ROCHESTER INSTITUTE OF TECHNOLOGY 2014 Medical Benefits Comparison Chart Medicare-Eligible Retirees in the Rochester Area

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1 Contacting the Carrier Voice: (877) TTY: (585) Website: Voice: (800) TTY: (800) Website: Deductible Carry Over None None Deductible, Coinsurance, Annual Out of Pocket Maximum No annual deductible. $3,400 out of pocket maximum (excludes prescription drugs). Coinsurance only applies to benefits noted. No annual deductible. Coinsurance only applies to benefits notes $4,000 annual out of pocket maximum (excludes Part D prescription drug costs, acupuncture, eyewear, hearing aids). Services (sorted alphabetically) Acupuncture Covered at 50% for up to 10 visits per member per calendar Covered at 50% for up to 10 visits per member per calendar year. year. Allergy Tests & Injections $20 copay per visit. $15 copay per Primary Care Physician. $30 copay per Specialist visit. Serum covered in full. Ambulance $50 copay. $100 copay per service when medical treatment is required Chemical Dependence-Inpatient Chemical Dependence-Outpatient Chemotherapy Chiropractic Services ROCHESTER INSTITUTE OF TECHNOLOGY Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 2 copays per calendar year, or $500). 20% coinsurance per visit. during transportation. Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). $30 copay per visit. $20 copay per visit. $30 Office copay & $30 Admin Copay per visit (professionally administered). $20 copay per visit (manual manipulation to correct $20 copay per visit; for manual manipulation of the spine subluxation). only. Rochester Institute of Technology -1- Medicare-Eligible Plans-Rochester Area 2014

2 Dental Covered when related to an accidental injury to sound, $30 copay; when related to an accidental injury to sound, natural teeth. natural teeth. Durable Medical Equipment Covered at 80% with no deductible at network providers. Covered at 80% with no deductible at network providers. (DME) Emergency Care $50 copay; waived if admitted within 23 hours. $65 copay medical emergencies; waived if admitted. $20 copay for routine eye exams, annually. $100 material $30 copay for routine and diagnostic eye exams, once per allowance for eyeglasses and contact lenses every year, year. Eyeglasses after cataract surgery: Covered at 80%. Eye Exams and Eyewear including 25% discount at participating providers. Routine eye wear purchase: $100 eyewear allowance every Eyeglasses covered in full after cataract surgery. Glaucoma two years at network providers. Additional discounts may screening covered in full. apply, consult provider. Health and Wellness Silver&Fit is an exercise program that gives you the choice of: - Membership in a fitness club/exercise center ($25 annual fee) - Home Fitness Program ($10 annual fee) - $150 annual reimbursement toward paid membership at non-participating fitness clubs/exercise centers. Blue 365: Exclusive online discounts to health related products and services Up to $100 annually to Health Dollars to use toward health programs such as weight loss and smoking cessation. Any unused dollars do not carry over to the next calendar year. The SilverSneakers Fitness Program provides free fitness center membership benefits at a participating fitness center near you, including use of equipment and other amenities, at no charge. Members also receive free health education programs and support services to help you improve or maintain your health and independence, including classes on exercise and fitness, healthier eating, improving memory, preventing falls and improving balance, skills for living with diabetes, grief support, living with a chronic condition, and more. Rochester Institute of Technology -2- Medicare-Eligible Plans-Rochester Area 2014

3 Hearing Evaluations & Hearing $20 copay per visit for exam, and $300 Hearing Aid Routine Hearing Evaluations covered with a $30 copay. Aids allowance every 3 years. $600 Hearing Aid allowance every 3 years. Home Health Care Covered in full when medically necessary and approved in Covered in Full. advance. Hospice Covered in full by Medicare. Covered in full by Medicare. $50 copay Hospital Observation Stay: $60 per stay, copay waived if Hospital-Outpatient admitted as Inpatient. Emergency Rm copay waived if sent surgery/observation to Observation. Hospital Pre-admission Testing Covered in full. Covered in full. Hospital Services-Inpatient $250 copay per admission (limit 2 copays per calendar year or $500). Services include physician visits, anesthesia and surgery. $250 copay per admission (limit 3 copays per calendar year or $750). Services include physician visits, anesthesia, laboratory and surgery. Laboratory & Pathology Covered in full. Diagnostic covered in full, $10 copay Maintenance. Mental Health-Inpatient Covered with a $250 copayment, maximum of two visit per year. Up to 190 days of non-renewable coverage per lifetime in psychiatric hospital. Unlimited days of acute hospital and physician care subject to the inpatient copay of $250. (Limit 2 copays per calendar year, or $750). Up to 190 days of non-renewable coverage per lifetime to psychiatric hospital. Mental Health-Outpatient 20% coinsurance. No maximum number of visits. Covered with $30 copay. No maximum number of visits. MRI, PET, CAT Scans $20 copay. $60 copay. Occupational Therapy $20 copay per visit. $30 copay per visit. The plan will pay a maximum of $1,900 per calendar year for occupational, physical, and speech therapy, combined. Rochester Institute of Technology -3- Medicare-Eligible Plans-Rochester Area 2014

4 Coverage provided worldwide; urgent or emergent care is Worldwide Coverage for emergency care covered as innetwork; covered as if you are in-network. Routine care can be Nationwide coverage for urgent care. In addition, provided as an out of network benefit with no referrals. The the out of network benefit allows you to go anywhere in the out of network benefit covers routine care when you are U.S. for routine and elective services. Examples of covered outside the plan service area for up to six months. There is services out of network include: office visits, lab, x-ray, Out of Area Coverage no deductible and you pay 20% coinsurance for covered mammograms, chiropractic care, durable medical services and the plan pays 80%. Up to a total of $5,000 of equipment, physical, speech and occupational therapies, out of network services are covered per year (i.e., you pay hospitalization (prior authorization required), outpatient up to $1,000, the plan pays up to $4,000). surgery (prior authorization required). There is no deductible, you pay 30% coinsurance for covered services and the plan pays 70%, up to a maximum of $5,000 per Physician Visit In Office, Diagnostic (ill or injured) Physician Visits In Office, Routine Preventive Services $20 copay for Primary Care Physician and $20 copay for Specialist visit. Periodic routine physicals, annual pelvic exam, Pap Smear, periodic routine mammograms and bone density screening, colorectal screening, prostate cancer screening covered in full. Immunizations (flu, pneumococcal, Hepatitis B, and other vaccines if patient is at risk) covered in full. year. $15 copay per Primary Care Physician. $30 copay per Specialist visit. Annual routine physicals, annual pelvic exam, Pap Smear, and periodic routine mammograms covered in full. Pneumococcal, Influenza and Hepatitis B vaccinations or immunizations covered in full. Office visit copay may apply. $20 copay per visit. $30 copay per visit. The plan will pay a maximum of $1,900 Physical Therapy per calendar year for occupational, physical, and speech therapy, combined. Podiatry (medically necessary) $20 copay per visit. $30 copay per visit. Rochester Institute of Technology -4- Medicare-Eligible Plans-Rochester Area 2014

5 Local Pharmacy: Short-term and maintenance medication can be purchased at the local pharmacy with the copay amounts as follows. amounts as follows. Prescription Drugs Covered Under Medical Plan Mail Order Maintenance: Certain types of medications can be purchased by mail order in up to a 90-day supply for the copays shown below. If you purchase a 90-day supply at the local retail pharmacy, the copay will be 3 times the 30- day supply copay amount. Local Pharmacy: Short-term and maintenance medication can be purchased at the local pharmacy with the copay Mail Order Maintenance: Certain types of medications can be purchased by mail order in up to a 90-day supply for the copays shown below. If you purchase a 90-day supply at the local retail pharmacy, the copay will by 3 times the 30- day copay amount. NOTE: the 90-day copays are for Mail Order only (mail order pharmacy with Express Scripts). RETAIL MAIL ORDER RETAIL MAIL ORDER 30-day supply 90-day supply 30-day supply 90-day supply Tier 1: $10 $30 Tier 1: $10 $20 generic generic Tier 2: $30 $90 Tier 2: $30 $60 formulary formulary Tier 3: $50 $150 Tier 3: $60 $120 non-formulary non-formulary Tier 4: Not applicable, covered in Tier 2 or Tier 3 Tier 4: $60 $120 specialty Tier 5: Not applicable, covered in Tier 1 Tier 5: $0 $0 select generics Medicare Part B drugs you pay 20% coinsurance. Diabetic supplies, you pay $20 copay for 30-day supply. Medicare Part B drugs you pay 20% coinsurance. Diabetic supplies you pay 10% coinsurance. Rochester Institute of Technology -5- Medicare-Eligible Plans-Rochester Area 2014

6 Coverage Gap (donut hole) : When total drugs costs paid by both you and Excellus BCBS reach $2,850, you continue to pay the copays listed above. Coverage for the generic drugs will be provided by the Part D plan. Coverage for the brand name drugs will be provided by a wraparound group health plan. Prescription Drugs Covered Under Medical Plan (cont'd) Catastrophic Coverage : If your total copays during a calendar year reach $4,550, then for the rest of the calendar year, you will pay reduced copays as follows: Coverage Gap (donut hole): When total drugs costs paid by both you and MVP reach $2,850, you continue to pay the copays listed above or less. Catastrophic Coverage: If your total copays during a calendar year reach $4,550, the rest of the calendar year, you will pay reduced copays as follows: Generic the greater of 5% of the drug s cost or $2.55 Generic the greater of 5% of the drug s cost or $2.55 Brand Name the greater of 5% of the drug s cost or $6.35 Brand Name the greater of 5% of the drug s cost or $6.35 This provision applies to drugs purchased at both retail and mail order pharmacies. This provision applies to drugs purchased at both retail and mail order pharmacies. In cases of selected brand name drugs where an FDAapproved generic is available, your benefit will be based on the generic drug s cost. If you or your doctor choose the brand-name drug, you will have to pay the difference, plus any applicable copays. If your prescription does not have an approved generic substitute, your benefit will not be affected. Private Duty Nursing Not Covered Not Covered Prosthetics (External) and Orthopedic Braces and Supports Covered at 80% with no deductible at network providers. Covered at 80% with no deductible at network providers. Rochester Institute of Technology -6- Medicare-Eligible Plans-Rochester Area 2014

7 Prosthetics (Internal) Covered in full with no deductible. Covered in full with no deductible at network providers. Radiation Therapy $20 copay per visit Covered in full. Respiratory Therapy $20 copay per visit. $30 copay per visit. Skilled Nursing Facility Days 1-20: Covered in full; Days : Covered at 50%. Days 1-20: $25 copay per day; Days : $150 per day Days 100 and beyond: Not covered. copay. $20 copay per day. $30 copay per visit. The plan will pay a maximum of $1,900 Speech Therapy per calendar year for occupational, physical, and speech therapy, combined. Surgery, ambulatory surgical $50 copay $60 hospital outpatient; $30 at ambulatory surgical center center or hospital outpatient Travel Benefit Refer to Out of Area Coverage Refer to Out of Area Coverage Urgent Care $20 copay for urgent care center. $30 copay for urgently needed services. X-Ray-Diagnostic $20 copay per visit. $30 copay per visit for x-rays. $60 copay per visit for CT, PET, MRI. Rochester Institute of Technology -7- Medicare-Eligible Plans-Rochester Area 2014

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