Contacting the Carrier Voice: (877) 668-7636 TTY: (585) 454-2845 Website: Voice: (877) 668-7636 TTY: (585) 454-2845 Website: www.excellusbcbs.com www.excellusbcbs.com Deductible Carry Over None Deductible, Coinsurance, Annual Out of Pocket Maximum No deductible. Annual out of pocket maximum of $2,500 for medical services only; does not include prescription drugs. After you reach the out of pocket maximum, the plan pays 100% for most covered services for the remainder of the calendar $500 deductible. $8,000 annual combined in-network and out-of-network out-of-pocket maximum. Lifetime Maximum Acupuncture None 50% coinsurance, up to 10 visits per 50% coinsurance, up to 10 visits per Allergy Tests & Injections $20 copay per visit to a specialist. $25 copay, after the deductible has been met. Ambulance $50 copay $50 copay Ambulatory Surgical Center $50 copay 30% coinsurance, after the deductible has been met. Bone Density screening Covered in full, limited to one per Cardiac Rehabilitation $20 copay $25 copay, after the deductible has been met. Chemical Dependence-Inpatient $500 copay per admission (maximum of 2 copays per 30% coinsurance, subject to the deductible per calendar year). admission. Chemical Dependence-Outpatient 20% coinsurance, unlimited visits. 35% coinsurance, after the deductible has been met. Chemotherapy $20 copay 30% coinsurance, after the deductible has been met. Chiropractic Services (manual manipulation to $20 copay correct subluxation) $25 copay, after the deductible has been met. Colorectal screening Covered in full for preventive colonoscopies, limited to one per Diabetic Education Covered in full. 30% coinsurance, after the deductible has been met. Diabetic Supplies ROCHESTER INSTITUTE OF TECHNOLOGY Meters and test strips: $20 copay per 30-day supply, from a preferred manufacturer 30% coinsurance, after the deductible has been met. Durable Medical Equipment (DME) 20% coinsurance 30% coinsurance, after the deductible has been met. Rochester Institute of Technology -1- PPO 2016
Emergency Care (covered worldwide) $50 copay per visit unless admitted within 23 hours. $50 copay per visit unless admitted within 23 hours. Covered worldwide. Covered worldwide. Eye Exam, Routine $20 copay, limited to one exam per $25 copay, subject to the deductible, limited to one exam per Eyewear Allowance $100 allowance available once every calendar Silver&Fit is an exercise program that gives you the choice of: - Membership in a fitness club/exercise center ($25 annual fee) Health and Wellness - Home Fitness Program ($10 annual fee) - $150 annual reimbursement toward paid membership at non-participating fitness clubs/exercise centers. Blue 365: Exclusive online discounts to health related products and services Hearing Exam, Routine Hearing Aid Allowance $20 copay, limited to one exam per $25 copay, subject to the deductible, limited to one exam per Home Care Covered in full. 30% coinsurance, after the deductible has been met. Hospice Covered by Original Medicare. Covered by Original Medicare. $500 copay per admission for unlimited days (maximum 30% coinsurance, subject to the deductible per Hospital Services-Inpatient of 2 copays per calendar year). admission, unlimited days. Hospitalization, Partial 20% coinsurance, unlimited visits. 35% coinsurance, after the deductible has been met. Immunizations (flu, pneumonia, Hepatitis B, 30% coinsurance, after the deductible has been met. Covered in full. and other vaccines if patient is at risk) Flu and pneumonia vaccines covered in full. Kidney Dialysis Covered in full. Covered in full. Laboratory & Pathology Covered in full. 30% coinsurance, after the deductible has been met. Mammography, Routine Preventive Mental Health-Inpatient $300 allowance available once every 3 calendar years. Covered in full, limited to one per $500 copay per admission (maximum of 2 copays per calendar year). 30% coinsurance, subject to deductible, limited to one per 30% coinsurance, subject to the deductible per admission. Rochester Institute of Technology -2- PPO 2016
Mental Health-Outpatient 20% coinsurance, unlimited visits. 35% coinsurance, after the deductible has been met. MRI, PET, CAT Scans $20 copay 30% coinsurance, after the deductible has been met. Occupational Therapy $20 copay $25 copay, after the deductible has been met. Out of Area Coverage Physician Visit In Office, Diagnostic (ill or injured): PCP or Specialist Coverage provided worldwide. $20 copay $25 copay, after the deductible has been met. $25 copay, after the deductible has been met, for annual $20 copay. Annual wellness exam and routine GYN wellness exam and routine GYN exam, each limited to Physician Visits In Office, Routine Preventive exam, each limited to one per Pap smear/pelvic one per Pap smear/pelvic exam 30% coinsurance, Services: PCP or Specialist exam limited to one every 24 months. after the deductible has been met, limited ot one yer Physical Therapy $20 copay $25 copay, after the deductible has been met. Podiatry (for medically necessary footcare) $20 copay $25 copay, after the deductible has been met. Rochester Institute of Technology -3- PPO 2016
Prescription Drugs See separate summary at end. Same as In-Network Medicare Part B Drugs, including 20% coinsurance 30% coinsurance, after the deductible has been met. chemotherapy drugs Prostate Cancer Screening Covered in full, limited to one per Prosthetic Devices 20% coinsurance. 30% coinsurance, after the deductible has been met. Pulmonary Rehabilitation $20 copay $25 copay, after the deductible has been met. Radiation Therapy $20 copay 30% coinsurance, after the deductible has been met. Skilled Nursing Facility $0 copay per day, days 1-20. 50% coinsurance per day, days 21-100. Not covered, days 100 and beyond. 50% coinsurance, subject to the deductible, days 1-100. Not coverd, days 100 and beyond. Smoking Cessation Covered in full. $25 copay, subject to deductible. Speech Therapy $20 copay $25 copay, after the deductible has been met. Surgery-In Physician's Office $20 copay $25 copay, subject to deductible. Surgical Care $50 copay 30% coinsurance, after the deductible has been met. Telehealth $20 copay. 20% coinsurance, mental health. Urgent Care (covered nationwide) $20 copay $20 copay $25 copay, after the deductible has been met. 35% coinsurance, subject to the deductible, mental health. X-Ray $20 copay 30% coinsurance, after the deductible has been met. Rochester Institute of Technology -4- PPO 2016
Calendar Year 2016 Prescription Drug Coverage PPO and Medicare Blue PPO The medical coverage is the same under both plans; the only difference is the prescription drug coverage, as outlined below. LOCAL RETAIL PHARMACY-Coverage for 30-Day Supply Tier PPO and Blue PPO WITHOUT RX COVERAGE GAP PPO and Medicare Blue PPO WITH RX COVERAGE GAP Initial Coverage 1. Generic $10 $5 2. Preferred Brand $30 $30 3. Non-Preferred Brand $50 $75 Coverage Gap (Donut Hole) After Initial Coverage (plan plus retiree cost) = $3,310 Catastrophic Coverage Reach this level when member copays in Initial Coverage + total member payments in Coverage Gap + Rx manufacturer 50% brand discount in Coverage Gap = $4,850 Part B Drugs (do not count toward Initial Coverage or Coverage Gap limits) N/A-continue to pay copays listed above greater. You will never pay more than the copay amount in the Initial Coverage stage. 65% generic 45% brand greater You pay 20% You pay 20% LOCAL RETAIL MAIL DER PHARMACY-Coverage for 90-Day Supply Tier PPO and Blue PPO WITHOUT RX COVERAGE GAP PPO and Medicare Blue PPO WITH RX COVERAGE GAP Initial Coverage 1. Generic $30 $12.50 2. Preferred Brand $90 $75 3. Non-Preferred Brand $150 $187.50 Coverage Gap (Donut Hole) After Initial Coverage (plan plus retiree cost) = $3,310 Catastrophic Coverage Reach this level when member copays in Initial Coverage + total member payments in Coverage Gap + Rx manufacturer 50% brand discount in Coverage Gap = $4,850 Part B Drugs (do not count toward Initial Coverage or Coverage Gap limits) N/A-continue to pay copays listed above greater. You will never pay more than the copay amount in the Initial Coverage stage. 65% generic 45% brand greater You pay 20% You pay 20%