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 Carelink from Coventry Schedule of Benefits: Plan ID#: Gold Carelink A (IL) (# ) This Schedule of Benefits summarizes Your obligation towards the cost of certain Covered. Refer to Your Certificate of Coverage (COC) for a detailed description of Covered and limitations or exclusions. To receive coverage according to your In-Network level of benefits, all Covered, except for Emergency and those Authorized in advance by the Plan, must be performed by a participating Provider in the Carelink from Coventry product. Additionally, your Carelink from Coventry Primary Care Physician may require an referral before you can receive services from a Carelink from Coventry specialty physician. must be Medically Necessary as a condition of Coverage and not otherwise limited or excluded. Some Covered may require Prior Authorization. Please refer to Your COC or contact Customer Service at the phone number listed on the back of Your ID card. Your Carelink from Coventry physician is responsible for obtaining required Authorizations for In- Network services. Except for Emergency, charges by Non-Participating Providers in excess of the Out-of- Network Rate will not be covered. Note that a 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 inpatient 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. 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 need only be met once per plan member per benefit year. Individual Individual $0 $6,000 Family Family $0 $12,000 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 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 Individual $6,600 $12,000 Family Family $13,200 $24,000 3 Maximum Lifetime Benefit Combined total of all benefits. Unlimited Unlimited

2 4 Physician Office Visit - Preventive Care 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. 5 BENEFIT AND SERVICES Physician Office Visit - Medical include diagnosis, consultation and treatment. include: - Adult immunizations - Vision examination - Surgery - Diagnostic lab work - Diagnostic radiology services - Injections - Allergy testing and treatment - Telemedicine Certain services require Prior Authorization. 6 E-Visits - Medical For Primary Care For Primary Care per visit No or Coinsurance for Immunizations to age 5 For Specialty Care For Specialty Care per visit No or Coinsurance for Immunizations to age 5 For Primary Care For Primary Care $30 Copay per visit For Specialty Care For Specialty Care $75 Copay per visit For Primary Care For Primary Care per visit For Specialty Care For Specialty Care $15 Copay per visit 7 8 Convenience Care / Walk in Clinic (WIC) Covered received at a retail health clinic for the treatment of minor health concerns that do not constitute an Emergency or an Urgent Care. Chiropractic 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 Coverage is provided for worldwide emergency health services as defined in the Certificate of Coverage. Includes facility and professional charges. $30 Copay per visit $20 Copay per visit $350 Copay per visit $350 Copay per visit (Waived if patient is admitted) (Waived if patient is admitted)

3 10 Ambulance Coverage is provided for Emergency as defined in the COC BENEFIT AND SERVICES Urgent Care 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 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. $300 Copay per occurrence $300 Copay per occurrence $90 Copay per visit $90 Copay per visit $30 Copay first visit only $750 Copay per admission 30% Coinsurance per admission 14 Outpatient 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. 15 High Technology Diagnostic, 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 Surgery Benefits are provided for Covered rendered at an outpatient hospital for free standing surgery center. Requires Prior Authorization. Injectable Medications Requires Prior Authorization. $500 Copay per visit $500 Copay per visit 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 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. $750 Copay per admission 30% Coinsurance per admission $750 Copay per admission 30% Coinsurance per admission 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 0% Coinsurance of covered expenses 100% of Covered Eyewear 30% Coinsurance of covered expenses 30% Coinsurance of covered expenses

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. $75 Copay per visit 27 Inpatient Rehabilitation Therapy Includes short-term inpatient rehabilitation services. $750 Copay per admission 30% Coinsurance per admission 28 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. $750 Copay per admission 30% Coinsurance per admission 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. $500 Copay per visit $75 Copay per visit 31 Transplant and supplies for transplants are Covered when Participating Coventry Transplant Network Providers are utilized. Requires Prior Authorization. $750 Copay per admission Not Covered 32 Modified Foods (PKU/Metabolic Formula) 50% Coinsurance 50% Coinsurance after 33 Temporomandibular Joint Disorder 34 Bariatric Surgery Requires prior authorization. 35 Family Planning Coverage includes diagnosis and treatment of infertility, including coverage for IVF, GIFT, and ZIFT. All services require Prior Authorization.

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 : 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 Maximum. Breast Feeding Durable Medical Equipment Maximum: Breast pumps and supplies are limited to 1 electric breast pump per 36 months Female Contraceptive Counseling : 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 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 For Primary Care $0 per visit No or Coinsurance for Immunizations to age 5 For Specialty Care For Specialty Care $0 per visit No or Coinsurance for Immunizations to age 5 For Primary Care For Primary Care $0 per visit For Specialty Care For Specialty Care $0 per visit

8 BENEFIT AND SERVICES 38 Hearing Aids (Children over 5 Years of age) 0% Coinsurance per hearing aid 30% Coinsurance per hearing aid **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 Not Applicable Not Applicable Important Reminder: Not Applicable PHARMACY BENEFIT PER PRESCRIPTION COPAYMENTS/COINSURANCE Prescription Drug - Retail: For each 31 day supply filled at a retail pharmacy. 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 Tier 1: Preferred Generic Drugs $3 Copay 50% Coinsurance after $6 Copay 50% Coinsurance after $10 Copay 50% Coinsurance after $20 Copay 50% Coinsurance after Tier 2: Preferred Brand Drugs Tier 3: Non-Preferred Brand/Generic Drugs Retail: Mail Order: Retail: $55 Copay 50% Coinsurance after $ Copay 50% Coinsurance after $80 Copay 50% Coinsurance after Mail Order: Tier 4: Preferred Specialty Drugs Covered when Prior Authorized by the Plan. 30% Coinsurance up to $250 maximum per prescription $240 copay 50% Coinsurance after 50% Coinsurance after Tier 5: Non-Preferred Specialty Drugs Covered when Prior Authorized by the Plan. 50% Coinsurance up to $500 maximum per prescription 50% Coinsurance after

10 Pediatric Vision Benefit Vision Care * * 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 100% coverage for provider designated frames 100% coverage for provider designated contact lenses Paid in Full 50% Coinsurance per visit

11 Pediatric Dental Care Benefit Schedule of Benefits Pediatric Dental Care Description of Covered Type In-Network Out-of-Network PREVENTIVE & DIAGNOSTIC Routine Exams/Evaluations (Limited to 1 per 6 months) I Cleanings (Limited to 1 per 6 months) I X-rays I Fluoride (One per year) I Sealants I BASIC Space Maintainer II 50% Coinsurance 50% Coinsurance Fillings II 50% Coinsurance 50% Coinsurance Denture Relines II 50% Coinsurance 50% Coinsurance General Anesthesia, IV Sedation, Conscious Sedation, Therapeutic Drug Injection, Nitrous Oxide (Requires pre-determination) II 50% Coinsurance 50% Coinsurance General II 50% Coinsurance 50% Coinsurance MAJOR Crowns Requires pre-determination Removable Prostodontic : Dentures (Complete: Upper and Lower; Partial: Upper and Lower) Requires pre-determination Fixed Prosthetic - Bridges Requires pre-determination III 50% Coinsurance 50% Coinsurance III 50% Coinsurance 50% Coinsurance III 50% Coinsurance 50% Coinsurance Endodontics III 50% Coinsurance 50% Coinsurance 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 50% Coinsurance 50% Coinsurance III 50% Coinsurance 50% Coinsurance IV 50% Coinsurance 50% Coinsurance & 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 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