2015 Benefits Summaries

Transcription

1 2015 Benefits Summaries SUMMARY OF BENEFITS DEDUCTIBLES & MAXIMUMS MEDICAL BENEFIT SUMMARY UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM PREMIUM PPO PLAN BENEFIT PLAN 001 DOMESTIC NETWORK UNC Providers Tier-1 IN-NETWORK UHC Choice Plus Providers Tier-2 NON-NETWORK Lifetime Benefit Maximum Unlimited Unlimited Unlimited Annual Deductible $600 Single $1,200 Family $1,000 Single $2,000 Family Tier-3 $1,000 Single $2,000 Family Member Coinsurance 15% 20% 30% Out-of-Pocket Maximum Includes Calendar Year Deductible, Medical Copays, Member Coinsurance & Rx Copays. $2,000 Single $4,000 Family $2,500 Single $5,000 Family $4,000 Single $8,000 Family TIERS-1 AND 2 CROSS-FEED FOR DEDUCTIBLE AND OUT-OF-POCKET MAXIMUM AMOUNTS. PREVENTIVE CARE & OFFICE VISITS Physician Office Visit Primary Care providers $15 Copay then 100% $25 Copay then 100% Specialist Office Visit $25 Copay then 100% $50 Copay then 100% Preventive Office Visit Primary Care or Specialist 100% 100% Well Baby Office Visit 100% 100% Routine Lab & X-rays Primary Care or Specialist Vision Care Diagnostic visits only 100% 100% calendar year for ages 19 and older; No maximum for calendar year for ages 19 and older; No maximum for Prenatal Care 100% 100% Postnatal Care INPATIENT & OUTPATIENT Inpatient Facility & Physician Services Outpatient Hospital & Surgery Services including Physician & Surgeon DIAGNOSTIC Outpatient Hospital Lab and X-rays Covered at 85% after Covered at 85% after Covered at 85% after $15 Copay then 100% Independent Clinical Lab Facilities $15 Copay then 100% Outpatient Advanced Imaging (MRI, MRA, CT, CAT Scan) $15 Copay then 100% PET Scans $15 Copay then 100% calendar year for ages 19 and older; No maximum for. Note: Surgery is excluded 33

2 2015 Benefits Summaries SUMMARY OF BENEFITS DOMESTIC NETWORK UNC Providers Tier-1 IN-NETWORK UHC Choice Plus Providers Tier-2 NON-NETWORK URGENT CARE & EMERGENCY Urgent Care Includes Lab & X-ray & Physician $30 Copay then 100% $50 Copay then 100% $50 Copay then 100% Emergency Room Facility Services & Physician $175 Copay and then 100% $175 Copay and then 100% $175 Copay and then 100% MENTAL HEALTH/SUBSTANCE DEPENDENCY Inpatient Facility Services Covered at 85% after Inpatient Physician Covered at 85% after Outpatient Hospital Services Covered at 85% after Outpatient Hospital Physician Covered at 85% after Physician Office Visit Primary Care providers $15 Copay then 100% $25 Copay then 100% Specialist Office Visit $25 Copay then 100% $50 Copay then 100% OTHER Chiropractic Care 30 Visits per Calendar Year combined for all tier levels Durable Medical Equipment Occupational and Physical Therapy 30 Visits per Calendar Year for Occupational Therapy combined for all tier levels 30 Visits per Calendar Year for Physical Therapy combined for all tier levels Speech Therapy 30 Visits per Plan Year combined for all tier levels Infertility Treatment PHARMACY INFORMATION Prescription Drugs Member Cost Share $25 Copay then 100% $50 Copay then 100% Covered at 85% after $25 Copay then 100% $25 Copay then 100% facility in which it is performed. Lifetime benefit maximum of $7,500. UNC In-house Pharmacies 30-day Supply Outpatient Hospital Setting Office Setting $50 Copay then 100% Outpatient Hospital Setting Office Setting $50 Copay then 100% facility in which it is performed. Lifetime benefit maximum of $7,500. Retail 30-day Supply Tier-3 facility in which it is performed. Lifetime benefit maximum of $7,500. UNC In-house Mail Order 90-day Supply Generic $0 $10 Copay $0 Preferred Brand $20 Copay $30 Copay $40 Copay Non-Preferred Brand $35 Copay $45 Copay $70 Copay Specialty $100 Copay No Coverage No Coverage 34

3 2015 Benefits Summaries MEDICAL BENEFIT SUMMARY UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM STANDARD PPO PLAN BENEFIT PLAN 002 SUMMARY OF BENEFITS DEDUCTIBLES & MAXIMUMS DOMESTIC NETWORK UNC Providers Tier-1 IN-NETWORK UHC Choice Plus Providers Tier-2 NON-NETWORK Lifetime Benefit Maximum Unlimited Unlimited Unlimited Annual Deductible $1,000 Single $2,000 Family $2,000 Single $4,000 Family Tier-3 $3,000 Single $6,000 Family Member Coinsurance 20% 25% 40% Out-of-Pocket Maximum Includes Calendar Year Deductible, Medical Copays, Member Coinsurance & Rx Copays. $3,000 Single $6,000 Family $5,000 Single $10,000 Family $7,000 Single $14,000 Family TIERS-1 AND 2 CROSS-FEED FOR DEDUCTIBLE AND OUT-OF-POCKET MAXIMUM AMOUNTS. PREVENTIVE CARE & OFFICE VISITS Physician Office Visit $25 Copay then 100% $30 Copay then 100% Primary Care providers Specialist Office Visit $50 Copay then 100% $60 Copay then 100% Preventive Office Visit Primary Care or Specialist 100% 100% Well Baby Office Visit 100% 100% Routine Lab & X-rays Primary Care or Specialist Vision Care Diagnostic visits only 100% 100% calendar year for ages 19 and older; No maximum for calendar year for ages 19 and older; No maximum for Prenatal Care 100% 100% Postnatal Care INPATIENT & OUTPATIENT Inpatient Facility Services Inpatient Physician Outpatient Hospital & Surgery Services Outpatient Hospital Physician & Surgeon DIAGNOSTIC Outpatient Hospital Lab and X-rays $25 Copay then 100% Independent Clinical Lab Facilities $25 Copay then 100% Outpatient Advanced Imaging (MRI, MRA, CT, CAT Scan, PET Scans $25 Copay then 100% calendar year for ages 19 and older; No maximum for. Note: Surgery is excluded.. Note: Surgery is excluded. 35

4 2015 Benefits Summaries SUMMARY OF BENEFITS DOMESTIC NETWORK UNC Providers Tier-1 IN-NETWORK UHC Choice Plus Providers Tier-2 NON-NETWORK URGENT CARE & EMERGENCY Urgent Care Includes Lab & X-ray & Physician $40 Copay then 100% $50 Copay then 100% $50 Copay then 100% Emergency Room Facility Services & Physician $175 Copay and then 100% $175 Copay and then 100% $175 Copay and then 100% MENTAL HEALTH/SUBSTANCE DEPENDENCY Inpatient Facility Services Inpatient Physician Outpatient Hospital Services Outpatient Hospital Physician Physician Office Visit Primary Care providers $25 Copay then 100% $30 Copay then 100% Specialist Office Visit $50 Copay then 100% $60 Copay then 100% OTHER Chiropractic Care 30 Visits per Calendar Year combined for all tier levels Durable Medical Equipment Occupational and Physical Therapy 30 Visits per Calendar Year for Occupational Therapy combined for all tier levels 30 Visits per Calendar Year for Physical Therapy combined for all tier levels Speech Therapy 30 Visits per Plan Year combined for all tier levels Infertility Treatment PHARMACY INFORMATION $50 Copay then 100% $60 Copay then 100% $50 Copay then 100% $50 Copay then 100% facility in which it is performed. Lifetime benefit maximum of $7,500. Outpatient Hospital Setting Office Setting $60 Copay then 100% Outpatient Hospital Setting Office Setting $60 Copay then 100% facility in which it is performed. Lifetime benefit maximum of $7,500. Tier-3 facility in which it is performed. Lifetime benefit maximum of $7,500. Prescription Drugs Member Cost Share UNC In-house Pharmacies 30-day Supply Retail 30-day Supply UNC In-house Mail Order 90-day Supply Generic $0 $10 Copay $0 Preferred Brand $35 Copay $45 Copay $70 Copay Non-Preferred Brand $60 Copay $70 Copay $120 Copay Specialty $125 Copay No Coverage No Coverage 36

5 2015 Benefits Summaries MEDICAL BENEFIT SUMMARY UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM HIGH DEDUCTIBLE HEALTH PLAN BENEFIT PLANS 003 AND 013 SUMMARY OF BENEFITS DEDUCTIBLES & MAXIMUMS DOMESTIC NETWORK UNC Providers Tier-1 IN-NETWORK UHC Choice Plus Providers Tier-2 NON-NETWORK Lifetime Benefit Maximum Unlimited Unlimited Unlimited Annual Deductible $1,500 Single $3,000 Family $2,000 Single $4,000 Family Tier-3 $2,500 Single $5,000 Family Member Coinsurance 20% 25% 35% Out-of-Pocket Maximum Includes Calendar Year Deductible & Member Coinsurance $3,000 Single $6,000 Family $3,500 Single $7,000 Family $5,000 Single $10,000 Family TIERS-1 AND 2 CROSS-FEED FOR DEDUCTIBLE AND OUT-OF-POCKET MAXIMUM AMOUNTS. PREVENTIVE CARE & OFFICE VISITS Physician Office Visit Primary Care & Specialist Preventive Office Visit Primary Care or Specialist 100% 100% Well Baby Office Visit 100% 100% Routine Lab & X-rays Primary Care or Specialist Vision Care Diagnostic visits only 100% 100% calendar year for ages 19 and older; No maximum for calendar year for ages 19 and older; No maximum for Prenatal Care 100% 100% Postnatal Care INPATIENT & OUTPATIENT Inpatient Facility Services Inpatient Physician Outpatient Hospital & Surgery Services Outpatient Hospital Physician & Surgeon DIAGNOSTIC Outpatient Hospital Lab and X-rays Independent Clinical Lab Facilities Outpatient Advanced Imaging (MRI, MRA, CT, CAT Scan) PET Scans calendar year for ages 19 and older; No maximum for. Note: Surgery is excluded. Note: Surgery is excluded 37

6 2015 Benefits Summaries SUMMARY OF BENEFITS URGENT CARE & EMERGENCY Urgent Care Includes Lab & X-ray & Physician Emergency Room Facility Services & Physician DOMESTIC NETWORK UNC Providers Tier-1 MENTAL HEALTH/SUBSTANCE DEPENDENCY Inpatient Facility Services Inpatient Physician Outpatient Hospital Services Outpatient Hospital Physician Physician Office Visit Primary Care providers Specialist Office Visit OTHER Chiropractic Care 30 Visits per Calendar Year combined for all tier levels Durable Medical Equipment Occupational and Physical Therapy 30 Visits per Calendar Year for Occupational Therapy combined for all tier levels 30 Visits per Calendar Year for Physical Therapy combined for all tier levels Speech Therapy 30 Visits per Plan Year combined for all tier levels Infertility Treatment PHARMACY INFORMATION Prescription Drugs Generic Preferred Brand Non-Preferred Brand Specialty facility in which it is performed. Lifetime benefit maximum of $7,500. UNC In-house Pharmacies 30-day Supply Covered at 90% after IN-NETWORK UHC Choice Plus Providers Tier-2 facility in which it is performed. Lifetime benefit maximum of $7,500. Retail 30-day Supply Covered at 90% after No Coverage NON-NETWORK Tier-3 Benefit varies based on the facility in which it is performed. Lifetime benefit maximum of $7,500. UNC In-house Mail Order 90-day Supply Covered at 90% after No Coverage 38

7 UNC Health Care Affiliates Dental Plan UNC Health Care Affiliates is offering employees in all locations a choice of two dental plan options that will go into effect 1/1/2015. These plans are referred to as the Standard Plan and the Premium Plan. You may select the plan that best meets you and your family s needs. Whichever plan is chosen will remain in effect until the next annual election period. Under either plan, you may cover your eligible dependents. Dependents would receive the same plan chosen by the employee. PPO Information Under both the Standard and the Premium plans, you have the choice of using any provider. Both plans provide access to Ameritas PPO network. To find a provider, visit ameritasgroup.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. When prompted to select your network, choose PPO Dental Network. Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of your responsibility and the covered insurance portion. That way, there won't be any surprises once the work has been completed. Ameritas Information We're Here to Help This plan was designed specifically for the employees of UNC Health Care Affiliates. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 8 a.m. to 1 a.m. (Eastern Time) Monday through Thursday, and 8 a.m. to 7:30 p.m. on Friday. You can speak to them by calling toll-free: For plan information any time, access our automated voice response system or go online to We are pleased to provide our Toll-Free Enrollment Welcome Line which is available for questions about the plan options, provider questions, work in progress, and more. This line is available 10/24/ /14/2014 by calling After the plan goes into effect on 1/1/2015, please call toll free: This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator. 39

8 UNC Health Care Affiliates Dental Plan Standard Dental Plan Summary Effective 1/1/2015 Coinsurance Type 1 100% Type 2 80% Type 3 50% Deductible Maximum (per person) Allowance Waiting Period $50/Calendar Year Type 2 & 3 Per Individual Waived Type 1 $100/family $1,000 per calendar year Usual & Customary None Orthodontia Summary - Adult and Child Coverage Allowance Coinsurance Lifetime Maximum (per person) Waiting Period Not Covered Sample Procedure Listing (Current Dental Terminology American Dental Association.) Type 1 Type 2 Type 3 Routine Exam (2 per benefit period) Bitewing X-rays (2 per benefit period) Full Mouth/Panoramic X-rays (1 in 3 years) Periapical X-rays Cleaning (2 per benefit period) Fluoride for Children 18 and under (1 per benefit period) Sealants (age 16 and under) Space Maintainers Restorative Amalgams Restorative Composites Periodontics (nonsurgical) Periodontics (surgical) Denture Repair Simple Extractions Complex Extractions Anesthesia Onlays Crowns (1 in 5 years per tooth) Crown Repair Endodontics (nonsurgical) Endodontics (surgical) Prosthodontics (fixed bridge; removable complete/partial dentures) ( 1 in 5 years) Implants 40

9 UNC Health Care Affiliates Dental Plan Premium Dental Plan Summary Effective 1/1/2015 Coinsurance Type 1 100% Type 2 80% Type 3 60% Deductible Maximum (per person) Allowance Waiting Period $0/Calendar Year Type 2 & 3 Per Individual Waived Type 1 No Family Maximum $1,500 per calendar year Usual & Customary None Orthodontia Summary - Adult and Child Coverage Allowance Usual & Customary Coinsurance 50% Lifetime Maximum (per person) $1,500 Waiting Period None Sample Procedure Listing (Current Dental Terminology American Dental Association.) Type 1 Type 2 Type 3 Routine Exam (2 per benefit period) Bitewing X-rays (2 per benefit period) Full Mouth/Panoramic X-rays (1 in 3 years) Periapical X-rays Cleaning (2 per benefit period) Fluoride for Children 18 and under (1 per benefit period) Sealants (age 16 and under) Space Maintainers Restorative Amalgams Restorative Composites Periodontics (nonsurgical) Periodontics (surgical) Denture Repair Simple Extractions Complex Extractions Anesthesia Onlays Crowns (1 in 5 years per tooth) Crown Repair Endodontics (nonsurgical) Endodontics (surgical) Prosthodontics (fixed bridge; removable complete/partial dentures) ( 1 in 5 years) Implants 41

10 UNC Health Care Affiliates Dental Plan Dental Rewards Both the Standard Plan and the Premium Plan include a valuable feature that allows qualifying plan members to carryover part of their unused annual maximum. A member earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. In addition, a person earning dental rewards who submits a claim for services received through the dental PPO network earns an extra reward, called the PPO Bonus. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year. Standard Plan & Premium Plan Benefit Threshold $500 Dental benefits received for the year cannot exceed this amount Annual Carryover Amount $250 Dental Rewards amount is added to the following year's maximum Annual PPO Bonus $100 Additional bonus is earned if the member sees a PPO provider Maximum Carryover $1,000 Maximum possible accumulation for Dental Rewards and PPO Bonus combined 42

11 UNC Health Care provides a comprehensive vision benefit through the EyeMed program for you and your eligible family members. EyeMed s vision benefit is designed to provide routine preventive care such as eye exams, eyewear and other vision services along with discounts on a second pair of glasses and balances over your allowances. EyeMed has a large network of providers that offers a wide selection of eyewear for you to choose from. You ll receive the most out of your benefit when you visit an EyeMed eye doctor, including discounts on non-covered services and selections. The EyeMed network is comprised of both independent and optical retail locations. You ll have access to thousands of private practitioners and the nation s leading optical retailers: LensCrafters, Target Optical, JCPenney Optical, Sears Optical and most Pearle Vision locations. To locate a participating provider, visit the EyeMed website at and choose the INSIGHT network. EyeMed Vision Standard Plan Feature/Service In-Network Out-of-Network Frequency of Exams, Lenses, Contacts, & Frames Exams, Lenses, Contacts: Once every 12 months Frames: Once every 24 months Exam Copay $10 Copay Up to $30 reimbursement Because many eye and vision conditions exhibit no obvious symptoms, individuals are often unaware that there is a problem. Early diagnosis and treatment of eye disorders such as cataracts, glaucoma and macular degeneration are important for maintaining good vision and preventing permanent vision loss. Adults should have at least one eye exam between the ages of 20 and 29, two exams between ages 30 and 39, one exam every four years from age 40 to 65 and one exam every one or two years after age 65. Basic Lenses Copay Single Vision Lined Bifocal Lined Trifocal Lenticular Frames Frame Allowance Contact Lens Elective Conventional Medically Necessary $25 Copay $25 Copay $25 Copay $25 Copay $0 copay, up to $150 retail allowance, then 20% discount off balance Up to $150 allowance Paid in Full Up to $25 reimbursement Up to $40 reimbursement Up to $60 reimbursement Up to $60 reimbursement Up to $75 reimbursement Up to $120 reimbursement Up to $210 reimbursement To access your vision benefit: 1. For a complete list of providers near you, use the Provider Locator on and choose the INSIGHT network or call Schedule an appointment. When making the appointment, tell the office that you are an EyeMed member and provide your name, the name of your organization or plan, and your member ID number. 3. When you arrive, identify yourself as an EyeMed member and present your ID card. 4. Your EyeMed provider will take care of the rest! Need eye exams or eyewear? (EyeMed) Monday Saturday 8am to 11pm Sundays 11am to 8pm Eastern Time Ready for LASIK? For Lasik providers, call LASER6 or visit To learn more about EyeMed... Visit 43

12 When you visit your eye doctor, be sure to bring: Your current contact lenses or eyeglasses, if available A copy of your last eyewear prescription, if available To Access Laser vision discount call the US Laser network at laser6 to find the laser correction provider most convenient for you When making an appointment tell the provider that you are an EyeMed member. EyeMed Vision Premium Plan Feature/Service In-Network Out-of-Network Frequency of Exams, Lenses, Contacts, & Frames Exams, Lenses, Contacts: Once every 12 months Frames: Once every 12 months Exam Copay $0 Copay Up to $32 reimbursement Basic Lenses Copay Single Vision Lined Bifocal Lined Trifocal Lenticular Frames Frame Allowance Contact Lens $20 Copay $20 Copay $20 Copay $20 Copay $0 copay, up to $200 retail allowance, then 20% discount off balance Up to $25 reimbursement Up to $40 reimbursement Up to $60 reimbursement Up to $60 reimbursement Up to $100 reimbursement Elective Conventional Medically Necessary Up to $200 allowance Paid in Full Up to $160 reimbursement Up to $210 reimbursement 44