% 100% 80% X-rays

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 $10 copay per visit, 50% of $10 copay per visit 100% 80% only; facility paid in full COMMON AND PREVENTIVE SERVICES Doctor s Office Visits $5 copay per visit $5 copay per visit, 50% of Specialist Office Visits $10 copay per visit $10 copay per visit, 50% of Routine GYN Examinations (one per year) $10 copay per visit, 50% of $5 copay per visit $5 copay per visit $5 copay per visit then 80% of $10 copay per visit $10 copay per visit 80% of $5 copay per visit $5 copay per visit then 80% Chlamydia Screening 50% 100% 80% Hearing Exams (PCP) (screening only) $5 copay per visit (PCP), 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% ; one baseline between ages 35-39; women ages 40-49, one every other year; women age 50 or above, every calendar year in approved facility 80% ; one baseline between ages 35-39; women ages 40-49, one every other year; women age 50 or above, every calendar year in approved facility Prostate Screening 50% 100% 80% Routine Physical ; one per ; limit one year 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), if medically necessary admitted) $5 copay per visit, including all related services; one every 36 months $5 copay per visit, limit of: 4 visits age 0-11 months; 3 visits age months; 1 annual visit age 2-6 years; 1 annual visit age 7-12 years Major medical benefit (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 $5 copay per visit, 80%, including all related services; one every 36 months $5 copay per visit, 80%, limit of: 4 visits age 0-11 months; 3 visits age months; 1 annual visit age 2-6 years; 1 annual visit age 7-12 years Major medical benefit (air transport not covered) admitted) then 100% $10 copay; 80% allowed benefit 3

4 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% 80% Delivery (inpatient) 50% 100% 80% Newborn Care (inpatient) 50% 100%, initial visit 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 80%, initial visit $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 lancets, test strips, and glucometers Insulin Family Planning and Fertility Testing $10 copay per visit; office visits and diagnostics covered as any other service, including lancets, test strips, disposable insulin needles, and glucometers 100%, including lancets, test strips, and glucometers Insulin and needles covered in full under prescription drug plan after copay $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 lifetime 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 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) Podiatry Services (nonroutine) Prosthetic Devices (such as artificial limbs) Second Surgical Opinions (in lieu of hospitalization) Covered as any other office visit 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; major medical benefit Major medical benefit 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% 90 days of unlimited visits; 100% with pre-authorization Mandatory pre-certification and medical necessity; major medical benefit Major medical benefit 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) N/A N/A N/A For major medical expenses only: CUB: $200 per person per policy year Local 44: $200 per person per policy year PSASA: $150 per person BTU: $150 per person PARAS: $200 per person Unaff: $250 per person per policy year 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 Benefit percentage for major medical expenses only: CUB/Local 44: $30,000 paid at 100% of allowed benefit; PSASA: $2,000 paid at 80% of ; BTU: $2,000 paid at 80% of ; thereafter 100% PARAS: $2,000 paid at 80% of ; Unaff: $30,000 paid at 100% of ; For major medical expenses only: CUB: $200 per person per policy year Local 44: $200 per person per policy year PSASA: $150 per person BTU: $150 per person PARAS: $200 per person Unaff: $250 per person per policy year Benefit percentage for major medical expenses only: CUB/Local 44: $30,000 paid at 100% of allowed benefit; ; PSASA: $2,000 paid at 80% of ; BTU: $2,000 paid at 80% of ; thereafter 100% PARAS: $2,000 paid at 80% of ; Unaff: $30,000 paid at 100% of ; 7

8 OTHER PLAN FEATURES (continued) Lifetime Maximum Benefit Are referrals in this plan? Dependent Eligibility 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 No Please note: If you plan to travel overseas, call your health plan for coverage information. 8

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