FCPS S COMPARISON Medical Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Individual Annual Deductible None $250 None $250 None Family Annual Deductible Limit None $500 None $500 None Plan Coinsurance None Medical Plan Out-of-Pocket Maximum Pharmacy Out of Pocket Maximum Total Out of Pocket Maximum $500 Individual/$1,000 Family $1,500 Individual/$3,000 Family $500 Individual/$1,000 Family $1,500 Individual/$3,000 Family $1,500 Individual/$3,000 Family The combined out-of-pocket limit for medical and pharmacy copays, s and coinsurance is $6,600 person / $13,200 family. Applies to covered/allowable charges $1,500 Individual/$3,000 Family The combined out-of-pocket limit for medical and pharmacy copays, s and coinsurance is $6,600 person / $13,200 family. Applies to covered/allowable charges. $3,500 person/$9,400 family Applies to all copayments Physician's Office Visit (non-preventive care) Specialist Office Visit (non-preventive care) PREVENTIVE CARE In-Network Plan Pays Out-of-Network - Plan Pays In-Network Plan Pays Out-of-Network - Plan Pays In-Network Well Child Care Well Child: Age/Frequency Limits 7 exams in 1st 12 months 3 exams in 2nd 12 months 3 exams 3rd 12 months; After: 1 per calendar year 7 exams in 1st 12 months 3 exams in 2nd 12 months 3 exams 3rd 12 months; After: 1 per calendar year As recommended by the American Academy of Pediatrics, through age 17 As recommended by the American Academy of Pediatrics, through age 17 All Primary Care Visits up to age 5 Adult Routine Physical Exam Covered at 100% Adult Routine Physical Exam: Age/Frequency Limits 1 per calendar year 1 per calendar year 1 per calendar year Immunizations - applies to well child and adult routine care; includes flu shots; excludes travel immunizations excludes immunizations for travel ; excludes immunizations for travel 100%; excludes immunizations for travel ; excludes immunizations for travel Covered at 100%. Obesity Preventive Counseling (refer to plan documents for limitations) Covered at 100% for preventive care 1 1
FCPS S COMPARISON Tobacco Cessation Preventive Counseling (refer to plan documents for limitations) Covered at 100% for preventive care Alcohol/Drug Preventive Counseling (refer to plan documents for limitations) Covered at 100% for preventive care Routine GYN Exam Covered at 100% Routine GYN Exam/Pap Age/Frequency Limits 1 routine GYN exam per calendar year with 1 pap smear & related lab fees; may self-refer 1 routine GYN exam per calendar year with 1 pap smear & related lab fees; may self refer 1 routine gyn visit per calendar year w/1 pap Routine Mammogram Cost Sharing Covered at 100% Routine Mammogram Age/Frequency Limits No age or frequency limit. Members should follow American Cancer Society guidelines. No age or frequency limit. Members should follow American Cancer Society guidelines. Determined by KP physician and patient Routine Prostate Specific Antigen Test / Digital Rectal Exam Cost Sharing Covered at 100% for preventive care Routine Prostate Specific Antigen Test and Digital Rectal Exam Age/Frequency Limits No age or frequency limit No age or frequency limit As medically indicated Colorectal Cancer Screening (AMA guidelines) for all members age 50+: Fecal occult blood test every year, Sigmoidoscopy (1 every 5 years), Double contrast barium enema (1 every 5 years), Colonoscopy (1 every 10 years). Covered at 100% for preventive care Routine Eye Exam Cost Sharing Vision exam using calibrated instruments. 100% after $15 copay. Uses Aetna Vision Preferred Network. limited to $40 per year 100% after $15 copay. Uses Davis Vision Network. limited to $40 per year Covered at Routine Eye Exam Frequency Limits applies to all members covered under the plan Once per calendar year Once per calendar year Unlimited Vision Eyewear Benefit - coverage for eyeglass lenses, frames and contacts Covered under Aetna Vision Preferred vision benefit Covered under Davis Vision vision benefit $150 Combined Allowance lenses frames contacts Routine Hearing Exam Cost Sharing - hearing exam utilizing calibrated instruments Covered at Hearing Aids Evaluation Not Covered 2 2
FCPS S COMPARISON Hearing Aids - Maximum (covered only in the event of accidental injury) for Hearing Aids covered as a result of accidental injury Hearing Aids covered only as a result of accidental injury for Hearing Aids covered as a result of accidental injury for Hearing Aids covered as a result of accidental injury Not Covered FAMILY PLANNING and MATERNITY S In-Network Out-of-Network In-Network Out-of-Network In-Network Female Contraceptive Counseling, Administration; Voluntary Sterilization All Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity. Excludes reversals. See Pharmacy benefit for additional contraceptive coverages.. 100%, no copay Covered at 100% Male Voluntary Sterilization - Vasectomy Excludes reversals. 100%, after $20 copay for services provided in an office setting., no for services provided at a surgical facility. Covered at 100% Infertility: refer to each carrier's Medical Policy for coverage $100,000 lifetime maximum benefit for pharmacy and medical across all FCPS self-insured plans. Carrier must obtain approval once benefits equal $50,000. Covered at 50%; Excludes IVF Maternity / Obstetrics - Hospital/Facility delivery charges are covered under the hospital benefit. Pre and postnatal care: 100%, no copay. Delivery and all inpatient services: $100 copay/ admission, plus 10% coinsurance. Pre and postnatal care: 70% coinsurance after Delivery and all inpatient services: $100 copay/ admission, plus 70% coinsurance, subject to. Pre and postnatal care: 100%, no copay. Delivery and all inpatient services: $100 copay/ admission, plus 10% coinsurance. Pre and postnatal care: 70% coinsurance after Delivery and all inpatient services: $100 copay/ admission, plus 70% coinsurance, subject to. Pre and postnatal care: 100%, no copay. Delivery and all inpatient services: $100 copay Breast Pump & Supplies Covered as part of Durable Medical Equipment when medically necessary. 70% coinsurance, after. Covered as part of Durable Medical Equipment when medically necessary Covered as part of Durable Medical Equipment when medically necessary 3 3
FCPS S COMPARISON OTHER PHYSICIAN /PROVIDER SERVICES In-Network Out-of-Network In-Network Out-of-Network In-Network Acupuncture covered if in a lieu of anesthesia for a procedure covered under the plan, and the provider administering it is a legally qualified physician practicing within the scope of his/her license 70% coinsurance after Not Covered Physician Allergy Testing and Treatment - covers both testing and treatment, including injections/serum when billed with an office visit. Allergy Injections - covers the injections/serum when there is no office visit charged. Covered at applicable Physician or Specialist Office Visit cost sharing; independent lab covered at plan coinsurance Covered at applicable Physician or Specialist Office Visit cost sharing; Independent Lab covered at plan coinsurance Covered at Covered at SURGERY In-Network Out-of-Network In-Network Out-of-Network In-Network Second Surgical Opinion Same as any other office visit Same as any other office visit Same as any other office visit Same as any other office visit Covered at Outpatient Surgery - Surgeon's Charges Performed in an office setting. If an office visit is billed with a surgery or x-ray or lab (or any combination of the three) the Office Visit copay (if any) will be applied to the office visit and the remaining services billed that day will be paid at. Covered at 100% after $75 copay Outpatient Surgery - Surgeon's Charges performed in other settings (outpatient department of hospital or ambulatory surgery center) Oral Surgery Includes surgical procedures to remove, repair, revise, reposition or replace the jaw or jaw joints. Does not include dental-related procedures (unless covered under Accidental Injury benefit). Covers medical in nature oral surgery Covered at 100% Covers medical in nature oral surgery Covers medical in nature oral surgery Temporomandibular Joint Dysfunction (TMJ) Covers medical-innature treatment only, including exams, TMJ surgery, x-rays, injections, anesthetics, physical therapy and oral surgery Follows applicable office visit or surgical copay/coinsurance. Appliance therapy covered in select cases based on medical review. Follows applicable office visit or surgical copay/coinsurance. Follows Medical Policy Follows applicable office visit or surgical copay/coinsurance. Follows Medical Policy Bariatric Surgery - Inpatient Hospital Cost Sharing Surgical treatment of morbid obesity. Refer to plan documents for limitations/exclusions. after $100 /admission copay 70% coinsurance after $100 /admission copay after $100 /admission copay 70% coinsurance after $100 /admission copay Refer to Evidence of Coverage Bariatric Surgery - performed in Hospital Outpatient Refer to plan documents. 70% coinsurance after Refer to Evidence of Coverage 4 4
FCPS S COMPARISON DIAGNOSTIC PROCEDURES In-Network Out-of-Network In-Network Out-of-Network In-Network Diagnostic X-ray and Lab - Performed in physician's office. Included with office visit copayment. Included with office visit copayment. Covered at 100% Diagnostic X-ray and Lab - Performed in an outpatient hospital or freestanding facility setting, including independent lab. Complex Imaging Services - MRIs, CAT Scans, etc 100% Referring provider must obtain prior authorization. Covered in full. 100% if provided at participating free standing facility. Free standing facility does not include services provided in an outpatient hospital setting. Preauthorization required within the CareFirst service area for outpatient hospital radiology. Covered at 100% Covered at 100% EMERGENCY MEDICAL CARE In-Network Out-of-Network In-Network Out-of-Network In-Network Urgent Care Facility 100% no, after $20 copay (see note 3) 100% no, after $20 copay (see note 3) Covered at Non-Urgent Use of Urgent Care Provider Covered at Emergency Room; Facility Charges. Waived if admitted. Refer to plan documents for more details and limitations. $50 copay, then 90% coinsurance. Paid at In-network level $50 copay, then 90% coinsurance. Paid at In-network level Covered at 100% after $75 copay Non-Emergency Use of Emergency Room layperson definition applies (see note 2) Prudent Not covered Not covered Not covered Not covered Not Covered Ambulance Covers medically necessary transport. Ground ambulance for member convenience or for non-clinical reasons is not covered. $75 copay HOSPITAL CARE In-Network Out-of-Network In-Network Out-of-Network In-Network Inpatient Hospital Copayments & Coinsurance Applies to Inpatient Hospital; Skilled Nursing Facility; Inpatient Rehabilitative Hospital, Inpatient Hospice and Inpatient Mental Health & Substance Abuse facilities. Also includes Free Standing Birthing Centers. $100 copay/admission, then 90% coinsurance; no. $100 copay/admission, then 70% coinsurance, after Coinsurance does not apply. See copay See plan documents for limitations. 5 5
FCPS S COMPARISON Outpatient Hospital/Outpatient Surgical Facilities Services performed in outpatient dept. of hospital or ambulatory surgery center setting. Includes short term rehabilitation in a hospital outpatient setting / Covered at MENTAL HEALTH & SUBSTANCE ABUSE In-Network Out-of-Network In-Network Out-of-Network In-Network Behavioral Health Network Must use an Aetna Behavioral health provider to receive innetwork benefits. May use any licensed behavioral health provider practicing within the scope of licensure. Inside the BlueChoice Advantage Service area: must use Magellan providers to receive in-network benefits. Outside BlueChoice Advantage service area, must use participating PPO BlueCard providers to receive in-network benefits. May use any licensed behavioral health provider practicing within the scope of licensure. Plan Providers Mental / Behavioral Health Outpatient Services Mental / Behavioral Health Inpatient Services Substance Use Disorder Outpatient Services Substance Use Disorder Inpatient Services (outpatient hospital); $20 copay/ office visit (outpatient hospital); $20 copay/ office visit 70% coinsurance after 70% coinsurance after (outpatient hospital); $20 copay/ office visit 90% coinsurance (outpatient hospital); $20 copay/ office visit 90% coinsurance 70% coinsurance after 70% coinsurance after Individual: $20/visit; Group: $10/visit $100 / admission Individual: $20/visit; Group: $10/visit $100 / admission OTHER COVERED SERVICES In-Network Out-of-Network In-Network Out-of-Network In-Network Skilled Nursing Facility / Convalescent Facility Semi-private room rate. Prior hospital confinement not required. Refer to plan documents for limitations. Covered at 100% after $100 copay Skilled Nursing Facility/ Maximum. Refer to plan documents for limitations. Home Health Care Prior hospital confinement not required HHC Maximum Each visit by a Home Health Aide of up to 4 hours = 1 visit; each visit by a Nurse or Therapist = 1 visit. 6 120 days per year (combined in and out of network) 120 days per year (combined in and out of network) 90 visits per year (combined in an out of network) 100 days maximum $0 copay; medical necessity required 90 visits per year (combined in and out of network) Unlimited, must meet medical necessity 6
FCPS S COMPARISON Private Duty Nursing (PDN) outpatient care provided by a R.N. or L.P.N. if the person's condition requires skilled nursing care and visiting nursing care is not adequate Private Duty Nursing Maximum 360 shifts per year (1 shift = up to 8 hours; combined in and out of network) Not covered 120 days per year (combined in and out of network) Not covered Short Term Rehabilitation - office setting. (Physical, speech, occupational therapy) Covered at Short term rehabilitation performed in an outpatient hospital / outpatient facility setting (non-office). UM approval required. Facility: Facility Practitioner: 90% coinsurance Facility: Facility Practitioner: 100% after $20 copay Facility: 70% coinsurance after Facility Practitioner: 70% after Covered at Short Term Rehabilitation Maximum - Outpatient 90 visits per condition, per therapy, per year; in and out of network visits are combined. Subject to preauthorization. 90 visits per condition, per therapy, per year; in and out of network visits are combined. 90 visits, Covered at 100% after $20 copay Durable Medical Equipment - e.g., rental of wheelchair; walker; cane; may cover purchase if more cost effective than rental. $0 copay; medical necessity required Prosthetics Devices - e.g., artificial limb; breast prosthesis.. Includes wigs limited to $500 per year. wigs limited to $500 per year. Includes wigs (covered at 100% - maximum $500 per year) 70% coinsurance. Includes wigs (covered at 100% - maximum $500 per year) $0 copay; medical necessity required Orthotics - Foot Orthotics, Orthopedic Shoes & supportive devices of the feet. Refer to carrier's medical policy for coverage guidelines., no, when medically necessary, when medically necessary, when medically necessary, when medically necessary $0 copay for diabetic foot disease MEDICAL MANAGEMENT & PRECERT PROGRAMS In-Network Out-of-Network In-Network Out-of-Network In-Network Precertification Non-emergency admissions or outpatient services must be precertified 14 days prior to the confinement or scheduled date of treatment. Notification of emergency stays should be made within 48 hours of admission. Refer to plan documents for services requiring precertification. Refer to plan documents for services requiring precertification. $100 per admission if authorized by Plan OTHER In-Network Out-of-Network In-Network Out-of-Network In-Network Reconstructive Surgery unless medically necessary. Cosmetic surgery required as a result of accident injury is covered during the year of and calendar year following the accident. unless medically necessary unless medically necessary (no time restriction) unless medically necessary. Custodial Care Experimental and Investigational Procedures 7 7
FCPS S COMPARISON Foreign Claims Emergency or urgent care visit. Urgent care is Emergency and Urgent care visit covered. Patient/subscriber defined as a condition or service that is non-preventative or nonroutine, and needed in order to prevent the serious must contact Aetna for treatment authorization beyond initial visit. Subscriber may be required to pay facility in full and deterioration of a member's health following an unforeseen submit to Aetna for reimbursement. illness, injury or condition and includes conditions that could Non-emergency/non-urgent care received outside the United not be adequately managed without immediate care or States not covered. treatment. Generic drugs (retail pharmacy) Emergency and urgent care covered at plan benefit PHARMACY S In-Network Out-of-Network In-Network Out-of-Network In-Network $7 (1-34 days supply) $14 (35-60 day supply) $21 (61-90 day supply) Emergency Care covered at after $50 copay; Urgent Care Covered at. Routine care coverage depends on physician's participation status. $7 (1-34 days supply) $14 (35-60 day supply) $21 (61-90 day supply) $15 at KP Pharmacy (max 60 day supply): $20 at Community Pharmacy (max 60 day supply) Generic drugs (mail order pharmacy) $14 (up to 90 day supply) $14 (up to 90 day supply) $15 at KP mail order pharmacy (max 90 day supply) Brand name/specialty drugs (retail pharmacy) 20% coinsurance, max $50 (per 30-34 day supply). For speciality drugs, must use Accredo after first retail fill. Reimbursement is limited to the plan cost if the prescription was obtained at a participating retail pharmacy, minus your applicable copayment. 20% coinsurance, max $50 (per 30-34 day supply). For speciality drugs, must use Accredo after first retail fill. Reimbursement is limited to the plan cost if the prescription was obtained at a participating retail pharmacy, minus your applicable copayment. $25 (Formulary) at KP Pharmacy (max 60 day supply) $40 (Non-Formulary) at KP Pharmacy (max 60 day) $45 (Formulary) at participating community pharmacy (max 60 day supply) $60 (Non-Formulary) at participating community pharmcy (max 60 day supply) Brand name/specialty drugs (mail order pharmacy) 20% coinsurance, max $100 (per 90 day supply) 20% coinsurance, max $100 (per 90 day supply) Applicable Generic, Preferred, and Non-Preferred copayments 8 8
FCPS S COMPARISON Notes: 1. In-network and out-of-network reimbursement levels are based on the Allowed Benefit. Allowed Benefit described by Aetna : limit on the amount your health plan will pay. Also called the "recognized charge." This is the part of the bill that is eligible to be paid under your health plan. Out-of-network reimbursement is based on a reasonable and customary rate (R&C). Allowed Benefit described by CareFirst : Allowed Benefit for a covered service is the lesser of the actual charge which, in some cases, will be a rate set by a regulatory agency; or the amount CareFirst allows for the service in effect on the date the service is rendered. 2. The prudent layperson definition of an emergency medical condition commonly in practice is any medical or behavioral condition of recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient s health in serious jeopardy, cause serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy. This prudent layperson definition of emergency medical condition focuses on the patient s presenting symptoms rather than the final diagnosis when determining whether to pay emergency medical claims. 3. If using a non-participating urgent care center, you may be required to pay in full and submit for reimbursement. 9 9