Coventry Health & Life Insurance Company Small Group PPO Schedule of Benefits:

Transcription

1 Coventry Health & Life Insurance Company Small Group PPO Schedule of Benefits: Plan ID#: Silver Traditional (# ) 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 phone 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. BENEFIT AND SERVICES 1 Annual Deductible Total amount a plan member is required to pay each benefit year before he or she is eligible for certain Covered Services. Deductible amounts accumulate separately for In- and Out-of- Network benefits. The family is satisfied when all family members combine to meet the family amounts. The annual Deductible need only be met once per plan member per benefit year. In some cases, In-Network Deductible will not apply. Individual $3,000 Family $6,000 Individual $7,500 Family $15,000 2 Annual Out-of-Pocket Maximum Copayments, coinsurance, s and pharmacy 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 annual Out-of-Pocket Maximum need only be met once per plan member per benefit year.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 $6,350 Family $12,700 Individual $15,000 Family $30,000 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, telemedicine, well-child care, immunizations and injections, routine hearing and vision screening, 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 per visit For Primary Care Services No Deductible or Coinsurance for Immunizations through age 5 For Specialty Care Services For Specialty Care Services per visit No Deductible or Coinsurance for Immunizations through age 5 5 Physician Office Visit - Medical Services Services include diagnosis, consultation and treatment, telemedicine, adult immunizations, vision examination, surgery, diagnostic lab work, diagnostic radiology services, and allergy testing and treatment. Certain services require Prior Authorization. For Primary Care Services Co-pay per visit For Primary Care Services For Specialty Care Services For Specialty Care Services 6 Chiropractic Services Coverage is provided for chiropractic services up to 26 visits per benefit year without Prior Authorization. Maximum benefit is an In- and Out-of-Network combined limit without Prior Authorization. Coinsurance per visit after 7 Emergency Room Services Coverage is provided for worldwide emergency health services as defined in the Certificate of Coverage. Includes facility and professional charges. 8 Ambulance Services Coverage is provided for Emergency Services as defined in the COC. Prior Authorization is required for non-emergent facility-to-facility ambulance transportation. (Waived if patient is admitted) Co-insurance per occurrence after (Waived if patient is admitted) Co-insurance per occurrence after

3 BENEFIT AND SERVICES 9 Urgent Care Services Covered Service for urgent care services at participating alternate facilities both in and out of the Service Area. 10 Maternity Care Office Visits Coverage for maternity care, includin prenatal, delivery, and post-natal care. 11 Maternity Care, Inpatient Hospital Covered Services include all pysician/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. Inpatient stays beyond 48 (vaginal) / 96 (caesarian) require Prior Authorization. Newborn stay after mother's discharge is considered a separate admission. Note that For all related Maternity services, including outpatient observation stay, any applicable cost-share will be consistent with the type of services received. 12 Outpatient Services and Diagnostic Procedures and Tests Coverage includes diagnostic procedures and tests, including but not limited to bone density testing, mammograms, radiation therapy and therapeutic treatments such as dialysis, inhalation, chemotherapy and 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. Co-insurance first visit only after after after $1,000 penalty for failure to Pre-Certify 13 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. 14 Outpatient Surgery Benefits are provided for Covered Services rendered at an outpatient hospital for free standing surgery center. Requires Prior Authorization.

4 15 BENEFIT AND SERVICES Injectible Medications Requires Prior Authorization. Covered Service for Injectible Medication. 16 Medications considered by the Plan to be Self-Injectible Medications are Covered under a Pharmacy Rider, if purchased. 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. 17 Skilled Nursing Facility Coverage is provided in lieu of an inpatient hospital admission when Prior Authorized. Coverage is provided for a semi-private room. Prior Authorization is required. Limited to 90 days per benefit year. 18 Home Health Care Coverage is provided for home health care and/or home infusion therapy services provided in Your home when Prior Authorized. Home health care is limited to 90 days per benefit year. Private duty nursing provided in the home setting is limited to $50,000 per benefit year and $100,000 per lifetime. 19 Hospice Covered for hospice services provided in Your home when Prior Authorized. 20 Durable Medical Equipment Coverage is provided when services are Prior Authorized for equipment purchased in excess of $500 and for all rental equipment. after after Co-insurance of covered expenses after after $1,000 penalty for failure to Pre-Certify after $1,000 penalty for failure to Pre-Certify Co-insurance of covered expenses after

5 BENEFIT AND SERVICES 21 Prosthetics and Orthotics Coverage is provided when services are Prior Authorized for equipment purchased in excess of $10,000 and for all rental equipment. Co-insurance of covered expenses after Co-insurance of covered expenses after Eyeglasses and Contacts Coverage is provided for the first pair of eyeglasses or corrective lenses following cataract surgery. Outpatient Rehabilitative and Habilitative Services - Other Physical Therapy Coverage is provided for prescribed services performed by a licensed physical therapist. Outpatient physical therapy visits will be limited to 20 visits per benefit year. Note: Your Copayment or Coinsurance for services received from a licensed physical therapist will be no greater than the Copayment or Coinsurance charged for the services provided by a Primary Care Physician for an office visit. 100% of Covered Eyewear Co-insurance of covered expenses after Occupational, Speech and Other Therapies Coverage is provided for Medically Necessary outpatient occupational, speech, cardiac, and pulmonary therapy. Occupational therapy limited to 20 visits per benefit year. Speech Therapy is unlimited when rendered as Physician Home Visits and Office Services or Outpatient Services. Pulmonary therapy is limited to 20 visits per benefit year. Cardiac therapy is limited to 36 visits per benefit year. 25 Inpatient Physical Medicine and Rehabilitation Therapy Services Coverage is provided for Medically Necessary short-term inpatient rehabilitation services when approved by the Plan. Coverage is provided on a semi-private basis. Limited to 60 days per benefit year. Requires Prior Authorization. MOSOBSGPPOCHL814 after after $1,000 penalty for failure to Pre-Certify MO DOI Approved

6 26 BENEFIT AND SERVICES Mental Health/Substance Use Disorder - Inpatient All inpatient mental health and Substance Abuse/Alcoholism and Chemical Dependency disorder services 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. 27 Mental Health/Substance Use Disorder - Outpatient Hopsital Coverage is provided for partial or full day non-residential treatment programs when Prior Authorized by calling the Coventry Health Care behavioral health line at the number on the back of Your ID Card. 28 Mental Health/Substance Use Disorder - Office Visits Includes outpatient mental health and Substance Abuse/Alcoholism and Chemical Dependency services. Some outpatient services may require Prior Authorization. Please ask Your Provider to call the Coventry Health Care Behavioral Health line on the back of Your ID card to determine whether a Covered Sefvice requires Prior Authorization. 29 Transplant Services Services and supplies for transplants are Covered when Participating Coventry Transplant Network Providers are utilized. Requires Prior Authorization. after after $1,000 penalty for failure to Pre-Certify Not Covered after Includes unrelated donor searches for bone marrow/ stem cell transplants for a Covered Transplant Procedure, as approved by Us. Transportation and lodging limited to $10,000 benefit limit per transplant 30 Accidental Dental Services Covered services limited to $3,000 per benefit year. Prior Authorization is required. 31 Autism Services Medically Necessary services to diagnose and treat Autism Spectrum Disorders. Services include: psychiatric and psychological services; habilitative or rehabilitative care; occupational, speech and physical therapy; medications (Covered under Your pharmacy benefit); equipment related to care; and applied behavioral analysis. Prior Authorization is required for some services. See applicable Coverage category for more information Day/visit limitations do not apply to Autism Spectrum Disorder services regardless of the Coverage category. See applicable Coverage category for more information Day/visit limitations do not apply to Autism Spectrum Disorder services regardless of the Coverage category.

7 32 BENEFIT AND SERVICES Hearing Aids Coverage is limited to one (1) Hearing Aid Appliance per ear and fitting every 36 months. Coverage for hearing aids is limited to a benefit maximum of $2,600 after Deductible; however this Benefit maximum limitation does not apply to initial amplification for newborns. Newborn Hearing Aids Hearing Aids provided to a newborn only for initial amplification following a newborn hearing screening (including any necessary rescreening, audio logical assessment and follow-up. **YOU ARE RESPONSIBLE FOR AMOUNTS IN EXCESS OF THE OUT OF NETWORK RATE IN ADDITION TO APPLICABLE COPAYMENT, COINSURANCE AND DEDUCTIBLES. Prescription Drugs - Retail (31-day supply) Note: You will be responsible for only one Copayment/Coinsurance for a covered Prescription Drug if the required single dosage is unavailable and/or a combination of dosage amounts is needed to fill the Prescription Order. PRESCRIPTION DRUG BENEFITS BENEFIT AND SERVICES Generic: Formulary Tier 1: Formulary Tier 1A: Tier 2: Non-Formulary Tier 3: $15 Copay $15 Copay $3 Copay $45 Copay $75 Copay Reimbursement limited to amount Plan would have paid if drug filled/refilled at Participating Pharmacy

8 BENEFIT AND SERVICES Specialty Medications Tier 4: Covered when Prior Authorized by the Plan Formulary: $150 Copay Reimbursement limited to amount Plan would have paid if drug filled/refilled at Participating Pharmacy Non-Formulary: Specialty Medications Tier 5: Covered when Prior Authorized by the Plan Formulary: Reimbursement limited to amount Plan would have paid if drug filled/refilled at Participating Pharmacy Non-Formulary: $300 Copay Prescription Drugs - Mail Order (three-month supply) Generic: Formulary Tier 1: Formulary Tier 1A: Formulary Tier 2: Non-Formulary Tier 3: $37.50 Copay $37.50 Copay $7.50 copay $ Copay $225 Copay Reimbursement limited to amount Plan would have paid if drug filled/refilled at Participating Pharmacy

9 Vision Care Services Exam with Dilation as Necessary Contact Lens Fit and Follow-Up: Pediatric Vision Benefit Member Cost Out-of-Network Reimbursement (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: 100% coverage for provider Designated available frame at provider location designated frames Standard Lenses (Glass or Plastic): Single Vision Bifocal Trifocal Lenticular Standard Progressive Lens Premium Progressive Lens Lens Options: UV Treatment Tint (Fashion & Gradient & Glass-Grey) Standard Plastic Scratch Coating Standard Polycarbonate - Adults Standard Polycarbonate - Kids under 19 Standard Anti-Reflective Coating Polarized Photocromatic / Transitions Plastic Oversized Premium Anti-Reflective Coating Other Add-Ons Contact Lenses: (Contact lens includes materials only) Extended Wear Disposables See attached Fixed Premium Progressive price list $40 $45 20% off Retail Price 20% off Retail Price See attached Fixed Premium Anti-Reflective Coating price list 20% off Retail Price 100% coverage for provider designated contact lenses Up to 6 mos supply of monthly or 2 week disposable, single vision spherical or toric contact lenses

10 Daily Wear / Disposables Medically Necessary / Conventional Laser Vision Correction: Lasik or PRK from U.S. Laser Network Additional Pairs Benefit: Up to 3 mos supply of daily disposable, single vision spherical contact lenses Paid In Full 15% off Retail Price or 5% off promotional price Members also receive a discount off complete pair eyeglass purchases and a 15% discount off conventional contact lenses once the funded benefit has been used. Frequency: Examination Lenses or Contact Lenses Frame Once every Calendar Year Once every Calendar Year Once every Calendar Year Progressive Price List Standard Lens: Member Out-of-Pocket Group Cost Per (Includes Lens Copay) Service/Plan Charged Standard Progressive $120 Premium Progressives (Scheduled): Tier 1 Tier 2 Tier 3 Tier 4 $20 Copay $30 Copay $40 Copay $0 copay, 80% of charge less $120 $120 $120 $120 $120 Allowance Anti-Reflective Coating Price List Lens Option: Member Out-of-Pocket Group Cost Per Service/Plan Charged Standard Progressive $45 $0 Premium Progressives (Scheduled): Tier 1 $57 $0 Tier 2 $68 $0 Tier 3 80% of charge $0 Out-of- Network Out-of- Network $70 $70 $70 $70 $70 Out-of- Network $51 Anti-Reflective Coating Price List Member Out-of-Pocket Group Cost Per Lens Option: Service/Plan Charged Photochromic/Transitions Plastic $0 $75

11 Pediatric Dental Care Benefit Schedule of Benefits Pediatric Dental Care Description of Services Type Coverage PREVENTIVE & DIAGNOSTIC Routine Exams/Evaluations I 100% Cleanings I 100% X-rays I 100% Fluoride I 100% Sealants I 100% BASIC Space Maintainer II 50% Fillings II 50% Denture Relines II 50% General Anesthesia General Services II 50% II 50% MAJOR Crowns III 50% Inlays III 50% Onlays III 50% Dentures Bridges III 50% Endodontics III 50% Periodontics III 50% Oral Surgery III 50% Implants III 50% ORTHODONTIA IV 50% Deductible Out-of-Pocket Maximum Deductible & Out-of-Pocket Maximum combined with medical; does not apply to preventive & diagnostic services.