Medical Benefits Comparison Book 2015 Employees and Pre-Medicare Retirees Human Resources Finance & Administration Rochester Institute of Technology
Medical Benefit Comparison This information provides a comparison of the major provisions of each medical plan -- it is not a contract. It is intended to highlight the coverage of the various plans; benefits are determined by the terms of the contract. If there is any confusion or conflict regarding plan features, the governing plan document/contract will be the final authority. The University intends to continue these benefit plans indefinitely, but reserves the right to modify or terminate such plans at any time with or without notice. Participation in these plans is provided to eligible employees and does not constitute a guarantee of employment, requires continued employment and eligibility and is subject to the terms and conditions of the Plan Documents. 2015 MEDICAL COVERAGE CONTRIBUTION AMOUNTS-EMPLOYEES... 4 GENERAL INFORMATION... 5 Contacting the Carriers... 5 Coverage Effective Dates... 5 Termination of Coverage... 5 Out of Network Allowances... 5 Pre-Authorizations and Exclusions... 6 Rochester Regional Health Systems Copay Option... 6 Deductible, Coinsurance, Out-of-Pocket Maximum Information-Medical (Excellus BCBS). 7 Deductible, Coinsurance, Out-of-Pocket Maximum Amounts-Medical (Excellus BCBS)... 7 Deductible, Coinsurance, Out-of-Pocket Maximum-Prescription Drug Plan (Express Scripts)... 8 SERVICES (SORTED ALPHABETICALLY)... 8 Acupuncture... 8 Allergy Tests & Injections... 9 Ambulance... 9 Bone Density Testing-Routine Preventive... 9 Cardiac Rehabilitation... 9 Chemical Dependence-Inpatient... 9 Chemical Dependence-Outpatient... 10 Chemotherapy... 10 Chiropractic Services... 10 Cochlear Implants... 11 Cochlear Implants Replacement of Properly Functioning Processor... 11 Colonoscopy-Diagnostic... 11 Colonoscopy-Routine... 12 Dental-Accidental Injury... 12 Diabetic Supplies... 13 Durable Medical Equipment (DME)... 14 Emergency Care... 14 Eye Exams-Diagnostic... 15 Eye Exams-Routine... 15 Eyewear... 16 Health and Wellness Programs... 16 Hearing Evaluations-Diagnostic... 16 Hearing Evaluations-Routine... 17 Hearing Aids... 17 Home Care... 17 Hospice... 17 Hospital Services-Inpatient... 18 Hospital Outpatient or Ambulatory Surgical Center... 19 Hospital Pre-Admission Testing... 19 Immunizations-Routine... 19 Laboratory & Pathology... 19-2-
Mammogram-Diagnostic... 20 Mammogram-Preventive... 20 Maternity-Hospital Charges for Mother (including Delivery Room)... 20 Maternity-Newborn Nursery Care-Routine... 20 Maternity-Prenatal and Postpartum Care... 20 Medical Supplies... 21 Mental Health-Inpatient... 21 Mental Health-Outpatient... 21 Occupational Therapy... 22 Out-of-Area Coverage... 23 Pap Smear-Diagnostic... 23 Pap Smear-Preventive... 24 Physical Rehabilitation - Inpatient... 24 Physical Therapy... 24 Physician Visit In Office, Diagnostic (ill or injured)... 25 Physician Visit In Office, Routine Preventive Services... 26 Precertification Requirements... 27 Prescription Drug Coverage under Medical Plan (Excellus BCBS)... 28 Prescription Drug Coverage Information under RIT Prescription Drug Plans (Express Scripts, formerly Medco)... 30 Prescription Drug Coverage Details under RIT Prescription Drug Plans (Express Scripts, formerly Medco)... 31 Preventive Care... 32 Private Duty Nursing... 32 Prostate Cancer Screening... 32 Prosthetics & Orthopedic Braces & Supports (External)... 33 Prosthetics (Internal)... 33 Radiology (MRI, CAT, X-Ray)... 33 Radiation Therapy... 33 Second Medical Opinion... 33 Skilled Nursing Facility... 34 Speech Therapy... 34 Surgery-Hospital Inpatient... 34 Surgery-Hospital Outpatient or Ambulatory Surgical Center... 35 Surgery-Physician s Office... 35 Urgent Care... 35 Well Child Visits... 36 X-Ray-Diagnostic... 36-3-
2015 Medical Coverage Contribution Amounts-Employees Employee contributions for coverage are made 24 times per year for exempt employees (salaried employees paid on a semi-monthly basis) and 26 times per year for non-exempt employees (hourly employees paid on a bi-weekly basis). Contributions are made on a before-tax basis they are not subject to federal, FICA (Medicare and Social Security), and state taxes. See the chart below for contribution amounts. Retiree contributions for coverage are made monthly by check to RIT s administrator. There is a separate monthly contribution amount schedule for retirees. Published amounts include both medical and prescription drug contribution amounts combined (generally, no prescription drug coverage with POS B No Drug) FULL-TIME SALARY LEVEL 1* Salary < $40,000 FULL-TIME SALARY LEVEL 2* Salary = $40,000-83,999 Per Pay Period Employee Contribution FULL-TIME SALARY LEVEL 3* Salary = $84,000-125,999 FULL-TIME SALARY LEVEL 4* Salary => $126,000 EXTENDED PART-TIME ALL SALARIES Medical Level of Exempt Non-Exempt Exempt Non-Exempt Exempt Non-Exempt Exempt Non-Exempt Exempt Non-Exempt Plan Coverage (24 Deductions) (26 Deductions) (24 Deductions) (26 Deductions) (24 Deductions) (26 Deductions) (24 Deductions) (26 Deductions) (24 Deductions) (26 Deductions) Individual $52.87 $48.81 $76.84 $70.92 $88.58 $81.77 $99.76 $92.08 $125.09 $115.47 2 Person $125.99 $116.30 $167.21 $154.35 $186.32 $171.99 $206.84 $190.93 $275.74 $254.53 Family $172.41 $159.15 $235.46 $217.34 $259.02 $239.10 $284.57 $262.68 $351.39 $324.36 One-Parent Fam $145.32 $134.14 $194.66 $179.69 $216.38 $199.74 $239.40 $220.99 $303.52 $280.17 Individual $45.40 $41.91 $66.95 $61.80 $77.97 $71.97 $88.48 $81.67 $116.01 $107.08 2 Person $105.55 $97.43 $143.82 $132.75 $161.08 $148.69 $179.92 $166.08 $254.31 $234.75 Family $153.95 $142.11 $208.26 $192.24 $229.65 $211.98 $253.25 $233.77 $326.54 $301.42 One-Parent Fam $114.52 $105.71 $150.94 $139.33 $167.23 $154.37 $186.75 $172.38 $266.49 $245.99 No Drug Individual $2.60 $2.40 $16.54 $15.27 $24.07 $22.22 $31.09 $28.70 $64.49 $59.53 2 Person $26.37 $24.34 $39.41 $36.38 $49.36 $45.56 $60.92 $56.24 $147.59 $136.23 Family $57.48 $53.06 $79.15 $73.06 $94.53 $87.26 $109.27 $100.86 $194.82 $179.83 One-Parent Fam $28.18 $26.01 $44.99 $41.53 $55.15 $50.90 $67.46 $62.27 $162.10 $149.63 Individual $2.92 $2.70 $19.14 $17.67 $26.53 $24.49 $33.43 $30.85 $46.20 $42.64 2 Person $32.04 $29.57 $45.23 $41.75 $55.10 $50.86 $66.54 $61.42 $152.79 $141.03 Family $63.00 $58.16 $84.64 $78.13 $99.81 $92.13 $114.38 $105.58 $200.06 $184.67 One-Parent Fam $34.38 $31.74 $51.27 $47.32 $61.36 $56.64 $73.55 $67.89 $167.25 $154.38 For employees, contributions are made on a before-tax basis -- they are not subject to federal, FICA (Medicare and Social Security) and state taxes. For retirees, multiply the Exempt amount for the approripate Salary Level (the Level you were in when you retired) by 2 to obtain the monthly amount. -4-
General Information Contacting the Carriers Medical Coverage No Drug Prescription Drug Coverage Excellus BlueCross BlueShield Voice: (877) 253-4797 TTY (585) 454-2845 Website: www.excellusbcbs.com/rit Express Scripts (formerly Medco) Voice: (800) 230-0508 TTY (800) 759-1089 Website: www.express-scripts.com Coverage Effective Dates No Drug Termination of Coverage No Drug New employees: Coverage is effective the first of the month after date of hire; if date of hire is the first of the month, coverage will be effective on date of hire. Retirees: Coverage is effective the first of the month after your retirement date; employee coverage continues through the end of the month in which you retire. Current employees: Coverage changes will be effective the date of the event (e.g., marriage coverage effective date is the date of the marriage). Open Enrollment changes are effective January 1. At termination of employment coverage ends the last day of the month in which the employee terminates. If eligible for RIT retirement, coverage may continue in one of the retiree plans. When coverage ends, an individual may elect to continue coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) for up to 18 months. In such cases, individuals are responsible for paying the full monthly premium plus a 2% administrative fee, as allowed under federal law. At the end of the COBRA coverage period, an individual may elect to convert coverage to an individual policy directly with Excellus BlueCross BlueShield. Refer to the Medical Care and Prescription Drug Plan Summary on the HR website for more details. Out of Network Allowances No Drug Out of Network providers may charge more than the allowed amount; the allowed amount is based on Excellus contracts with network providers and is the most the plan pays for a specific covered service or supply. If an out of network provider charges more than the allowed amount, you will be responsible for the portion of a charge for a service or supply that exceeds the allowed amount for such service or supply. In addition, only the amount you pay up to the allowed amount will be applied toward the deductible and out-of-pocket maximum; any amount you pay in excess of the allowed amount will not count toward the out-of-pocket maximum. -5-
Pre-Authorizations and Exclusions No Drug Rochester Regional Health Systems Copay Option No Drug Some covered services require pre-authorization in order to be covered (e.g., hospitalization). If you are uncertain about the requirement for a particular service, contact Excellus BlueCross BlueShield directly. Refer to the Medical Care and Prescription Drug Plan Summary on the HR website for specific Plan exclusions. In support of the strategic alliance between RIT and Rochester Regional Health System (RRHS), there is an RRHS Copay Option within our point of service medical plans. Under this option, there is a lower copay when you obtain the following medical services from RRHS providers: office visit to primary care physician (PCP) office visit to specialists emergency room visits inpatient hospitalization outpatient facility The lower copays do not apply to tests, treatments or any other services (e.g., allergy shots, chiropractic services, x-rays, etc.). These lower copays are outlined in each applicable section of this booklet. If you use an RRHS provider and believe you are not being charged the proper copay, you can request that they verify the copay with Excellus. RRHS Find-a-Physician Service for RIT Employees and Pre-Medicare Retirees To help employees and pre-medicare retirees enrolled in RIT medical plans locate a physician within the RRHS network, RRHS has introduced a find-aphysician service, just for RIT. You can now search for a physician online at https://rghs.wufoo.com/forms/finding-a-primary-care-provider/ or by calling the dedicated phone line at (585)-922-7480/V. You will be asked for your information and preferences, and the RRHS Call Center representative will contact physician practices and identify the next available new patient appointments. Information about available appointments will be sent to you within 24-48 hours via e-mail or by home mailing, as you request. There is a listing of participating providers on the RIT Human Resources page (www.rit.edu/benefits) in the Medical and Prescription Drug section. Since the list is very long you can search for any of the fields in the file (name, specialty, etc.) instead of printing it. Simply hold down the Ctrl key (the Command key for Macs) and press the F key, then enter the text you are searching for and click Next. -6-
Deductible, Coinsurance, Out-of-Pocket Maximum Information-Medical (Excellus BCBS) No Drug No deductibles. Most services have a copay but some services (e.g., acupuncture) have coinsurance. Refer to specific services listed for details. Once the in-network out-of-pocket maximum is met, covered services in-network will be paid in full for the remainder of the calendar year. Prescription drugs covered under the separate Express Scripts coverage do not count toward this out-of-pocket maximum (does not apply to POS B No Drug). The In-Network and Out of Network Out-of-pocket maximums accrue separately. There is an annual deductible. Once the deductible has been met, you will pay coinsurance for most covered services. You will continue to pay coinsurance until you reach the annual out-of-pocket maximum. Once the out-of-network out-ofpocket maximum is met, covered services out-of-network will be paid in full for the remainder of the calendar year. Prescription drugs covered under the separate Express Scripts coverage do not count toward this out-of-pocket maximum (excludes POS B No Drug). The In-Network and Out of Network Out-of-pocket maximums accrue separately. Deductible, Coinsurance, Out-of-Pocket Maximum Amounts-Medical (Excellus BCBS) * The annual out-of pocket maximum for medical expenses is $4,000 for individual and $8,000 for two person, family or one parent family. No Drug The annual out-of pocket maximum for medical expenses is $5,000 for individual and $10,000 for two person, family or one parent family. The annual out-of pocket maximum for medical expenses is $5,000 for individual and $10,000 for two person, family or one parent family. Annual deductible is $300 for individual, $300 per person for two person and $750 per family per calendar year. Coinsurance is 20% for most covered services (the Plan will pay 80%). The annual out-of pocket maximum is $6,000 for individual and $12,000 for two person, family or one parent family. Annual deductible is $500 for individual, $500 per person for two person and $1,250 per family per calendar year. Coinsurance is 25% for most covered services (the Plan will pay 75%). The annual out-of pocket maximum is $7,500 for individual and $15,000 for two person, family or one parent family. Annual deductible is $700 for individual, $700 per person for two person and $1,750 per family per calendar year. Coinsurance is 30% for most covered services (the Plan will pay 70%). The annual out-of pocket maximum is $9,000 for individual and $18,000 for two person, family or one parent family. *NOTE: Out of Network providers may charge more than the allowed amount; the allowed amount is based on Excellus contracts with network providers and is the most the plan pays for a specific covered service or supply. If an out of network provider charges more than the allowed amount, you will be responsible for the portion of a charge for a service or supply that exceeds the allowed amount for such service or supply. In addition, only the amount you pay up to the allowed amount will be applied toward the deductible and outof-pocket maximum; any amount you pay in excess of the allowed amount will not count toward the out-ofpocket maximum. -7-
Deductible, Coinsurance, Out-of-Pocket Maximum-Prescription Drug Plan (Express Scripts) The annual out-of pocket maximum None for prescription drug expenses is $1,500 for individual and $3,000 for two person, family or one parent family. The annual out-of pocket maximum None for prescription drug expenses is $1,500 for individual and $3,000 for two person, family or one parent family. No Drug N/A no prescription drug coverage N/A no prescription drug coverage Annual prescription drug deductible of $1,000 per person (retail and mail combined; in and out of Annual prescription drug deductible of $1,000 per person (retail and mail combined; in and out of network combined). network combined). No out-of-pocket maximum. The annual out-of pocket maximum for prescription drug expenses is $1,600 for individual and $3,200 for two person, family or one parent family. *NOTE: If you fill a prescription for a brand name medication when a generic equivalent is available, the amount you pay for the difference between the cost of a brand name drug and its generic equivalent will count toward the out-of-pocket maximum. If you fill a prescription for a drug that is excluded by the pharmacy benefit manager and you pay the full cost for that prescription, it will not count toward the outof-pocket maximum. If you purchase a maintenance medication at a retail pharmacy other than Wegmans, beginning with 4 th fill, the amount you pay in excess of the normal copay will not count toward the out-ofpocket maximum. If you fill a prescription at a non-participating pharmacy, any cost difference you are responsible for paying beyond your plan copay will not count toward the out-of pocket maximum. Prescription drugs administered while in the hospital are covered under the medical plan s hospitalization coverage. Prescription drugs administered while in the doctor s office are generally covered under the medical plan. Services (sorted alphabetically) Acupuncture You pay 50% and the Plan pays 50% pay 50% and the Plan pays 50% for for up to 10 visits per member per up to 10 visits per member per calendar year. No Drug You pay 50% and the Plan pays 50% for up to 10 visits per member per calendar year. You pay 50% and the Plan pays 50% for up to 10 visits per member per calendar year. NOTE: maximum coverage is combined in and out of network calendar year. pay 50% and the Plan pays 50% for up to 10 visits per member per calendar year. pay 50% and the Plan pays 50% for up to 10 visits per member per calendar year. -8-
Allergy Tests & Injections $25 PCP / $40 Specialist per visit. pay 20% and the Plan pays 80% $30 PCP / $45 Specialist per visit. No Drug $35 PCP / $50 Specialist per visit. Ambulance No Drug Bone Density Testing-Routine Preventive Covered in full for certain ages, according to the Grade A and Grade No Drug B recommendations from the U.S. Preventive Services Task Force (http://www.uspreventiveservicest askforce.org/uspstf/uspsabrecs.ht m). Cardiac Rehabilitation $40 per visit. $45 per visit. No Drug $50 per visit. Chemical Dependence-Inpatient Precertification is required. No Drug $75 copay per visit to detoxify. Other providers: $150 copay per visit to detoxify. Precertification is required. $225 copay per visit to detoxify. Other providers: $300 copay per visit to detoxify. Precertification is required. $325 copay per visit to detoxify. Other providers: $400 copay per visit to detoxify. pay 20% and the Plan pays 80% to detoxify. Precertification required. pay 25% and the Plan pays 75% to detoxify. Precertification required. pay 30% and the Plan pays 70% to detoxify. Precertification required. -9-
Chemical Dependence-Outpatient $40 copay per visit. Precertification required. No Drug $45 copay per visit. Precertification required. $50 copay per visit. Precertification required. Chemotherapy $45 copay per visit. No Drug $50 copay per visit. Chiropractic Services $40 copay per visit. $45 copay per visit. No Drug $50 copay per visit. -10-
Cochlear Implants $75 copay per admission Other providers: $150 copay per admission Must be medically necessary and prior authorization is required. No Drug Must be medically necessary and prior authorization is required. Covered under hospital inpatient and internal prosthetic. $225 copay per admission Other providers: $300 copay per admission Must be medically necessary and prior authorization is required. Covered under hospital inpatient and internal prosthetic. $325 copay per admission Other providers: $400 copay per admission Must be medically necessary and prior authorization is required. Covered under hospital inpatient and internal prosthetic. Must be medically necessary and prior authorization is required. Must be medically necessary and prior authorization is required. Cochlear Implants Replacement of Properly Functioning Processor You pay 20% and the plan pays 80%. The Plan pays up to $6,000 in total every six years. Not covered. No Drug You pay 20% and the plan pays 80%. The Plan pays up to $6,000 in total every six years. Not covered. Not covered. Not covered. Colonoscopy-Diagnostic Depends on where service is performed. Refer to Surgery categories. No Drug Depends on where service is performed. Refer to Surgery categories. Depends on where service is performed. Refer to Surgery categories. -11-
Colonoscopy-Routine Covered in full for certain ages, according to the Grade A and Grade No Drug B recommendations from the U.S. Preventive Services Task Force (http://www.uspreventiveservicest askforce.org/uspstf/uspsabrecs.ht m). Dental-Accidental Injury $40 copay per visit for services related to accidental injury to sound natural teeth; services must be within twelve months of injury. pay 20% and the Plan pays 80% for services related to accidental injury to sound natural teeth; services must be within twelve No Drug $45 copay per visit for services related to accidental injury to sound natural teeth; services must be within twelve months of injury. $50 copay per visit for services related to accidental injury to sound natural teeth; services must be within twelve months of injury. months of injury. pay 25% and the Plan pays 75% for services related to accidental injury to sound natural teeth; services must be within twelve months of injury. pay 30% and the Plan pays 70% for services related to accidental injury to sound natural teeth; services must be within twelve months of injury. -12-
Diabetic Supplies Medications and most diabetic supplies (e.g., test strips, lancets) are covered under the separate prescription drug benefit with Express Scripts (refer to the Prescription Drug section of this comparison). No Drug For insulin pumps and supplies, refer to the Durable Medical Equipment (DME) section in this comparison. For diabetic education, refer to Physician Visit section in this comparison. Medications and most diabetic supplies (e.g., test strips, lancets) are covered under the separate prescription drug benefit with Express Scripts (refer to the Prescription Drug section of this comparison). For insulin pumps and supplies, refer to the Durable Medical Equipment (DME) section in this comparison. For diabetic education, refer to Physician Visit section in this comparison. Diabetic medications and supplies are not covered. For insulin pumps and supplies, refer to the Durable Medical Equipment (DME) section in this comparison. For diabetic education, refer to Physician Visit section in this comparison. Medications and most diabetic supplies (e.g., test strips, lancets) are covered under the separate prescription drug benefit with Express Scripts (refer to the Prescription Drug section of this comparison). For insulin pumps and supplies, refer to the Durable Medical Equipment (DME) section in this comparison. For diabetic education, refer to Physician Visit section in this comparison. -13-
Durable Medical Equipment (DME) You pay 20% and the plan pays 80% for standard equipment when purchased from a participating provider. No Drug You pay 20% and the plan pays 80% for standard equipment when purchased from a participating provider. You pay 20% and the Plan pays 80% for standard equipment when purchased from a participating provider. Emergency Care pay 20% and the Plan pays 80% for standard equipment. pay 25% and the Plan pays 75% for standard equipment. pay 30% and the Plan pays 70% for standard equipment. $50 copay per visit Other providers: $100 copay Emergency Room care for emergency medical conditions. Emergency Room copay waived if admitted within 24 hours and hospital copay would apply. Emergency Room care for Emergency Medical Conditions - $100 copay per visit unless admitted within 24 hours. No Drug A separate copay may apply for a specialist visit. $75 copay per visit Other providers: $150 copay per visit Emergency Room care for emergency medical conditions. Emergency Room copay waived if admitted within 24 hours and hospital copay would apply. A separate copay may apply for a specialist visit. $100 copay per visit Other providers: $175 copay per visit Emergency Room care for emergency medical conditions. Emergency Room copay waived if admitted within 24 hours and hospital copay would apply. A separate copay may apply for a specialist visit. Emergency Room care for Emergency Medical Conditions - $150 copay per visit unless admitted within 24 hours. Emergency Room care for Emergency Medical Conditions - $175 copay per visit unless admitted within 24 hours. -14-
Eye Exams-Diagnostic $20 copay per visit. No Drug Other Providers: $40 copay per visit. $25 copay per visit. Other Providers: $45 copay per visit. $30 copay per visit. Other Providers: $50 copay per visit. Eye Exams-Routine Not covered. $20 copay per visit. Other Providers: $40 copay per visit. No Drug Copay is for routine eye exams, once every 2 years. Children under age 19, once every year. There is also coverage for routine eye exams under RIT s separate Vision Care Plan. Refer to that Plan Summary for details. $25 copay per visit. Other Providers: $45 copay per visit. Copay is for routine eye exams, once every 2 years. Children under age 19, once every year. There is also coverage for routine eye exams under RIT s separate Vision Care Plan. Refer to that Plan Summary for details. $30 copay per visit. Other Providers: $50 copay per visit. Copay is for routine eye exams, once every 2 years. Children under age 19, once every year. There is also coverage for routine eye exams under RIT s separate Vision Care Plan. Refer to that Plan Summary for details. Not covered. Not covered. -15-
Eyewear No coverage through medical plan, but 20-50% discount available on eye wear through BluePoint2 Preferred and Participating providers. One pair of corrective lenses after cataract surgery covered in full. There is coverage under RIT s separate Vision Care Plan. Refer to that Plan Summary for details. No Drug Health and Wellness Programs No Drug Hearing Evaluations-Diagnostic No coverage through medical plan, but 20-50% discount available on eye wear through BluePoint2 Preferred and Participating providers. One pair of corrective lenses after cataract surgery covered in full. There is coverage under RIT s separate Vision Care Plan. Refer to that Plan Summary for details. No coverage through medical plan, but 20-50% discount available on eye wear through BluePoint2 Preferred and Participating providers. One pair of corrective lenses after cataract surgery covered in full. There is coverage under RIT s separate Vision Care Plan. Refer to that Plan Summary for details. One pair of corrective lenses after cataract surgery. After you pay the deductible, you pay 20% and the Plan pays 80%. One pair of corrective lenses after cataract surgery. After you pay the deductible, you pay 25% and the Plan pays 75%. One pair of corrective lenses after cataract surgery. After you pay the deductible, you pay 30% and the Plan pays 70%. Find over 6,000 topics on the Excellus website in their Healthwise Knowledgebase. Blue 365 is a national program that gives you exclusive access to information, discounts and savings, making it easier and more affordable to make healthy choices. Explore all the choices at www.excellusbcbs.com/blue365 for more details. $20 copay per visit. No Drug Other Providers: $40 copay per visit. $25 copay per visit. Other Providers: $45 copay per visit. $30 copay per visit. Other Providers: $50 copay per visit. pay 25% and the Plan pays 75%. -16-
Hearing Evaluations-Routine No Drug No coverage for routine care. No coverage for routine care. Hearing Aids You pay 20% and the Plan pays 80%, Not covered. one per ear every three years; plan pays a maximum of $3,000 per ear. Not covered. No Drug Not covered. Home Care No Drug Hospice Precertification required. Precertification required. Precertification required. Covered in full for unlimited visits. Covered in full for unlimited visits. No Drug Covered in full for unlimited visits. -17-
Hospital Services-Inpatient $75 copay per admission No Drug Other providers: $150 copay per admission Covered for unlimited days of semiprivate accommodations and all medically necessary services for acute care. Precertification required. Private room covered when medically necessary and authorized in advance by the Blue Point2 Medical Director. Services include physician visits, anesthesia and surgery. $225 copay per admission Other providers: $300 copay per admission Covered for unlimited days of semiprivate accommodations and all medically necessary services for acute care. Precertification required. Private room covered when medically necessary and authorized in advance by the Blue Point2 Medical Director. Services include physician visits, anesthesia and surgery. $325 copay per admission Other providers: $400 copay per admission Covered for unlimited days of semiprivate accommodations and all medically necessary services for acute care. Precertification required. Private room covered when medically necessary and authorized in advance by the Blue Point2 Medical Director. Services include physician visits, anesthesia and surgery. pay 20% and the Plan pays 80% for unlimited days of semi-private accommodations and all medically necessary services for acute care. Precertification required. Private room covered when medically necessary. pay 25% and the Plan pays 75% for unlimited days of semi-private accommodations and all medically necessary services for acute care. Precertification required. Private room covered when medically necessary. pay 30% and the Plan pays 70% for unlimited days of semi-private accommodations and all medically necessary services for acute care. Precertification required. Private room covered when medically necessary. -18-
Hospital Outpatient or Ambulatory Surgical Center Facility: Covered in full No Drug Hospital Pre-Admission Testing Non-RRHS Facility: $100 copay All Physicians: $40 copay (RRHS and non-rrhs) Additional copays may apply (e.g., anesthesiology). Facility: $50 copay Non-RRHS Facility: $150 copay All Physician: $45 copay (RRHS and non-rrhs) Additional copays may apply (e.g., anesthesiology). Facility: $75 copay Non-RRHS Facility: $175 copay All Physician: $50 copay (RRHS and non-rrhs) Additional copays may apply (e.g., anesthesiology). No Drug Immunizations-Routine No Drug Covered in full according to American Medical Association guidelines. Adult immunizations are not covered. Laboratory & Pathology No Drug -19-
Mammogram-Diagnostic $45 copay. No Drug $50 copay. Mammogram-Preventive No Drug Maternity-Hospital Charges for Mother (including Delivery Room) $75 copay per admission No Drug Other providers: $150 copay per admission $225 copay per admission Other providers: $300 copay per admission $325 copay per admission Other providers: $400 copay per admission Maternity-Newborn Nursery Care-Routine Covered in full, including physician charges. No Drug Covered in full, including physician charges. Covered in full, including physician charges. Maternity-Prenatal and Postpartum Care No Drug -20-
Medical Supplies You pay 20% and the plan pays 80% when purchased from a participating provider. No Drug You pay 20% and the plan pays 80% when purchased from a participating provider. You pay 20% and the plan pays 80% when purchased from a participating provider. Mental Health-Inpatient pay 20% and the Plan pays 80% for standard equipment. pay 25% and the Plan pays 75% for standard equipment. pay 30% and the Plan pays 70% for standard equipment. $75 copay per admission Other providers: Precertification required. No Drug Mental Health-Outpatient $150 copay per admission $225 copay per admission Other providers: $300 copay per admission. $325 copay per admission Other providers: $400 copay per admission. Precertification required. Precertification required. $20 Specialist per visit. Precertification required. Other Providers: No Drug $40 Specialist per visit. $25 Specialist per visit. Other Providers: $45 Specialist per visit. $30 Specialist per visit. Other Providers: $50 Specialist per visit. Precertification required. Precertification required. -21-
Occupational Therapy $40 copay per visit for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. Precertification required. pay 20% and the Plan pays 80% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member No Drug $45 copay per visit for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. Precertification required. $50 copay per visit for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. Precertification required. NOTE: maximum coverage is combined in and out of network per calendar year. pay 25% and the Plan pays 75% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. pay 30% and the Plan pays 70% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. -22-
Out-of-Area Coverage Emergency/Urgent Need: Coverage provided worldwide as innetwork when life threatening or urgent and PCP completes necessary referral as soon as possible. You have access to the BlueCard Program. With BlueCard you have access to a provider finder 24 hours a day by calling 1-800-810-BLUE. Referred out of the Area: Coverage provided as in-network if authorized by your Primary Care Physician and the Blue Point2 Medical Director. No Drug Pap Smear-Diagnostic Emergency/Urgent Need: Coverage provided worldwide as innetwork when life threatening or urgent and PCP completes necessary referral as soon as possible. You have access to the BlueCard Program. With BlueCard you have access to a provider finder 24 hours a day by calling 1-800-810-BLUE. Referred out of the Area: Coverage provided as in-network if authorized by your Primary Care Physician and the Blue Point2 Medical Director. Emergency/Urgent Need: Coverage provided worldwide as innetwork when life threatening or urgent and PCP completes necessary referral as soon as possible. You have access to the BlueCard Program, so you have access to a provider finder 24 hours a day by calling 1-800-810-BLUE. Referred out of the Area: Coverage provided as in-network if authorized by your Primary Care Physician and the Blue Point2 Medical Director. If you have an emergency or urgent need, care is covered as In Network. Refer to the In-Network column to the left. If you seek services outside the network and do not have a PCP referral and BCBS Approval: pay 20% and the Plan pays 80% for covered services. If you have an emergency or urgent need, care is covered as In Network. Refer to the In-Network column to the left. If you seek services outside the network and do not have a PCP referral and BCBS Approval: pay 25% and the Plan pays 75% for covered services. If you have an emergency or urgent need, care is covered as In Network. Refer to the In-Network column to the left. If you seek services outside the network and do not have a PCP referral and BCBS Approval: pay 30% and the Plan pays 70% for covered services. $25 copay, includes office visit. No Drug $30 copay, includes office visit. $35 copay, includes office visit. -23-
Pap Smear-Preventive Covered in full for certain ages, according to the Grade A and Grade B recommendations from the U.S. No Drug Preventive Services Task Force (http://www.uspreventiveservicest askforce.org/uspstf/uspsabrecs.ht m). Physical Rehabilitation - Inpatient No Drug Physical Therapy $150 copay. Maximum of 60 days per calendar year. $300 copay. Maximum of 60 days per calendar year. $400 copay. Maximum of 60 days per calendar year. pay 20% and the Plan pays 80% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. pay 25% and the Plan pays 75% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. pay 30% and the Plan pays 70% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. $40 copay per visit for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. Precertification required. pay 20% and the Plan pays 80% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member No Drug $45 copay per visit for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. Precertification required. $50 copay per visit for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. Precertification required. NOTE: maximum coverage is combined in and out of network per calendar year. pay 25% and the Plan pays 75% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. pay 30% and the Plan pays 70% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. -24-
Physician Visit In Office, Diagnostic (ill or injured) $15 PCP / $20 Specialist per visit. No Drug Other Providers: $25 PCP / $40 Specialist per visit. $20 PCP / $25 Specialist per visit. Other Providers: $30 PCP / $45 Specialist per visit. $25 PCP / $30 Specialist per visit. Other Providers: $35 PCP / $50 Specialist per visit. -25-
Physician Visit In Office, Routine Preventive Services Adult routine physicals covered in full once per calendar year. Routine semi-annual GYN visits, including Pap Smear covered in full. Routine mammograms, prostate cancer screenings, and bone density testing covered in full. Adult immunizations covered in full, according to American Medical Association guidelines. Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered in full, according to the American Academy of Pediatrics guidelines. No Drug Adult routine physicals covered in full once per calendar year. Routine semi-annual GYN visits, including Pap Smear covered in full. Routine mammograms, prostate cancer screenings, and bone density testing covered in full. Adult immunizations covered in full, according to American Medical Association guidelines. Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered in full, according to the American Academy of Pediatrics guidelines. Adult routine physicals covered in full once per calendar year. Routine semi-annual GYN visits, including Pap Smear covered in full. Routine mammograms, prostate cancer screenings, and bone density testing covered in full. Adult immunizations covered in full, according to American Medical Association guidelines. Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered in full, according to the American Academy of Pediatrics guidelines. Adult routine physicals and adult immunizations not covered. For Pap Smears, periodic mammograms, prostate cancer screening and bone density testing, after you pay the deductible, you Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered at 80%, subject to the deductible, according to the American Academy of Pediatrics guidelines. Adult routine physicals and adult immunizations not covered. For Pap Smears, periodic mammograms, prostate cancer screening and bone density testing, after you pay the deductible, you Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered at 75%, subject to the deductible, according to the American Academy of Pediatrics guidelines. Adult routine physicals and adult immunizations not covered. For Pap Smears, periodic mammograms, prostate cancer screening and bone density testing, after you pay the deductible, you Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered at 70%, subject to the deductible, according to the American Academy of Pediatrics guidelines. -26-
Precertification Requirements No Drug Precertification is required for all inpatient admissions including organ transplants (not needed for normal pregnancy and hospice). Also required for cochlear implants, physical therapy, speech therapy, occupational therapy. If precertification not obtained, there is a penalty of 50% or $500, whichever is less. Precertification is required for all inpatient admissions including the following: mental health, chemical dependence, organ transplant services, inpatient acute facility and skilled nursing facility admissions and inpatient physical rehabilitation. Also required for cochlear implants, home care, air ambulance, outpatient mental health, outpatient chemical dependence. Also required for Durable Medical Equipment (DME) over $200, external prosthetics over $200, and orthotics over $200. If precertification not obtained, there is a penalty of 50% or $500, whichever is less. -27-
Prescription Drug Coverage under Medical Plan (Excellus BCBS) No Drug Injectable Drugs: $40 copay for all physician-administered injectable drugs including, but not limited to, chemotherapy agents and injectable contraceptives. The copay is on the injectable agent and is in addition to any other copay. Prescription drugs administered while in the hospital are covered under the hospitalization coverage. Prescription drugs administered while in the doctor s office may be covered under the medical plan. Copay does not apply to immunizations, vaccinations and allergy serums. Injectable Drugs: $45 copay for all physician-administered injectable drugs including, but not limited to, chemotherapy agents and injectable contraceptives. The copay is on the injectable agent and is in addition to any other copay. Prescription drugs administered while in the hospital are covered under the hospitalization coverage. Prescription drugs administered while in the doctor s office may be covered under the medical plan. Copay does not apply to immunizations, vaccinations and allergy serums. Injectable Drugs: $45 copay for all physician-administered injectable drugs including, but not limited to, chemotherapy agents and injectable contraceptives. The copay is on the injectable agent and is in addition to any other copay. Prescription drugs administered while in the hospital are covered under the hospitalization coverage. Prescription drugs administered while in the doctor s office may be covered under the medical plan. Copay does not apply to immunizations, vaccinations and allergy serums. Required coverage under the Affordable Care Act (ACA): 1. For women, generic contraceptives are covered with a copay of $0. If there is no generic equivalent, the copay is $0 for a brand name contraceptive. If a generic equivalent is available and you or your doctor chooses the brand name, you will pay the full cost for the brand name. Note: If there is a medical reason certified by your physician through the prior authorization process that you are unable to take the generic equivalent, the copay for the brand contraceptive would be $0. 2. Generic Vitamin D supplements are covered for those age 65 and older with no copay. This coverage includes both over-the-counter and prescriptions, as follows: 3. Vitamin D2 or D3 containing 1,000 IU or less per dosage; and 4. Combination calcium/vitamin D products (only those two). In order to get the Vitamin D with a $0 copay, request a prescription from your physician and take it to the prescription counter at a local participating pharmacy. 5. There will be a $0 copay for breast cancer risk-reducing medications (tamoxifen or raloxifene) for patients age 35 and older who have not had a breast cancer diagnosis, who are at increased risk for breast cancer, and who are at low risk for adverse medication effects. It is important to note that the Task Force did not approve a $0 copay for women who have been diagnosed with breast cancer in the past or for women who are not at increased risk for breast cancer. 6. All smoking cessation medications, including over-the-counter nicotine replacement products (e.g., nicotine patch, gum, lozenges), for those over the age of 18 will be covered in full for a quantity duration limit of 180 day supply within a 365 day period, provided there is a written prescription from a physician. -28-
Injectable Drugs: $50 copay for all physician-administered injectable drugs including, but not limited to, chemotherapy agents and injectable contraceptives. The copay is on the injectable agent and is in addition to any other copay. Prescription drugs administered while in the hospital are covered under the hospitalization coverage. Prescription drugs administered while in the doctor s office may be covered under the medical plan. Copay does not apply to immunizations, vaccinations and allergy serums. -29-
Prescription Drug Coverage Information under RIT Prescription Drug Plans (Express Scripts, formerly Medco) The prescription drug coverage for medical plans POS A, B, and D is provided by Express Scripts (formerly Medco). There is no prescription drug coverage for POS B No Drug except as indicated in the previous section titled Prescription Drug Coverage under Medical Plan (Excellus BCBS). Prescription drugs administered while in the hospital or doctor s office may be covered under your medical plan. Copays and days-supply limits are based on the drug tier and where you fill your prescription: Wegmans Pharmacy, other participating retail pharmacy, Express Scripts mail pharmacy, or a nonparticipating retail pharmacy. The following rules apply: 1. In cases of brand name drugs where an FDA-approved generic equivalent is available, your benefit will be based on the generic drug s cost. If you or your doctor chooses the brand name drug, you will be required to pay the difference, plus any applicable copay. If your prescription does not have an approved generic equivalent, your benefit will not be affected. 2. If you fill your prescription at a non-participating pharmacy, you will be required to pay the pharmacy s full charge for your medication at the time you purchase it. You may then submit a claim form to Express Scripts to obtain reimbursement. Your total amount paid after reimbursement may be more than it would have been if you had gone to a participating pharmacy. 3. Some medications are not covered, have limits, require prior authorization, or have clinical management requirements. Refer to the Medical and Prescription Drug Plan Summary on the HR website for more details. 4. Required coverage under the Affordable Care Act (ACA) a. For women, generic contraceptives are covered with a copay of $0. If there is no generic equivalent, the copay is $0 for a brand name contraceptive. The deductible under POS D would not apply if you have a $0 copay. All other plan rules will otherwise apply. Note: If there is a medical reason certified by your physician through the prior authorization process that you are unable to take the generic equivalent, the copay for the brand contraceptive would be $0. b. Generic Vitamin D supplements are covered for those age 65 and older with no copay. In order to get the Vitamin D with a $0 copay, request a prescription from your physician and take it to the prescription counter at a local participating pharmacy. This coverage includes both over-the-counter and prescriptions, as follows: Vitamin D2 or D3 containing 1,000 IU or less per dosage; and Combination calcium/vitamin D products (only those two). c. There will be a $0 copay for breast cancer risk-reducing medications (tamoxifen or raloxifene) for patients age 35 and older who have not had a breast cancer diagnosis, who are at increased risk for breast cancer, and who are at low risk for adverse medication effects. This $0 copay will also apply patients age 35 and older who have had a breast cancer diagnosis. Those covered under POS D do not need to meet the deductible before the $0 copay. d. All smoking cessation medications, including over-the-counter nicotine replacement products (e.g., nicotine patch, gum, lozenges), for those over the age of 18 will be covered in full for a quantity duration limit of 180 day supply within a 365 day period, provided there is a written prescription from a physician. -30-
Prescription Drug Coverage Details under RIT Prescription Drug Plans (Express Scripts, formerly Medco) POS A and POS B WEGMANS PHARMACY OTHER PARTICIPATING RETAIL EXPRESS SCRIPTS MAIL CATEGORY 30-day supply, 30-day supply, 30-day supply 4th 90-day supply no limit on fills up to 3 fills fill and after (1) 90-day supply T ier 1: Generic Drugs $10.00 $25.00 $12.00 $30.00 $25.00 T ier 2: Brand Name Formulary Drugs $25.00 $62.50 $30.00 $75.00 $62.50 T ier 3: Brand Name Non-Formulary Drugs $40.00 $100.00 $50.00 $125.00 $100.00 POS D WEGMANS PHARMACY OTHER PARTICIPATING RETAIL EXPRESS SCRIPTS MAIL CATEGORY 30-day supply, 30-day supply, 30-day supply 4th 90-day supply no limit on fills up to 3 fills fill and after (1) 90-day supply Annual Deductible - each person must pay $1,000 annual deductible before copay amounts are charged in a plan year (2) T ier 1: Generic Drugs $20.00 $50.00 $25.00 $62.50 $50.00 T ier 2: Brand Name Formulary Drugs $60.00 $150.00 $70.00 $175.00 $150.00 T ier 3: Brand Name Non-Formulary Drugs $120.00 $300.00 $140.00 $350.00 $300.00 (1) applies to maintenance medications only; does not apply to acute medications or medications that cannot be filled through mail order (e.g., certain controlled substances) -31-
Preventive Care No Drug Private Duty Nursing Routine health care that includes screenings, check-ups, and counseling to prevent illnesses, disease, or other health problems are covered in full, according to the Grade A and Grade B recommendations from the U.S. Preventive Services Task Force (http://www.uspreventiveservicest askforce.org/uspstf/uspsabrecs.ht m). Guidelines for women s preventive services covered without cost sharing can be found at http://www.hrsa.gov/womensguid elines. Refer to Physician Visit In Office, Routine Preventive Services and other specific services for more details. Some preventive care services are not covered Out of Network. Refer to Physician Visit In Office, Routine Preventive Services and other specific services for more details. No Drug Not covered. Not covered. Prostate Cancer Screening $15 PCP / $20 Specialist per visit. No Drug Other Providers: $25 PCP / $40 Specialist per visit. $20 PCP / $25 Specialist per visit. Other Providers: $30 PCP / $45 Specialist per visit. $25 PCP / $30 Specialist per visit. Other Providers: $35 PCP / $50 Specialist per visit. -32-
Prosthetics & Orthopedic Braces & Supports (External) For standard equipment, you pay 20% and the Plan pays 80%. No Drug Prosthetics (Internal) For standard equipment, you pay 20% and the Plan pays 80%. For standard equipment, you pay 20% and the Plan pays 80%. No Drug Radiology (MRI, CAT, X-Ray) $40 copay. $45 copay. No Drug $50 copay. Radiation Therapy No Drug $45 copay. $50 copay. Second Medical Opinion If copay charged, contact Excellus Member Services to have claim adjusted. No Drug If copay charged, contact Excellus Member Services to have claim adjusted. If copay charged, contact Excellus Member Services to have claim adjusted. -33-
Skilled Nursing Facility $150 copay per admission for up to 45 days in semi-private accommodations and all medically necessary services. Custodial care is not covered. pay 20% and the Plan pays 80% for up 45 days per admission in semi-private accommodations and all medically necessary services. Precertification required. Custodial care is not No Drug Speech Therapy $300 copay per admission for up to 45 days in semi-private accommodations and all medically necessary services. Custodial care is not covered. $400 copay per admission for up to 45 days in semi-private accommodations and all medically necessary services. Custodial care is not covered. NOTE: maximum coverage is combined in and out of network covered. pay 25% and the Plan pays 75% for up 45 days per admission in semi-private accommodations and all medically necessary services. Precertification required. Custodial care is not covered. pay 30% and the Plan pays 70% for up 45 days per admission in semi-private accommodations and all medically necessary services. Precertification required. Custodial care is not covered. $40 copay per visit for up to a pay 20% and the Plan pays 80% for combined 45 visit maximum on up to a combined 45 visit maximum physical, speech and occupational on physical, speech and therapy per member per calendar occupational therapy per member year. Precertification required. No Drug Surgery-Hospital Inpatient $45 copay per visit for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. Precertification required. $50 copay per visit for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. Precertification required. NOTE: maximum coverage is combined in and out of network per calendar year. pay 25% and the Plan pays 75% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. pay 30% and the Plan pays 70% for up to a combined 45 visit maximum on physical, speech and occupational therapy per member per calendar year. No Drug Refer to Hospital Services-Inpatient Refer to Hospital Services-Inpatient -34-
Surgery-Hospital Outpatient or Ambulatory Surgical Center Facility: Covered in full No Drug Surgery-Physician s Office Non-RRHS Facility: $100 copay All Physicians: $40 copay (RRHS and non-rrhs) Facility: $50 copay Non-RRHS Facility: $150 copay All Physician: $45 copay (RRHS and non-rrhs) Facility: $75 copay Non-RRHS Facility: $175 copay All Physician: $50 copay (RRHS and non-rrhs) $40 copay. $45 copay. No Drug $50 copay. Urgent Care $45 copay. No Drug $50 copay. $55 copay. -35-
Well Child Visits Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered in full, according to the American Academy of Pediatrics guidelines. Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered at 80%, subject to the deductible, according to the American Academy of Pediatrics No Drug X-Ray-Diagnostic Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered in full, according to the American Academy of Pediatrics guidelines. Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered in full, according to the American Academy of Pediatrics guidelines. guidelines. Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered at 75%, subject to the deductible, according to the American Academy of Pediatrics guidelines. Well child visits, including immunizations, laboratory and other services ordered at the time of the visit covered at 70%, subject to the deductible, according to the American Academy of Pediatrics guidelines. $40 copay. $45 copay. No Drug $50 copay. -36-