Coventry Health & Life Insurance Company

Transcription

1 Coventry Health & Life Insurance Company (Benefits underwritten by Coventry Health & Life Insurance Company and Administered by Coventry Health Care of Missouri, Inc.) Small Group PPO Schedule of Benefits: Plan ID#: Bronze Q4800U (IL) (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain Covered Services. Refer to Your Certificate of Coverage (COC) for a detailed description of Covered Services and limitations or exclusions. To receive In-Network benefits, all Covered Services, except for Emergency Services, must be performed or referred by a Participating Provider with Coventry Health Care or Authorized in advance by the Plan. All services must be Medically Necessary as a condition of coverage and not otherwise limited or excluded. Certain services require Prior Authorization. Call the telephone number on the back of Your ID Card to Prior Authorize. Except for Emergency Services, charges by Non-Participating Providers in excess of the Out-of-Network Rate will not be Covered. Note that failure to Prior Authorize a service where Prior Authorization is required may result in the application of a penalty of the lesser of up to $1,000 or 50% of the billed charge. For in-patient hospitalizations, the penalty will be no more frequent than a per confinement basis. BENEFIT AND SERVICES 1 Annual Total amount a plan member is required to pay each benefit year before he or she is eligible for certain Covered Services. amounts accumulate separately for In- and Out-of- Network benefits. The family deductible is satisfied when all family members combine to meet the family deductible amounts. If you have individual coverage, you must satisfy the individual before any benefit will be paid. If you have family coverage, you must satisfy the family before any benefits will be paid for any member. Pharmacy Services are included in the. 2 Annual Out-of-Pocket Maximum Copayments, coinsurance, s and prescription drug costs all apply to the out-of-pocket maximum. Out-of-pocket amounts accumulate separately for In- and Out-of-Network benefits. The family out-of-pocket amount is satisfied when all family members combine to meet the family out-of-pocket maximum amounts. The following services do not apply to the out-of-pocket maximum: charges above the Out-of-Network Rate and penalties for failure to Prior Authorize services. Individual Individual $4,800 $9,000 Family Family $9,600 $18,000 Individual Individual $5,500 $18,000 Family Family $11,000 $36,000 3 Maximum Lifetime Benefit Combined total of all benefits. Unlimited Unlimited

2 BENEFIT AND SERVICES 4 Physician Office Visit - Preventive Care Services include routine health assessment, well-child care, immunizations and injections, routine hearing test, prostate specific antigen testing, annual self-referred gynecological examination and pap smear, and mammogram screening and other preventive care services mandated by the Affordable Care Act. Consult Your Certificate of Coverage for more information. For Primary Care Services For Primary Care Services $0 Copay per visit admission after No or Coinsurance for Immunizations to age 5 For Specialty Care For Specialty Care Services Services $0 Copay per visit admission after No or Coinsurance for Immunizations to age E-Visits - Medical Services 7 8 Physician Office Visit - Medical Services Services include diagnosis, consultation and treatment. Services include: - Adult immunizations - Vision examination - Surgery - Diagnostic lab work - Diagnostic radiology services - Injections - Allergy testing and treatment - Telemedicine Certain services require Prior Authorization. Convenience Care / Walk in Clinic (WIC) Covered Services received at a retail health clinic for the treatment of minor health concerns that do not constitute an Emergency or an Urgent Care. Chiropractic Services Services include treatment that is Medically Necessary, clinically appropriate and within the chiropractor's scope of practice up to 12 visits per benefit year. Maximum benefit is an In- and Out-of-Network combined limit without Prior Authorization. 9 Emergency Room Services Coverage is provided for worldwide emergency health services as defined in the Certificate of Coverage. Includes facility and professional charges. For Primary Care Services For Specialty Care Services For Primary Care Services For Specialty Care Services (Waived if patient is admitted) For Primary Care Services admission after For Specialty Care Services admission after For Primary Care Services admission after For Specialty Care Services admission after admission after admission after (Waived if patient is admitted)

3 BENEFIT AND SERVICES 10 Ambulance Services Coverage is provided for Emergency Services as defined in the COC. occurrence after occurrence after Urgent Care Services Covered Service for urgent care services provided at a true Urgent Care Facility as that term is defined under Illinois Emergency Medical Treatment Act both in and out of the Service Area. Maternity Care Office Visits Coverage for maternity care, including prenatal, delivery, and post-natal care. Maternity Care, Inpatient Hospital Covered Services include all physician/facility services for mother and newborn(s), newborn nursery services, and semiprivate room for a minimum of 48 hours (vaginal) and 96 (caesarian) following delivery. Also includes treatment of complications of pregnancy. Inpatient stays beyond 48 hours (vaginal) / 96 hours (caesarian) require Prior Authorization. 0% Coinsurance after admission after admission after admission after High Technology Diagnostic Services, Tests, and Procedures Including, but not limited to: MRI, MRA, CT Scans, Thallium Scans, Nuclear Stress Tests, PET Scans, Echocardiograms (regardless of where service is performed). Requires Prior Authorization Outpatient Services and Diagnostic Procedures and Tests Coverage includes diagnostic procedures and tests, including but not limited to lab and radiology, not performed in the physician's office. Certain procedures and tests may be considered surgery, including but not limited to colonoscopy and endoscopy. Refer to the Outpatient Surgery section of Your COC for more information. Certain services require Prior Authorization. Outpatient Surgery Benefits are provided for Covered Services rendered at an outpatient hospital for free standing surgery center. Requires Prior Authorization. Injectable Medications Requires Prior Authorization. admission after admission after admission after admission after Covered according to the type of benefit incurred and the place where the service is received. Covered according to the type of benefit incurred and the place where the service is received.

4 BENEFIT AND SERVICES 18 Inpatient Hospital Services Coverage is provided for Medically Necessary Physician and surgeon services, semi-private room, operating room and related facilities, intensive and coronary care units, laboratory, x-rays, radiology services and procedures, medications and biologicals, anesthesia, short-term rehabilitation services, nursing care, meals and special diets. Inpatient alcoholism treatment is Covered the same as any other sickness. Requires Prior Authorization. 19 Skilled Nursing Facility Coverage is provided in lieu of an inpatient hospital admission when Prior Authorized. Coverage is provided for a semiprivate room. 20 Home Health Care and Hospice Coverage is provided for home health care and/or home infusion therapy services provided in Your home when Prior Authorized. admission after admission after admission after admission after admission after 21 Private Duty Nursing 22 Hospice Covered for hospice services provided in Your home when Prior Authorized. 23 Durable Medical Equipment Coverage is provided when services are Prior Authorized for equipment purchased in excess of $500 and for all rental equipment. 24 Prosthetics and Customized Orthotic Devices State mandated coverage is for prosthetic and custom-made orthotic devices (except foot orthotics) under terms and conditions no less favorable than that applied to substantially all medical and surgical benefits provided under the plan. Requires Prior Authorization for prosthetic devices purchased in excess of $ Eyeglasses and Contacts Coverage is provided for the first pair of eyeglasses or corrective lenses following cataract surgery. 0% Coinsurance of covered expenses after 0% Coinsurance of covered expenses after 100% of Covered Eyewear after admission after admission after 30% Coinsurance of covered expenses after 30% Coinsurance of covered expenses after admission after

5 BENEFIT AND SERVICES 26 Outpatient Physical, Occupation and Speech Therapy Coverage is provided for Medically Necessary outpatient physical, occupational and speech therapy. Includes coverage for Medically Necessary habilitative services for persons who have a congenital, genetic or early acquired disorder, preventive physical therapy for insureds diagnosed with multiple sclerosis and speech therapy for PDD. Physical Therapy in a custodial setting requires prior authorization. admission after Inpatient Rehabilitation Therapy Services Includes short-term inpatient rehabilitation services. Mental Health/Substance Use Disorder - Inpatient All inpatient mental health and Substance use disorder services, except emergency admissions, must be Prior Authorized by calling the Coventry Health Care behavior health line toll free at the number on the back of Your ID Card. admission after admission after admission after admission after Diagnosis, detoxification, and treatment of medical complications of alcoholism is covered the same as any other illness. Coverage includes inpatient treatment for mental health and Substance use in a: - Hospital or psychiatric hospital - Residential treatment facility - Partial Hospitalization treatment program - Detoxification program

6 29 Mental Health/Substance Use Disorder - Outpatient Hospital Coverage includes outpatient mental health and Substance use disorder services in an: - Outpatient Hospital or psychiatric hospital - Intensive Outpatient Program (IOP) - Residential treatment facility 30 BENEFIT AND SERVICES Mental Health/Substance Use Disorder - Office Visits Includes outpatient mental health and substance use disorder services performed in an office setting. Diagnosis, detoxification, and treatment of medical complications of alcoholism is covered the same as any other illness. admission after admission after 31 Transplant Services Services and supplies for transplants are Covered when Participating Coventry Transplant Network Providers are utilized. Requires Prior Authorization. 32 Modified Foods (PKU/Metabolic Formula) 33 Temporomandibular Joint Disorder admission after Not Covered admission after 34 Bariatric Surgery Requires prior authorization. admission after 35 Family Planning Coverage includes diagnosis and treatment of infertility, including coverage for IVF, GIFT, and ZIFT. All services require Prior Authorization. admission after

7 36 Well Baby/Child Exams Coverage is limited to: Covered Persons through age BENEFIT AND SERVICES Limited to 7 exams in the first 12 months Limited to 3 exams in the second 12 months Limited to 3 exams in the third 12 months Limited to 1 exam thereafter per benefit period Screening and Counseling Office Visits: Obesity and healthy diet counseling Misuse of alcohol and/or drugs Use of tobacco products Sexually transmitted infection counseling Genetic risk counseling for breast and ovarian cancer Maximums: Obesity and Healthy Diet Counseling: Maximum Visits per benefit period: 26 visits (however, of these only 10 visits will be allowed under the These maximums applies only to Covered Persons ages 22 & older. Misuse of Alcohol and/or Drugs: Maximum Visits per benefit period: 5 visits* Use of Tobacco Products: Maximum Visits per benefit period: 8 visits* Sexually Transmitted Infection Counseling: Maximum visits per benefit period: 2 visits* Genetic Risk Counseling for Breast and Ovarian Cancer: Not subject to any age or frequency limitations Lactation Counseling Services : Maximum Visits per benefit period either in a group or individual setting: 6 visits* Note: Applicable PCP or Specialist cost-share will apply for visits in excess of the Lactation Counseling Services Maximum. Breast Feeding Durable Medical Equipment Maximum: Breast pumps and supplies are limited to 1 electric breast pump per 36 months Female Contraceptive Counseling Services: Maximum Visits per benefit year either in a group or individual setting: 2 visits* Note: Applicable PCP or Specialist cost-share will apply for visits in excess of the Female Contraceptive Counseling Services Maximum Lung cancer screenings are limited to 1 screening per Calendar Year. Additional visits are subject to PCP or Specialist cost share. For Primary Care Services For Primary Care Services $0 per visit admission after No or Coinsurance for Immunizations to age 5 For Primary Care Services For Primary Care Services $0 per visit admission after For Specialty Care Services $0 per visit No or Coinsurance for Immunizations to age 5 For Specialty Care Services For Specialty Care Services $0 per visit admission after For Specialty Care Services admission after

8 BENEFIT AND SERVICES 38 Hearing Aids (Children over 5 Years of age) hearing aid after admission after **YOU ARE RESPONSIBLE FOR AMOUNTS IN EXCESS OF THE OUT OF NETWORK RATE IN ADDITION TO APPLICABLE COPAYMENT, COINSURANCE AND DEDUCTIBLES.

9 PRESCRIPTION DRUG BENEFITS Important Note: '- If you or your prescriber request a covered brand-name Prescription Drug when a covered generic Prescription Drug equivalent is available, you will be responsible for the cost difference between the generic Prescription Drug and the brand name Prescription Drug, plus the applicable cost sharing. PLAN FEATURES Prescription Drug Individual: Family: Not Applicable Not Applicable Important Reminder: -The benefit year s that apply to medical benefits under this plan are found earlier in this Schedule of Benefits under the Annual section on page 1. - All Prescription Drug Covered Benefits Are Subject To The Annual Unless Noted in the Schedule of Benefits Below. Not Applicable Not Applicable PHARMACY BENEFIT PER PRESCRIPTION COPAYMENTS/COINSURANCE Prescription Drug - Retail: For each 31 day supply filled at a retail pharmacy. Tier 1: Preferred Generic Drugs Retail: Mail Order: Retail: Mail Order: Prescription Drug - Mail Order: For each 90 day supply filled at a mail order pharmacy. Tier 1A: Value Drugs $3 Copay after $6 Copay after $10 Copay after $20 Copay after Tier 2: Preferred Brand Drugs Tier 3: Non-Preferred Brand/Generic Drugs Retail: Mail Order: Retail: $30 Copay after $75 Copay after $75 Copay after Mail Order: $225 Copay after Tier 4: Preferred Specialty Drugs Covered when Prior Authorized by the Plan. 30% Coinsurance up to $250 maximum per prescription after Tier 5: Non-Preferred Specialty Drugs Covered when Prior Authorized by the Plan. 50% Coinsurance up to $500 maximum per prescription after

10 Pediatric Vision Benefit Vision Care Services * * Covered only through the EyeMed Network Exam with Dilation as Necessary Vision Screening for Children under 19 One routine eye examination per calendar year Vision Hardware Eye Glasses for Children under 19 One pair of standard eyeglass lenses or contact lenses per year; one frame every calendar year Contact Lens Fit and Follow-Up: (Contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed.) Standard Contact Lens Fit and Follow-Up: Premium Contact Lens Fit and Follow-Up: Frames: Designated available frame at provider location Standard Lenses (Glass or Plastic): Single Vision Bifocal Trifocal Lenticular Standard Progressive Lens Lens Options: UV Treatment Tint (Fashion & Gradient & Glass-Grey) Standard Plastic Scratch Coating Standard Polycarbonate - Kids under 19 Contact Lenses: (Contact lens includes materials only) Extended Wear Disposables - Up to 6 month supply of monthly or 2 week disposable, single vision spherical or toric contact lenses. Daily Wear / Disposables - Up to 3 month supply of daily disposable, single vision spherical contact lenses Medically Necessary / Conventional: Low Vision Evaluation, low vision aides, follow up care once every calendar year (includes examination, lenses or contact lenses, frame); once every 5 years includes comprehensive low vision evaluation; Follow up care for low vision services - 4 visits in a 5 year period. In-Network EyeMed Network Member Cost $0 Copay $0 Copay after $0 Copay after 100% coverage for provider designated frames $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after $0 Copay after 100% coverage for provider designated contact lenses after Paid in Full 5

11 Pediatric Dental Care Benefit Schedule of Benefits Pediatric Dental Care Description of Covered Services Type In-Network Out-of-Network PREVENTIVE & DIAGNOSTIC Routine Exams/Evaluations (Limited to 1 per 6 months) I $0 Copay $0 Copay Cleanings (Limited to 1 per 6 months) I $0 Copay $0 Copay X-rays I $0 Copay $0 Copay Fluoride (One per year) I $0 Copay $0 Copay Sealants I $0 Copay $0 Copay BASIC Space Maintainer Fillings Denture Relines General Anesthesia, IV Sedation, Conscious Sedation, Therapeutic Drug Injection, Nitrous Oxide (Requires pre-determination) II II II II General Services II MAJOR Crowns Requires pre-determination Removable Prostodontic Services: Dentures (Complete: Upper and Lower; Partial: Upper and Lower) Requires pre-determination Fixed Prosthetic Services - Bridges Requires pre-determination Endodontics Periodontics (Gingevectomy, Scaling and Root Planing) Requires pre-determination Oral Surgery (Extractions, Surgical Extractions, Alveoplasty) (Surgical Extractions and Alveoplasty require pre-determination) ORTHODONTIA Covered only in cases of medical necessity and subject to pre-determination. Out-of-Pocket Maximum III III III III III III IV & Out-of-Pocket Maximum combined with medical

12 Note that Prior Authorization may be required for some services. * Coverage: The amount of reimbursement by Us for pediatric dental services Covered under this Rider will depend upon whether You receive those services from Participating or Non-Participating Dental Providers. Participating Dental Providers are those licensed dentists who have a contract with Us and have agreed to accept a discounted rate as payment in full for those services. You will receive the highest level of coverage if you receive Covered Services from Participating Dental Providers. If You receive Covered pediatric dental services from Non-Participating Dental Providers, Our reimbursement for those services will be limited and based upon the Out-of-Network Rate for the service, which is a rate established by Us based upon our contracted rate with Participating Providers in our dental network. We will pay the enumerated percentage of that Out-of-Network Rate as and for our reimbursement to the Non-Participating Dental Provider, and You will be responsible for any amount over and above the Out-of-Network Rate in addition to other applicable member responsibility, such as or Coinsurance