Deductible: $500/$1000* Out-of-Pocket Max: $2,000/$4,000** including deductible
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1 First State Basic Plan (highmark delaware) Description of Benefit Deductible: $500/$1000* Out-of-Pocket Max: $2,000/$4,000** Deductible: $1,000/$2,000* Out-of-Pocket Max: $4,000/$8,000** Inpatient Room & Board Inpatient Physicians /Surgeons Services Outpatient Services Prenatal and Postnatal Care Delivery Fee Hospice 365 days 365 days 240 days per plan year 240 days per plan year Urgent Care 100% after $25 copay 100% after $25 copay Mental Health Care/SUBSTANCE ABUSE CARE Inpatient Acute/ Partial Hospitalization 90% after deductible 70% after deductible Outpatient Other Services Durable Medical Equipment Skilled Nursing Facility 90% for up to 120 days per confinement 70% for up to 120 days per confinement Emergency Ambulance Physician Home/Office Visits (sick) Specialist Care 75% after deductible, for up to Allergy Testing/Allergy Treatment X-Ray, MRI s, CT Scans, Lab & other Diagnostic Services *** Short-Term Therapies: Physical, Speech, Annual Gyn Exam/Pap Smear 100% covered, no deductible 70% covered, no deductible Periodic Physical Exams, 100% covered, no deductible 70% covered, no deductible Immunizations, Diabetes Education Hearing Tests 100% covered, no deductible 70% covered, no deductible Hearing Aids 90% after deductible, under age 24 70% after deductible, under age 24 75% after deductible; $10,000 lifetime 75% after deductible, $15,000 lifetime max. for 90% after deductible if Blue Distinction Center for is used; 75% after deductible if an authorized hospital/surgical center is used 55% after deductible; $10,000 lifetime 55% after deductible; $15,000 lifetime max. for 55% after deductible * Two individuals must meet the deductible each plan year in order for the family deductible to be met. ** Out-of-pocket maximums apply to each plan year and include your deductible but do not include your prescription costs. 11
2 Description of Benefits Aetna CDH Gold Plan Out-of-Pocket Max: $4,500/$9,000** Out-of-Pocket Max: $7,500/$15,000** Health Reimbursement Account $1,250 Employee/$2,500 Family In-Network Out-of-Network Inpatient Room & Board Inpatient Physicians and Surgeons Services Outpatient Services Prenatal and Postnatal Care Delivery Fee Hospice 240 days per plan per plan year 240 days per plan per plan year Urgent Care MENTAL HEALTH & SUBSTANCE ABUSE Inpatient Acute/Partial Hospitalization Outpatient OTHER COVERED SERVICES Durable Medical Equipment Skilled Nursing Facility 90% after deductible for up to 120 days per confinement 120 days per confinement Emergency Ambulance Physician Home/Office Visits (non-routine) Specialist Care 30 visits per plan year 75% after deductible for up to 30 visits per plan year Allergy Testing/Allergy Treatment X-ray, MRI s, CT Scans, PET Scans, Lab & Other Diagnostic Services*** Short-term Therapies: Physical, Speech, Annual Gyn Exam/Pap Smear 100%, no deductible 70% covered, after deductible Routine Physical Exam & Immunizations 100%, no deductible 70% after deductible Hearing Tests - 1 exam every 12 months 100%, no deductible 70% after deductible Hearing Aids Children to age 24 90% after deductible, under age 24 70% after deductible, under age 24 75% covered; $10,000 lifetime 75% covered; $15,000 lifetime maximum for 55% covered; $10,000 lifetime maximum for medical services 55% covered; $15,000 lifetime maximum for 90% after deductible if Institute of Excellence for is used; 75% after deductible if other center is used. 55% after deductible. * Once the Family Deductible Limit is met, all family members will be considered as having met their deductible. 12 Benefits Supplement, effective september 1, 2015
3 HIGHMARK delaware CDH Gold Plan Description of Benefits Out-of-Pocket Max: $4,500/$9,000** Out-of-Pocket Max: $7,500/$15,000** Health Reimbursement Account $1,250 Employee/$2,500 Family In-Network Out-of-Network Inpatient Room & Board Inpatient Physicians and Surgeons Services Outpatient Services Prenatal and Postnatal Care Delivery Fee Hospice 240 days per plan year 240 days per plan year Urgent Care MENTAL HEALTH & SUBSTANCE ABUSE care Inpatient Acute/Partial Hospitalization Outpatient OTHER COVERED SERVICES Durable Medical Equipment Skilled Nursing Facility 120 days per confinement 120 days per confinement Emergency Ambulance Physician Home/Office Visits (non-routine) Specialist Care 75% after deductible for up to Allergy Testing/Allergy Treatment X-ray, MRI s, CT Scans, PET Scans, Lab & Other Diagnostic Services*** Short-term Therapies: Physical, Speech, Annual Gyn Exam/Pap Smear 100%, no deductible 70% covered, after deductible Routine Physical Exam & Immunizations 100%, no deductible 70% after deductible Hearing Tests - 1 exam every 12 months 100%, no deductible 70% after deductible Hearing Aids Children under age 24 75% covered; $10,000 lifetime 75% covered; $15,000 lifetime maximum for 90% after deductible if Blue Distinction Center for is used; 75% after deductible if an authorized hospital/surgical center is used 55% covered; $10,000 lifetime maximum for medical services 55% covered; $15,000 lifetime maximum for 55% after deductible * Once the Family Deductible Limit is met, all family members will be considered as having met their deductible. 13
4 Description of Benefits Aetna HMO highmark delaware ipa/hmo Out-of-Pocket Max: $4,500/$9,000** Out-of-Pocket Max: $4,500/$9,000** Inpatient Room & Board $100 copay/day with max of $200 per admission $100 copay/day with max of $200 per admission Inpatient Physicians and Surgeons Services 100% 100% Outpatient Surgery Ambulatory Center $50 copay $50 copay Outpatient Surgery Doctors Office Visit $20 copay $20 copay Outpatient Surgery Hospital $100 copay $100 copay Prenatal and Postnatal Care * MRI, MRA, CT and PET scans require a prior authorization 14 Benefits Supplement, effective september 1, % after $20 initial copay (inpatient copays do apply to hospital deliveries/birthing centers) 100% after $20 initial copay (inpatient copays do apply to hospital deliveries/birthing centers) Delivery Fee 100% 100% Hospice 100% upto 365 days 100% up to 365 days 100% for up to 240 visits per plan year 100% for up to 240 visits per plan year Urgent Care $20 copay $20 copay Emergency Services $150 copay (waived if admitted) $150 copay (waived if admitted) Mental Health Care/SUBSTANCE ABUSE CARE Inpatient Acute/Partial Hospitalization $100 copay/day with max. of $200/hospitilization $100 copay/day with max. of $200/hospitilization Outpatient $20 copay per visit $10 copay per visit OTHER SERVICES Durable Medical Equipment 80% 80% Skilled Nursing Facility 100% 100% Emergency Ambulance $50 copay $50 copay Physician Home/Office Visits (sick) $15 copay per office visit $25 copay per home or after hours visit $15 copay per office visit/ $25 copay per home or after hours visit Specialist Care $25 copay per visit $25 copay per visit 80% of the allowable charges 80% of the allowable charges; limited to one visit per day and 60 consecutive days per acute condition Allergy Testing/Allergy Treatment $20 copay per visit (allergy testing)/ $5 copay per visit (allergy treatment) $20 copay per visit (allergy testing)/ $5 copay per visit (allergy treatment) X-Ray, Lab & other Diagnostic Services Lab: $10 copay per visit/ X-Ray:$20 copay per visit Lab: $10 copay per visit/ X-Ray: $20 copay per visit MRI s, CT Scans and PET Scans* $35 copay per visit $35 copay per visit Short-Term Therapies: Physical, Speech, 80%, 45 visits per condition for physical and occupational therapy combined/ 80%, 45 visits per condition for speech therapy 80%, 60 consecutive days/except for physical therapy. Physical therapy/45 visits per condition Annual Gyn Exam/Pap Smear 100% 100% Periodic Physical Exams, Immunizations, 100% 100% Diabetes Education Vision Care 100% after office visit copay (one exam every 24 months) 100% after office visit copay (one exam every 24 months) Hearing Tests 100% after office visit copay 100% after office visit copay 75% covered $10,000 lifetime maximum for medical services; 75% covered; $15,000 lifetime 100% if Institute Excellence for is used; 75% if an authorized hospital/ surgical center is used 75% covered; $10,000 lifetime maximum for medical services. 75% covered; $15,000 lifetime 100% if Blue Distinction Center for Bariatric Surgery is used; 75% if an authorized hospital/surgical center is used ** Out-of-pocket maximums apply to each plan year. There are separate out-of-pocket maximums for prescription drugs.
5 HIGHMARK delaware Comprehensive Preferred Provider OrganizATION Description of Benefit Out-of-Pocket Max: $4,500/$9,000 Deductible: $300/$600* Out-of-Pocket Max: $7,500/$15,000 ** Inpatient Room & Board $100 copay/day with max. of $200/admission 80% after deductible Inpatient Physicians and Surgeon 100% 80% after deductible Outpatient Surgery-Ambulatory Center $50 copay 80% after deductible Outpatient Surgery-Hospital Surgery Cntr. $100 copay 80% after deductible Prenatal and Postnatal Care 100% (inpatient room and board copays do apply to hospital deliveries/birthing centers) 80% after deductible Delivery Fee 100% 80% after deductible Hospice 100% up to 365 days 80% after deductible up to 365 days 100% 80% after deductible for up to 240 visits per plan year Urgent Care $25 copay 80% after deductible Emergency Services $150 copay (waived if admitted) Physician: 100% $150 copay (waived if admitted) Physician: 100% after deductible Mental Health Care/Substance Abuse Care Inpatient Acute/Partial Hospitalization $100 copay/day with max of $200/admission 80% after deductible Outpatient 100% after $15 copay 80% after deductible Other Services Durable Medical Equipment 100% 80% after deductible Skilled Nursing Facility 100% up to 120 days per confinement 80% after deductible up to 120 days per confinement Emergency Ambulance 100% 100% no deductible Physician Home/Office Visits (sick) $20 copay 80% after deductible Specialist Care $30 copay 80% after deductible 85% covered; 80% after deductible; Allergy Testing/Allergy Treatment Testing: $25 copay/treatment :$5 copay 80% after deductible X-Ray, Lab & other Diagnostic Services Lab: $10 copay per visit; X-ray: $20 copay per visit 80% after deductible MRI s, CT Scans, PET Scans*** $35 copay 80% after deductible Short-Term Therapies: Physical, Speech, 85% 80% after deductible Therapies Annual Gyn Exam/Pap Smear 100% 80% after deductible Periodic Physical Exams, Immunizations, 100% 80% after deductible Diabetes Education Hearing Tests 100% after office visit copay 80% after deductible Hearing Aids 100%, under age 24 80% after deductible, under age 24 75% covered, $10,000 lifetime 75% covered, $15,000 lifetime 55% after deductible; $10,000 lifetime 55% after deductible; $15,000 lifetime * Two individuals must meet the deductible each plan year in order for the family deductible to be met. 15
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$ 500 Individual $1,000 Family. $ No
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Health Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436.
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