SUMMARY OF BADGERCARE PLUS BENEFITS
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1 SUMMARY OF BADGERCARE PLUS BENEFITS Medical, mental health and substance abuse services Dental emergency NOT Pharmacy, chiropractic and dental services NOT 13
2 Ambulatory surgery centers Coverage of certain surgical procedures and related lab services per service Coverage of certain surgical procedures and related lab services Coverage of certain surgical procedures and related lab services per service Chiropractic services Your chiropractic benefits are covered by the state, not Security Health Plan $.50 to $3 copayment per service $.50 to $3 copayment per service Dental services Your dental benefits are covered by the state, not Security Health Plan Limited coverage of preventive, diagnostic, simple restorative, Coverage limited to emergency services only periodontics and extractions for pregnant women and children. Coverage limited to $750 per enrollment year $.50 to $3 copayment per service A $200 deductible applies to all services except preventive and diagnostic. Cost-sharing equal to 50% of allowable fee on all services Pregnant women are exempt from deductible and cost-sharing requirements for dental services. Disposable medical supplies (DMS) Certain diabetic supplies are covered by the state, not Security Health Plan Coverage of diabetic supplies, Coverage of diabetic supplies, ostomy supplies, and other DMS that ostomy supplies, and other DMS that are required with the use of durable are required with the use of durable medical equipment (DME) medical equipment (DME) for items covered by Security Health Plan; $.50 to $3 copayment per service and $.50 per prescription for diabetic supplies covered by the state for items covered by Security Health Plan; $.50 copayment per prescription for diabetic supplies and for other DMS for items covered by Security Health Plan; $.50 to $3 copayment per service for items covered by the state 14
3 Drugs Your pharmacy benefits are covered by the state, not Security Health Plan Comprehensive drug benefit with coverage of generic and brand-name prescription drugs, and some overthe-counter (OTC) drugs Members are limited to 5 prescriptions per month for opioid drugs. Copayments are as follows: $.50 for OTC drugs $1 for generic drugs $3 for brand-name drugs Copayments are limited to $12 per member, per provider, per month. Over-the-counter drugs are excluded from this $12 maximum. Durable medical equipment (DME) Generic-only formulary drug benefit and some over-the-counter (OTC) drugs Members are limited to 5 prescriptions per month for opioid drugs. Members will be automatically enrolled in BadgerRx Gold. This is a separate program administered by Navitus Health Solutions. $5 copayment with no upper limits up to $2,500 per enrollment year $5 copayment per item Rental items are not subject to copayment but count toward the $2,500 enrollment year limit. The following items do not count towards the $2,500 enrollment year limit: Hearing aids, hearing aid batteries, and accessories Bone-anchored hearing aids Cochlear implants Hearing aid repairs are subject to the $2,500 enrollment year limit. Generic-only formulary drug benefit and some over-the-counter (OTC) drugs Some brand-name drugs are covered Members are limited to 5 prescriptions per month for opioid drugs. Members will be automatically enrolled in BadgerRx Gold. This is a separate program administered by Navitus Health Solutions. Up to $4 copayment for generic drugs and up to $8 for brand-name drugs with a $24 copayment limit per month, per provider up to $2,500 per enrollment year per item Rental items are not subject to copayment but count toward the $2,500 enrollment year limit. 15
4 End-stage renal disease (ESRD) Health screenings for children of HealthCheck screenings and other services for individuals under the age of 21 per service Hearing services per service of HealthCheck screenings and other services for individuals under the age of 21 $1 copayment per screening for members 18, 19, and 20 years of age for members 17 years of age and younger, regardless of the number or type of procedures administered during one visit Home care services (Home health, private duty nursing and personal care) of private duty nursing, home health, and personal care services Hospice services of home health services Coverage limited to 60 visits per enrollment year Private duty nursing and personal care are not covered, up to 360 days per lifetime Not applicable No coverage Coverage of home health services for 30 days following an inpatient stay if discharge from the hospital is contingent on the provision of followup home health services Coverage is limited to 100 visits within the 30-day post-hospitalization period Private duty nursing and personal care are not covered 16
5 Inpatient hospital services Mental health and substance abuse treatment (not including room and board) Copayments are as follows: $100 copayment per stay for medical stays $50 copayment per stay for mental heath and/or substance abuse treatment Coverage of this service is based on the Wisconsin State Employee Health Plan. Covered services include outpatient mental health; outpatient substance abuse (including narcotic treatment); mental health day treatment for adults; substance abuse day treatment for adults and children; child/adolescent mental health day treatment; and inpatient stays for mental health and substance abuse. Services not covered are crisis intervention; community support program; comprehensive community services; outpatient mental health services in the home and community for adults; community recovery services; and substance abuse residential treatment. (not including inpatient psychiatric stays in either an Institute for Mental Disease or the psychiatric ward of an acute care hospital and inpatient substance abuse treatment) for members with income up to 100 percent of the federal poverty level $100 copayment per stay for members with income from 100 percent to 200 percent of the federal poverty level There is a $300 total copayment cap per enrollment year for inpatient and outpatient hospital services for all income levels. Coverage limited to services provided by a psychiatrist under the physician services benefit 17
6 Mental health and substance abuse treatment (continued), limited to the first 15 hours or $825 of services, whichever comes first, provided per calendar year Nursing home services $10 to for all outpatient services; $10 per day for all day treatment services $15 per visit for narcotic treatment services (no copayment for lab tests) $15 per visit for outpatient mental health diagnostic interview exam, psychotherapy individual or group (no copayment for electroconvulsive therapy and pharmacological management) $15 per visit for outpatient substance abuse services for stays at skilled nursing homes limited to 30 days per enrollment year Outpatient hospital Emergency room $60 copayment per visit (waived if member is admitted to a hospital) No coverage for members with income up to 100 percent of the federal poverty level $60 copayment per visit for members with income from 100 percent to 200 percent of the federal poverty level (waived if member is admitted to a hospital inpatient hospital copayment will apply) 18
7 Outpatient hospital services 19 Outpatient mental health and substance abuse treatment services are not covered. for members with income up to 100 percent of the federal poverty level for members with income from 100 percent to 200 percent of the federal poverty level $300 total copayment cap per enrollment year for inpatient and outpatient hospital services for all income levels Physical therapy (PT), occupational therapy (OT), and speech and language pathology (SLP), limited to 20 visits per, limited to 20 visits per therapy discipline, per enrollment year therapy discipline, per enrollment year Physician services, including laboratory and radiology Also covers up to 36 visits per enrollment year for cardiac rehabilitation provided by a physical therapist (the cardiac rehabilitation visits do not count towards the 20-visit limit for PT.) Also covers up to a maximum of 60 SLP therapy visits over a 20-week period following boneanchored hearing aid or cochlear implant surgeries for members 17 years of age and younger. These SLP services do not count towards the 20-visit limit for SLP., per provider There are no monthly or annual copayment limits., including laboratory and radiology for emergency services, anesthesia, or clozapine management (Cardiac rehabilitation visits count towards the 20-visit limit for PT.), including laboratory and radiology
8 Podiatry services Prenatal/maternity care, including prenatal care coordination (PNCC), and preventive mental health and substance abuse screening and counseling for women at risk of mental health or substance abuse problems. Note: PNCC is covered by the state, not Security Health Plan. Reproductive health services, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization for family planning services Routine vision including coverage of eyeglasses, including prenatal care coordination (PNCC), and preventive mental health and substance abuse screening and counseling for women at risk of mental health or substance abuse problems. Note: PNCC is covered by the state, not Security Health Plan., excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization for family planning services One eye exam per enrollment year, with refraction Transportation Ambulance, specialized medical vehicle (SMV) of emergency and nonemergency transportation to and from a certified provider for a covered service Copayments are as follows: for non-emergency ambulance trips for transportation by emergency ambulance for transportation by SMV of emergency and nonemergency transportation to and from a certified provider for a covered service Copayments are as follows: $50 copayment per trip for emergency transportation by ambulance $1 copayment per trip for transportation by SMV Not applicable Family planning services provided by family planning clinics will be covered separately under the Family Planning Only Services (FPOS). General ophthalmological services are covered if billed with CPT codes and certain qualifying diagnosis codes. Coverage limited to emergency transportation by ambulance 20
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CENTRAL MICHIGAN UNIVERSITY - Premier Plan (PPO1) 007000285-0002 0004 Effective Date: July 1, 2015 Benefits-at-a-Glance This is intended as an easy-to-read summary and provides only a general overview
Physicians Plus Insurance Corporation Coverage Period: 01/01/2016 12/31/2016
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pplusic.com or by calling 1-800-545-5015. Important Questions