2016 Optima Health Plan Comparison Summary of Benefits

Transcription

1 2016 Optima Health Plan Comparison Summary of Benefits The following are highlights of the health plan design changes effective January 1, Some services may have limits associated with them or may require Pre-Authorization. The City of Virginia Beach and Virginia Beach City Public Schools reserve the right to modify, amend, or terminate the health and retirement benefits as they apply to all future, current, and/or retired employees. The Administrator of each benefit plan has the discretionary authority to determine eligibility for benefits and to interpret the Plan s terms. PLAN FEATURES Deductible (per calendar year) 3 $850 per Individual $1,700 per Family $1,700 per Individual $3,400 per Family $1,300 Employee only coverage $2,600 per Family $2,600 Employee only coverage $5,200 per Family $2,000 Employee only coverage $4,000 per Family $4,000 Employee only coverage $8,000 per Family Maximum Out-of-Pocket Limit (per calendar year) $3,000 per Individual 4 $6,000 per Family 4 $4,500 per Individual 5 $9,000 per Family 5 $3,500 Employee only coverage 4 $7,000 Family 4 (not to exceed $6,850 for one individual) $5,500 Employee only coverage 5 $11,000 per Family 5 $4,000 Employee only coverage 4 $8,000 per Family 4 (not to exceed $6,850 for one individual) $6,500 Employee only coverage 5 $13,000 per Family 5 PHYSICIANS OFFICE VISITS Includes Covered Services performed in the Physician s office during the Physician office visit. Includes, but is not limited to, Office consults and exams; In-office surgery; In-office lab, x-ray, injections, and diagnostic and treatment services; Family planning services including injectables and vasectomy; Physical, Occupational, and Speech Therapy; Cardiac, Pulmonary, and Vascular Rehabilitation Services; Chemo, Radiation, IV, and Respiratory therapy services; Dialysis treatments. Pre-Authorization is required for in-office surgery 6 MDLIVE Services $10 Copay 1 $10 Copay 1 Covered at 80% AD Covered at 80% AD Covered at 75% AD Covered at 75% AD Physicians Office Visit (PCP) $20 Copay 1 Covered at 60% 1 Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD Specialist Office Visit $40 Copay 1 Covered at 60% 1 Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD Preventive Care 10 Covered at 100% 1 Covered at 60% AD Covered at 100% 1 Covered at 50% AD Covered at 100% 1 Covered at 50% AD Routine Annual Physical Exams, Well Baby Exams, Annual GYN Exams and Pap Smears, PSA Tests, Colorectal Cancer Tests, Routine Adult and Childhood Immunizations Screening Colonoscopy, Screening Mammograms Women s Preventive Services Physical/Occupational Therapy Speech Therapy OUTPATIENT THERAPY SERVICES, REHABILITATON SERVICES Limited to a maximum combined benefit with In-Network and benefits and for all places of service of 30 visits per illness or condition. 7 Copayment or Coinsurance applies at any place of service. Limited to a maximum combined benefit with In-Network and benefits and for all places of service of 30 visits per illness or condition. 7 Copayment or Coinsurance applies at any place of service. Cardiac Rehabilitation, Pulmonary Rehabilitation, Vascular Rehabilitation, Vestibular Rehabilitation Chemotherapy, Radiation Therapy, IV Therapy, Inhalation Therapy Services are limited to a maximum combined benefit with In-Network and benefits and for all places of service of 90 consecutive days per illness or condition. 7 Copayment or Coinsurance applies at any place of service. Per visit: $20 Copay 1 - Physicians Office $40 Copay 1 - Specialist Office Covered at 85% AD - Outpatient Facility Per visit: Covered at 60% 1 - Physicians Office Covered at 60% 1 - Specialist Office Covered at 60% AD - Outpatient Facility ADAfter Deductible (deductible must be paid first before the plan will provide coverage as indicated) 1Deductible does not apply to this service (plan will provide coverage as indicated and before the deductible has been met) Covered at 80% AD Covered at 50% AD Per visit: Covered at 75% AD Per visit: Covered at 50% AD

2 OTHER OUTPATIENT TREATMENTS Pre-Authorized Injectable and Infused Medications Includes injectable and infused medications, biologics, and IV therapy medications that require prior authorization. Coinsurance applies when medications are provided in a Physician s office, outpatient facility, or in the Member s home as part of Skilled Home Health Care Services benefit. Coinsurance is in addition to any applicable office visit or outpatient facility Copayment or Coinsurance. OUTPATIENT DIALYSIS SERVICES Dialysis Services Outpatient Surgery Copayment or Coinsurance applies at any place of service. OUTPATIENT SURGERY Coinsurance or Copayment applies to services provided in a free-standing ambulatory surgery center or hospital outpatient surgical facility. OUTPATIENT DIAGNOSTIC PROCEDURES Copayment or Coinsurance will apply when a procedure is performed in a free-standing outpatient facility or lab, or a hospital outpatient hospital facility or lab. Outpatient Diagnostic Procedures Outpatient X-Ray, Ultrasound, Doppler Studies Outpatient Lab Work OUTPATIENT ADVANCED IMAGING AND TESTING PROCEDURES MRI, MRA, PET Scans, CT Scans, CTA Scans Copayment or Coinsurance applies to procedures done in a free-standing outpatient facility or hospital outpatient facility. MATERNITY CARE Maternity Care 8,10,11 $350 Copayment 1 Covered at 60% AD Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD Pre-Authorization is Required for prenatal services 6 Includes prenatal, delivery, postnatal, postpartum services, and home health visits for subscriber and spouse. Coverage for any maternity related services for obstetrical, prenatal, perinatal, or post-partum care for a dependent child is excluded from Coverage. Copayment or Coinsurance is in addition to any applicable inpatient hospital Copayment or Coinsurance. Inpatient Hospital Services INPATIENT SERVICES Transplants are covered at contracted facilities only. Skilled Nursing Facilities/Services 7 Ambulance Services 9 Pre-Authorization is required 6 for non-emergent transportation only. Following inpatient hospital care or in lieu of hospitalization. Covered Services include up to 100 days combined in and out of network per calendar year that in the Plan s judgment requires Skilled Nursing Facility Services. 7 AMBULANCE SERVICES Covered at 85% 1 Covered at 85% 1 Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD If transported by a Virginia Beach Volunteer Rescue Squad Covered at 100%. Includes air and ground ambulance for emergency transportation, or non-emergent transportation that is Medically Necessary and Pre-Authorized by the Plan. Copayment or Coinsurance is applied per transport each way.

3 Emergency Services 9 Pre-authorization is not required Urgent Care Center Services 9 Pre-Authorization is not required. Inpatient Services (Residential Treatment is not covered) Outpatient Services Pre-Authorization may be required 6 EMERGENCY SERVICES Covered at 85% AD Covered at 85% AD Covered at 80% AD Covered at 80% AD Covered at 75% AD Covered at 75% AD Includes Emergency Services, Physician, and ancillary services provided in an emergency department facility. Coinsurance waived for facility charges if admitted. Inpatient copayment /coinsurance will apply if admitted. URGENT CARE CENTER SERVICES Covered at 85% 1 Covered at 60% 1 Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD Includes Urgent Care Services, Physician services, and other ancillary services received at an Urgent Care facility. If You are transferred to an emergency department from an urgent care center, You will pay an Emergency Services Copayment or Coinsurance. MENTAL/BEHAVIORAL HEALTH CARE Covered at 85% Covered at 60% Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD $20 Copay 1 Covered at 60% AD Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD Includes inpatient and outpatient services for the treatment of mental health and substance abuse. Also includes services for Biologically Based Mental Illnesses for the following diagnoses: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, autism, and drug and alcoholism addiction. OTHER COVERED SERVICES Allergy Care Covered at 85% 1 Covered at 60% AD Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD Prosthetic Limbs & Components Includes Allergy testing, Injections, Serum and RAST testing. Services include coverage for medically necessary prosthetic devices. This also includes repair, fitting, replacement and components. Definitions: Component means the materials and equipment needed to ensure the comfort and functioning of a prosthetic device. Limb means an arm, a hand, a foot, or any portion of an arm, hand, a leg or foot. Prosthetic device means an artificial device to replace, in whole or in part, a limb. Prosthetic device coverage does not mean or include repair and replacement due to enrollee neglect, misuse, or abuse. Coverage also does not mean or include prosthetic devices designed primarily for an athletic purpose. Chiropractic Care 7 - Optima Health contracts with American Specialty Health Networks (ASHN) to administer this benefit 6. Pre-Authorization is required by ASHN for all chiropractic care services. 6 Covered at 85% 1 of ASHN Fee Schedule Covered at 60% 1 of ASHN Fee Schedule Covered at 80% AD of ASHN Covered at 50% AD of ASHN Covered at 75% AD of ASHN Covered at 50% AD of ASHN To receive services, contact ASHN's Member Services at Representatives are available from 8:00 AM to 9:00 PM Monday-Friday. Coverage is limited to a combined maximum benefit with in and out-of-network benefits of 30 visits per Person, per calendar year. 7 For providers not in the ASHN network the Member will be responsible for payment of all charges in excess of ASHN s allowable charge in addition to any coinsurance amount. Allowable charge is the lesser of the provider s actual charge or ASHN s In- Network fee schedule for the same services.

4 Diabetic Supplies and Equipment Includes FDA approved for the treatment of diabetes and in person outpatient self-management training and education including medical nutrition therapy. insulin pump infusion sets if Covered at 100% 1 100% 1 therapy: Covered at 100% 1 insulin pump infusion sets if Covered at 60% 1 100% 1 therapy: Covered at 100% 1 Covered at 100% AD 100% AD therapy: Covered at 100% AD Covered at 50% AD 100% AD therapy: Covered at 100% AD Covered at 80% AD 50% AD therapy: Covered at 100% AD Covered at 50% AD 50% AD therapy: Covered at 50% AD Insulin, syringes, and needles are covered under the Plan s Prescription Drug Benefit for the applicable Copayment or Coinsurance per 31 day supply. An annual diabetic eye exam is covered from an Optima Plan Provider, a participating EyeMed Provider, or a Non-Plan Provider at the applicable office visit Copayment or Coinsurance amount. For more information about how to access this benefit for meters, strips and lancets, please call one of the following providers: Liberty Medical Supplies: Home Care Delivered: EdgePark Medical Supplies: You may also call or SENTARA for information on educational classes. Durable Medical Equipment & Supplies 7, Orthopedic Devices & Prosthetic Appliances 7 Pre-Authorization is required for single items over $ Pre-Authorization is required for all rental items. 6 Pre-Authorization is required for repair and replacement. 6 Covered Services include durable medical equipment, orthopedic devices, prosthetic appliances other than artificial limbs, colostomy, ileostomy and tracheostomy supplies, suction and urinary catheters, and repair/replacement. Early Intervention Services 6 Members are responsible for any Applicable Copayment, Coinsurance, or Deductible dependent on the type and place of service. Pre-Authorization is Required. 6 Coverage for Dependents from birth to age three who are certified as eligible by the Virginia Department of Behavioral Health and Developmental Services. Covered Services include: Medically Necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices. Family Planning - Depo-Provera Injection, Lunelle Injection, Tubal Ligation. Vasectomy (Subject to any applicable outpatient/inpatient surgery copayment) Hearing Aid Rider Covered at 100% 1 Covered at 60% AD Covered at 100% 1 Covered at 50% AD Covered at 100% 1 Covered at 50% AD Covered at 100% AD Covered at 60% AD Covered at 100% AD Covered at 50% AD Covered at 100% AD Covered at 50% AD $40 Copay per visit AD Covered at 60% AD Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD Covered up to $1,250 per hearing aid. Includes replacement every 36 months. Batteries are not covered. Home Health Care Skilled Covered at 85% Services 7 AD Covered at 60% AD Covered at 80% AD Covered at 50% AD Covered at 75% AD Covered at 50% AD Pre-Authorization is Required. 6 Services are covered up to a maximum combined benefit with In-Network and benefits of 100 visits per calendar year for Members who are home bound, and in the Plan s judgment require Home Health Skilled Services. 7 You will pay a separate outpatient therapy Copayment or Coinsurance amount for physical, occupational, and speech therapy visits received at home. Therapy visits received at home will count toward Your Plan s annual outpatient therapy benefit limits. You will pay a separate outpatient rehabilitation services Copayment or Coinsurance amount for cardiac, pulmonary, vascular, and vestibular rehabilitation visits received at home. Rehabilitation visits received at home will count toward Your Plan s annual outpatient rehabilitation benefit limits. Hospice Care

5 Vision Care & Materials 7 - Optima Health contracts with EyeMed Vision Care to administer this benefit. To locate a participating EyeMed Vision Care provider please call or visit Medical conditions related to the eye, such as glaucoma, are covered under the medical plan Specialist Office Visit. Pharmacy Maximum Limit Pharmacy Preferred Network (Walgreens, Walmart or Sam s Club Preferred Pharmacy) Spectacle Exam: $20 Copay OR Contact Exam: $40 Copay $40 maximum reimbursement for eye exam only. Spectacle Exam: $20 Copay OR Contact Exam: $40 Copay Limited to one eye examination every 12 months (from the date of last exam) by a participating EyeMed Provider. Lenses: Covered at 100% (single vision bifocal, trifocal) Frames: Covered in full up to $100 retail Contacts: Covered in full up to $95 retail (in lieu of glasses) No coverage for eyeglasses/ contacts out-of-network. Lenses: Covered at 100% (single vision bifocal, trifocal) Frames*: Covered in full up to $100 retail Contacts*: Covered in full up to $95 retail (in lieu of glasses) $40 maximum reimbursement for eye exam only. No coverage for eyeglasses/ contacts out-of-network. Spectacle Exam: $20 Copay OR Contact Exam: $40 Copay Lenses: Covered at 100% (single vision bifocal, trifocal) Frames: Covered in full up to $100 retail Contacts: Covered in full up to $95 retail (in lieu of glasses) $40 maximum reimbursement for eye exam only. No coverage for eyeglasses/contacts out-of-network. Limited to one pair of frames, lenses (single vision, bifocal, trifocal) or contact lenses from a participating EyeMed Vision Care Provider once every 12 months (from the date of last exam). If you choose contact lenses when they are not medically indicated, you will receive an allowance of $95 toward the purchase price. (Contact lenses are deemed medically) PRESCRIPTION DRUG BENEFIT Outpatient prescription drug copays or coinsurance are applied to the plans Maximum Out-of-Pocket Limit. Tier 1: $10 Copay 1 Tier 2: $25 Copay 1 Tier 3: Covered at 75% 1 (Max. $50) Non-Preferred Pharmacy Tier 1: $25 Copay 1 Tier 2: $45 Copay 1 Tier 3: Covered at 75% 1 (Max. $75) Mail Order Prescriptions (90-day supply of maintenance drugs) Specialty Drugs Tier 1: $25 Copay 1 Tier 2: $60 Copay 1 Tier 3: Covered at 75% 1 (Max. $125) Tier 1: $25 Copay 1 Tier 2: $45 Copay 1 Tier 3: Covered at 75% 1 (Max. $75) Tier 1: $10 Copay AD Tier 2: $25 Copay AD Tier 3: Covered at 75% AD (Max. $50) Tier 2: $45 Copay AD Tier 3: Covered at 75% AD (Max. $75) Tier 2: $60 Copay AD Tier 3: Covered at 75% AD (Max. $125) Covered at 50% AD Tier 1: $10 Copay AD Tier 2: $25 Copay AD Tier 3: Covered at 75% AD (Max. $50) Tier 2: $45 Copay AD Tier 3: Covered at 75% AD (Max. $75) Tier 2: $60 Copay AD Tier 3: Covered at 75% AD (Max. $125) Covered at 50% AD Specialty Drugs (medications that require management and monitoring, special handling/storage, delivery via injection, inhalation, or oral administration) are only available through Optima Health s specialty mail order pharmacy - BriovaRX TM Covered at 75% 1 (Max. $200) Covered at 75% AD (Max. $200) Covered at 75% AD (Max. $200) Prescription Drugs You may receive up to a consecutive 31-day supply of a covered drug. A Copayment is a flat dollar amount. A Coinsurance is a percent of Optima s Allowable Charge. Certain prescription drugs will be covered at a generic product level established by the Plan. If a generic product level has been established for a drug and You or Your prescribing Physician requests the brand-name drug or a higher costing generic, You must pay the difference between the cost of the dispensed drug and the generic product level in addition to the Copayment charge (not to exceed $150 per each 31-day supply prescription). Note: Prescription medications used to prevent any of the following medical conditions are not subject to the deductible including medications for Hypertension, high cholesterol, diabetes, asthma, osteoporosis, stroke, prenatal nutrient deficiency. Pharmacy (POS Premium & POS Standard plans ONLY) - You may go to the pharmacy of your choice and pay for the prescription or refill at the time it is filled, and then file for reimbursement with the Plan. Upon receipt and verification of your claim, you will be reimbursed at the Plan s allowable rate minus your copayment/coinsurance per prescription or refill. If you or your physician insist on a brand name drug when a generic equivalent is available, you are responsible for the difference in cost between the generic and the brand name drug (not to exceed $150 per each 31-day supply prescription), plus your brand name Copayment Mail Order Prescriptions - Some Outpatient prescription drugs are available through the Plan s Mail Order Provider. This does not include Tier 4 Specialty Drugs. You may call OptumRx Home Delivery at to find out if a drug is available. If Your drug is available You may purchase up to a 90-day supply for the Copayment or Coinsurance amount.

6 NOTES The Covered Services herein are subject to the terms and conditions set forth in the Plan Document. Words that are capitalized are defined terms listed in the Definitions section of the Plan Document. Optima Health has an internal claims appeal process and an external review process. Please look in Your Plan Document for details about how to file a complaint or an appeal. Under certain circumstances Your coverage can be terminated. However, Your Coverage can only be rescinded for fraud or intentional misrepresentation of material fact. Please look in Your Plan Document in the section on When Your Coverage Will End. For Optima Health plans that require that You choose a primary care provider (PCP), You have the right to choose any PCP who participates in our network and who is available to accept new patients. For children, You may choose a pediatrician as the PCP. AD After Deductible (deductible must be paid first before the plan will provide coverage as indicated) 1. Deductible does not apply to this service (plan will provide coverage as indicated and before the deductible has been met) 2. Copayment and Coinsurance are out of pocket amounts You pay directly to a Provider for a Covered Service. A Copayment is a flat dollar amount. A Coinsurance is a percent of Optima s Allowable Charge (AC) for the Covered Service You receive. Allowable Charge is the amount Optima determines should be paid to a Provider for a Covered Service. When You use In-Network benefits from Plan Providers Allowable Charge is the Provider s contracted rate with Optima or the Provider s actual charge for the service, whichever is less. Plan Providers accept this amount as payment in full. Medically Necessary Covered Services provided by a Non-Plan Provider during an Emergency, or during an authorized Admission to a Plan Facility, will be Covered under In-Network benefits. All other Covered Services received from Non-Plan Providers will be Covered under Your Out of Network benefits. When You use benefits from Non-Plan Providers Allowable Charge may be a negotiated rate; or if there is no negotiated rate Allowable Charge is Optima s In-Network contracted rate for the same service performed by the same type of Provider or the Provider s actual charge for the service, whichever is less. Non-Plan Providers may not accept this amount as payment in full. If You use a Non-Plan Provider who charges more than our allowable amount the Provider may balance bill You for the difference. You will have to pay the difference to the Provider in addition to Your Copayment or Coinsurance amount. Charges from Non-Plan Providers will be higher than the Plan s Allowable Charge so You will usually pay more out of pocket when You use Out of Network benefits. 3. Deductible means the dollar amount You must pay out of pocket each calendar year for Covered Services before the Plan begins to pay for Your benefits. Your Plan may have different Deductibles to meet for In Network Covered Services and for Covered Services. Amounts applied to an In Network Deductible will apply toward the Plan s In-Network Maximum Out-of-Pocket Limit. Amounts applied to an Out of Network Deductible will apply toward the Plan s Maximum Out-of-Pocket Limit. Amounts which You are required to pay for outpatient prescription drugs, preventive vision, vision materials, will not be applied to any Deductible amount in the Plan. Deductibles will not be reimbursed under the Plan. Any part of the calendar year Deductible that is satisfied in the last three months of a calendar year can be carried forward to the next calendar year. 4. Maximum Out-of-Pocket Limit for In-Network Benefits means the total dollar amount You pay out of pocket for most In-Network Covered Services during a calendar year. Your Plan has a separate out of pocket limit for Covered Services You receive under the Plan s Benefits. Copayments and Coinsurance amounts that You pay for most In-Network Covered Services will count toward Your In-Network Maximum Out-of-Pocket Limit. If a service does not count toward Your Maximum Out-of-Pocket Limit You must continue to pay Your Copayments, Coinsurance and any other charges for these services after Your Maximum Out-of-Pocket Limit has been met. Copayments, Coinsurance, or any other charges for the following will not count toward Your In-Network Maximum Out-of-Pocket Limit: 1) Amounts You pay for services not covered under Your Plan; 2) Amounts You pay for Out of Network Benefits; 3) Amounts You pay for Vision care; 4) Amounts You pay for any benefits covered under a plan rider; 5) Amounts You pay for Reduction Mammoplasty benefits, except for procedures associated with reconstructive breast surgery following mastectomy; 6) Ancillary charges which result from Your request for a brand name outpatient prescription drug when a generic drug is available. Ancillary charges are not Covered Services; 7) Amounts You pay for any services after a benefit limit has been reached; 8) Amounts You pay as a penalty for failure to comply with the Plan s Pre-authorization procedures; 9) Amounts applied to Your Deductible. 5. Maximum Out-of-Pocket Limit for Benefits means the total dollar amount You will pay during a calendar year for most Covered Services. Your Plan has a separate out of pocket limit for Covered Services You receive under the Plan s In- Network Benefits. Copayments and Coinsurance amounts that You pay for most Covered Services will count toward Your Maximum Out of Pocket Limit. If a service does not count toward Your Maximum Out-of-Pocket Limit You must continue to pay Your Copayments or Coinsurance for these services after Your Maximum Out-of-Pocket Limit has been met. Copayments, Coinsurance, or any other charges for the following will not count toward Your Maximum Out-of-Pocket Limit: 1) Amounts You pay for services not covered under Your Plan; 2) Amounts You pay for In- Network Benefits; 3) Amounts You pay for Vision care;

7 4) Amounts You pay for any benefits covered under a plan rider; 5) Amounts You pay for Reduction Mammoplasty benefits, except for procedures associated with reconstructive breast surgery following mastectomy; 6) Ancillary charges which result from Your request for a brand name outpatient prescription drug when a generic drug is available. Ancillary charges are not Covered Services; 7) Amounts You pay for any services after a benefit limit has been reached; 8) Amounts You pay as a penalty for failure to comply with the Plan s Pre-authorization procedures; 9) Amounts applied to Your In-Network Deductible; 10) Amounts that exceed the Plan s Allowable Charge for a Covered Service 6. This benefit requires Pre-Authorization before You receive services. Your benefits for Covered Services may be reduced or denied if You do not comply with the Plan's Pre-Authorization requirements. The Plan may also apply a penalty of up to $500 to any benefits paid for Covered Services if You do not comply with the Plan s Pre-Authorization requirements. 7. Coverage for this benefit or service is limited by a dollar amount and/or visit or day limits as stated. Maximum amounts are combined maximums of both In Network and Out-Of Network Covered Services unless otherwise stated. The Plan will not cover any additional services after the limits have been reached. You will be responsible for payment for all services after a benefit limit has been reached. Amounts You pay for any services after a benefit limit has been reached are excluded from Coverage and will not count toward Your Maximum Out of Pocket Maximum Limit. 8. Coverage for obstetrical services as an inpatient in a general hospital or obstetrical services by a physician shall provide such benefits with durational limits, deductibles, coinsurance factors, and Copayments that are no less favorable than for physical illness generally. If the Plan charges a Global Copayment for prenatal, delivery, and postpartum services You are entitled to a refund from the Delivering Obstetrician if the total amount of the Global Copayment for prenatal, delivery, and postpartum services is more than the total Copayments You would have paid on a per visit or per procedure basis. 9. All Emergency, Urgent Care, Ambulance, and Emergency Mental/Behavioral Health Services may be subject to Retrospective Review to determine the Plan s responsibility for payment. If the Plan determines that the condition treated was not an Emergency Service, the Plan will have no responsibility for the cost of the treatment and You will be solely responsible for payment. Members who receive Emergency Services from Non-Plan Providers may be responsible for charges in excess of what would have been paid had the Emergency Services been received from Plan Providers. In no event will the Plan be responsible for payment for services from Non-Plan Providers where the service would not have been covered had the member received care from a Plan Provider. 10. Preventive Care includes recommended preventive care services under the Patient Protection and Affordable Care Act (PPACA) listed below. You may be responsible for an office visit copayment or coinsurance when you receive preventive care. Some services may be administered under Your prescription drug benefit under the Plan. 1) Evidence-based items or services that have in effect a rating of A or B in the recommendations of the U.S. Preventive Services Task Force as of September 23, 2010, with respect to the individual involved; 2) Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. For purposes of this subdivision, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention; 3) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings in the Recommendations for Preventive Pediatric Health by the American Academy of Pediatrics and the Recommended Uniform Screening Panels by the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children; and 4) With respect to women, evidence-informed preventive care and screenings recommended in comprehensive guidelines supported by the Health Resources and Services Administration. Services include well-woman visits, screening for gestational diabetes, human papillomavirus, testing (HPV), counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus (HIV), FDA-approved contraception methods, sterilization procedures, and patient education and counseling for women, breastfeeding support, supplies, and counseling, screening and counseling for interpersonal and domestic violence. 11. You do not need prior authorization from Optima Health or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. Look in Your Plan Document in the Utilization Management section for more information on Pre- Authorization.