IU Health Plans Silver Copay On Exchange CSR 87 Plan. Schedule of Benefits

Transcription

1 Schedule of s / 1 IU Health Plans Silver Copay On Exchange CSR 87 Plan Schedule of s The Schedule of s is a summary of your s and Cost Sharing. The definitions stated in your Contract apply to this Schedule of s. Services provided by Non-Participating Providers are Non-Covered Services unless specifically covered under this Contract. You are responsible for all expenses for Non-Covered Services. Plan Year [date] through [December 31, 2016] : The is the amount you must pay for Covered Services in a Plan Year before we will pay s for Covered Services. The applies to all Covered Services except for Preventive Care, office visits with your Primary Care Physician, Maternity - Prenatal & Postnatal Care, Urgent Care Center Services, and Tier 1 & Tier 2 Prescription Drugs. Copayments do not apply toward the. Your payments for Non-Covered Services do not apply toward the. Per Covered $500 per Plan Year Per Family $1,000 per Plan Year Out of Pocket Maximum: The Out of Pocket Maximum is the maximum amount that you will pay for Covered Services in a Plan Year. The Out of Pocket Maximum includes the, Copayments and Coinsurance amounts you pay in a Plan Year for Covered Services. Your payments for Non-Covered Services do not apply toward the Out of Pocket Maximum. Once the Out of Pocket Maximum is satisfied, no additional Copayments or Coinsurance apply for the remainder of the Plan Year. Out of Pocket Maximum Per Covered $1,250 per Plan Year Per Family $2,500 per Plan Year Cost Sharing and Limitations: Cost Sharing is the Copayment and Coinsurance that you must pay for Covered Services. Some Covered Services are subject to limitations. Health Care Services received from Non-Participating Providers are Non-Covered Services unless the Contract specifically provides otherwise. See Article 6 Section B of the Contract for additional information on when Health Care Services received from Non-Participating Providers may be Covered Services. If Health Care Services received from Non-Participating Providers are determined to be Covered Services, the services are subject to the same s, Copayments, Coinsurance and limitations as Covered Services received from Participating Providers.

2 Ambulance Services Behavioral Health Services Office Visits Outpatient Services Inpatient Services Substance Abuse Disorder Outpatient Services Substance Abuse Disorder Inpatient Services Dental Services for Accidental Injury Diabetic Equipment, Education and Supplies $20 Copayment per visit after after Copayments/Coinsurance based on setting where Covered Services are received. For information on equipment and supplies, please refer to the "Medical Supplies, Durable Medical Equipment, and Appliances" provision in this Schedule. For information on Diabetic education, please refer to the Specialty Physician" or "Primary Care Physician" provisions in this Schedule. For information on Prescription Drug Coverage, please refer to the "Prescription Drugs" provision in this Schedule. Diagnostic Services Laboratory Services Radiology Services X-ray Services $30 Copay per Service

3 Emergency Services Emergency Room Cost sharing after waived if admitted Urgent Care Center Services Home Care Services Home Care Visits - limited to a maximum of 90 visits per Covered Per Year Private Nursing Visits - limited to a maximum of 82 visits per Covered Per Year and 164 visits per Covered per lifetime Hospice Services Inpatient Services Inpatient Facility Services Inpatient Physician and Surgical Services Physical Medicine and Day Rehabilitation - limited to a maximum of 60 days per Covered Per Year Inpatient Skilled Nursing Facility Services - limited to a maximum of 90 days per Covered Per Year Maternity Services Prenatal and Postnatal Care Delivery and Inpatient Services $200 Copayment per visit after $75 Copayment per visit after after $20 Copayment per visit after Medical Supplies, Durable Medical Equipment and Appliances Medical Supplies Durable Medical Equipment Prosthetics Orthotic Devices

4 Outpatient Services Outpatient Facility Outpatient Surgery Physician/Surgical Services Physician Visits Primary Care Physician Specialty Physician Preventive Care Services Surgical Services Telehealth Services Temporomandibular or Craniomandibular Joint Disorder and Craniomandibular Jaw Disorder Therapy Services Outpatient Rehabilitative Physical Medicine Services - limited to a maximum of 60 visits per Covered Per Year Physical Therapy - limited to a maximum of 20 visits per Covered Per Year Speech Therapy - limited to a maximum of 20 visits per Covered Per Year Occupational Therapy - limited to a maximum of 20 visits per Covered Per Year Manipulation Therapy limited to a maximum of 12 visits per Covered Per Year $20 Copayment per visit $40 Copayment per visit cost sharing based on service type and rendering provider Rehabilitation Services Cardiac Rehabilitation - limited to a maximum of 36 visits per Covered Per Year Pulmonary Rehabilitation - limited to a maximum of 20 visits per Covered Per Year Therapy Services Outpatient Habilitative

5 Physical Therapy - limited to a maximum of 20 visits per Covered Per Year Speech Therapy - limited to a maximum of 20 visits per Covered Per Year Occupational Therapy - limited to a maximum of 20 visits per Covered Per Year Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services: The Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services benefits or requirements described below do not apply to the following. Cornea and kidney transplants, and Any Covered Services, related to a Covered Transplant Procedure, received prior to or after the Transplant Period. Please note that the initial evaluation and any necessary additional testing to determine your eligibility as a candidate for transplant by your Provider and the harvest and storage of bone marrow/stem cells is included in the Covered Transplant Procedure benefit regardless of the date of service. The above Health Care Services are covered as Inpatient Services, Outpatient Services or Physician Home Visits and Office Services depending on where the service is performed, subject to Cost Sharing.

6 Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services Transplant Period Starts one day prior to a Covered Transplant Procedure and continues for the applicable case rate/global time period. The number of days will vary depending on the type of transplant received and the Participating Provider Agreement. Contact the Case Manager for specific Participating Provider information for Health Care Services received at or coordinated by a Participating Provider Facility or starts one day prior to a Covered Transplant Procedure and continues to the date of discharge at a Non- Participating Provider Facility. Not applicable Covered Transplant Procedure during the Transplant Period During the Transplant Period, no Copayment/Coinsurance up to the Allowed Amount. Prior to and after the Transplant Period, Covered Services will be paid as Inpatient Services, Outpatient Services or Physician Home Visits and Office Services depending where the Health Care Service is performed. Human Organ and Tissue Transplant (Bone Marrow/Stem Cell) Services - Professional and Ancillary (non-hospital) Providers Covered Transplant Procedure During the Transplant Period No Copayment/Coinsurance up to the Allowed Amount

7 Transportation and Lodging Covered, as approved by the Contract, up to a $10,000 benefit limit Unrelated Donor Searches for Bone Marrow/Stem Cell Transplants for a Covered Transplant Procedure Covered, as approved by the Contract, up to a $30,000 benefit limit Live Donor Health Services Prescription Drugs Retail 30 day supply Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand Name) Tier 4 (Non-Preferred Brand Name) Tier 5 (Specialty) Tier 6 (Preventive) Covered as determined by the Contract $5 Copayment per Prescription Order $15 Copayment per Prescription Order 30% Coinsurance after 30% Coinsurance after Mail Order 90 day supply Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand Name) Tier 4 (Non-Preferred Brand Name) $15 Copayment per Prescription Order $45 Copayment per Prescription Order 30% Coinsurance after

8 Tier 5 (Specialty) Tier 6 (Preventive) 30% Coinsurance after Pediatric Vision (persons under age 19) Eye exam - limited to 1 exam per Covered per Year Eyeglass Lenses - limited to 1 set of lenses per Covered per Year Eyeglass Frames - limited to 1 set of frames per Covered Per Year Contact Lenses includes materials only, covered once per Per Year in lieu of eyeglasses Conventional Extended Wear Disposables Daily Wear / Disposables for Provider Designated Frames for designated contact lenses One pair annually from selection of designated contact lenses Up to 6 month supply of monthly or 2 week disposable, single vision spherical or toric contact lenses Up to 3 month supply of daily disposable, single vision spherical contact lenses