2014 Summary of benefits plan comparison The tables below summarize the 2014 Benefits for the Samaritan Choice Medical Plan options (Basic, Wellness and High-Deductible Plans). Pease refer to your plan document and/or your Summary of Material Modification for a detailed description of your benefits. Important Notice: All services apply to the deductible unless otherwise specified. Samaritan Choice Plan options In-network ONLY PREVENTIVE SERVICES (some of these services are not applied to your deductible & some services will not have a cost share) Well baby care $0 $0 $0 Routine physicals $0 $0 $0 Routine gynecological exams $0 $0 $0 Immunizations $0 $0 $0 Colonoscopy $0 $0 $0 PRIMARY CARE HOME (PCH) SERVICES In-Network Only (All eligible services that are rendered and billed by assigned Primary Care Homes (PCM) are $0 covered (No cost shares or deductibles apply) Primary Care Home (PCH) services $0 PROFESSIONAL SERVICES Primary care visits 1 $20 co-pay $30 co-pay $20 co-pay Specialist visits $35 co-pay $40 co-pay $35 co-pay Urgent care center visits $20 co-pay $30 co-pay $20 co-pay Surgery professional (at hospital) $50 co-pay $50 co-pay $50 co-pay CARE COORDINATION SERVICES For asthma, diabetes, Congestive Heart Failure (CHF), Coronary Artery Disease (CAD), Chronic Obstructive Pulmonary Disease (COPD); does not apply to deductibles Office visit $0 $0 HEART HEALTH AND WELLBEING PROGRAM In-network services only. All eligible services that are rendered and billed by assigned Cardiac Prehab Coach are 100% covered only to those who are eligible for this Program. (No cost shares or deductibles apply) 1
Samaritan Choice Plan options In-network ONLY Cardiac services $0 EDUCATION SERVICES In-network providers only, regular cost-sharing is assessed for all out-of-network providers; does not apply to deductibles. Office visit for specified education services $0 $0 HOSPITAL / INPATIENT SERVICES Inpatient room and board Inpatient rehabilitative care Skilled Nursing Facility care $0 $0 $0 Bariatric surgery/ gastric banding (Lap band) surgery 2 OUTPATIENT SERVICES $5,000 co-pay $5,000 co-pay $5,000 co-pay Outpatient surgery (facility) $150 co-pay $250 co-pay $150 co-pay Emergency department visits (unless admitted to hospital) Diagnostic and therapeutic radiology and lab VALUE-BASED COST SERVICES In-Network only (Specified Surgical Procedures & High Tech Imaging) Specified surgical procedures (spine surgery for pain, arthroscopies, shoulder surgery for osteoarthritis) High tech imaging services (CT scans, MRIs and PET scans) $100 co-pay $100 co-pay $100 co-pay $0 10% $0 $400 co-pay 3,4 $200 co-pay 3,4 $500 co-pay 3,4 $200 co-pay 3,4 2
Samaritan Choice Plan options In-network ONLY MENTAL HEALTH AND CHEMICAL DEPENDENCY 3 Office visits $15 co-pay $15 co-pay $35 co-pay Inpatient care Residential programs 30% 30% 30% OTHER COVERED SERVICES Physical and occupational therapy $25 co-pay $25 co-pay $25 co-pay (combined limit/calendar year: $2,900) Samaritan physical therapy $20 co-pay $20 co-pay Speech therapy $25 co-pay $25 co-pay $25 co-pay (up to $2,900 limit/calendar year) Allergy injections (most) 6 $5 co-pay $5 co-pay $5 co-pay Injectables and other drugs administered other than orally (when rendered in the office) 6 10% 20% 10% Ambulance, ground 30% after $100 co-pay 30% after $100 co-pay 30% after $100 co-pay Ambulance, air 30% 30% 30% Durable Medical Equipment (DME) 30% 30% 30% Home health care $15 co-pay $15 co-pay $15 co-pay Hospice $0 $0 $0 Hearing aids $1,000 limit/year $1,000 limit/year $700 limit/year Acupuncture $35 co-pay $35 co-pay $35 co-pay Chiropractic 7 $25 12 visit limit/year $25 12 visit limit/year Panniculectomy 8 50% 50% 50%
1 Primary Care Provider visit is defined as services provided by a Pediatrics, Family Medicine, and Internal Medicine or OB-GYN provider. 2 Bariatric Surgery and Gastric Banding (Lap band) surgery co-pays do not apply to Out-of-Pocket Limit. 3 Co-pay does not apply if coded as Emergency s. Cost shares will default to normal benefit for Emergency s. 4 These Value-based co-pays do not count towards annual deductibles and Out-of-Pocket Limits. Regular co-payment or coinsurance must be separately paid as applicable. 5 OOP: Out-of Pocket Maximum or Limit. 2014 Prescription drug benefits 6 Contact Customer s at (541) 768-4550 or 1-800-832-4580 to determine your co-pay or coinsurance levels for applicable services. 7 Chiropractic benefit only includes manipulation. This benefit does not include x-rays, labs, other radiology or other services that are not considered to be a manipulation treatment. 8 Panniculectomy coinsurance does not apply to Out-Of-Pocket Limit. s will only be covered when gastric bypass has been rendered by contracted provider. Therapeutic Generic Preferred Brand Non-Preferred $0 for: 7 specified generic drugs Selected Asthma medications Tobacco Cessation drugs/supplies Diabetic Insulin, Syringes, and Needles High-Cost Specialty drugs $7 or 20% whichever is greater $25 or 25% whichever is greater 50% 10% IMPORTANT NOTES: Over the Counter (OTC) medications will not be covered by Samaritan Choice Plans (SCP) without a prescription. Reference the Plan s formulary for more specific medication coverage. The Therapeutic benefit for the administration of insulin applies to all Samaritan Choice Plan options. All medications covered by SCP are subject to the Pharmacy & Therapeutics Committee and are approved to be on the formulary list of covered drugs. Reference the Plan s formulary for more specific medication coverage information. Annual individual and family deductibles Your annual deductibles Annual individual deductible $200 $400 $2,500 Annual family deductible $600 $1,000 $7,500 4
Out of pocket limits This is only a brief summary of benefits. Please refer to the additional information throughout this Plan Document for further explanations of your benefits including limitations and exclusions. Samaritan Choice Wellness Plan Per member $2,000 Per family $6,000 Samaritan Choice Basic Plan Per member $3,000 Per family $9,000 Samaritan Choice High-Deductible Plan Per member $4,000 Per family $12,000 Preferred and Non-preferred out-of-pocket max limits are combined. Pharmacy benefit has a separate out-of-pocket limit of $2,000 per person/calendar year for all plan options. 5