PPO (PCA) Plan Benefits-at-a-Glance Trinity Health Tier 1 Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Personal Care Account Can be used to offset the Annual Deductible Copays/Coinsurance Fixed Dollar Copays $75 copay: Emergency Room $1,250 per member $2,500 two person $3,750 per family $400 per member $800 two person $1,200 per family $75 copay: Emergency Room Outpatient surgery-facility fee only $250 copay: Inpatient Admission $75 copay: Emergency Room $150 copay Outpatient surgery-facility fee only $500 copay for: Inpatient Admission Percent Coinsurance Out-of-Pocket Maximum Percent Coinsurance Includes, coinsurance and copays for all covered services Preventive Services Health Maintenance Exam - one per (age 18 and over) Routine Physical Related Test X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam - one per, in addition to health maintenance exam Pap Smear Screening - one per Mammography Screening - one per (one baseline age 35 39, then one annually age 40 and over) 0% - Trinity Health Facilities 10%/20% - Trinity Health Professional Services $3,000 per member $5,250 two person $7,500 per family 20% 40% Note: Services without a network are covered at the in-network level. $3,000 per member $5,250 two person $7,500 per family $4,750 per member $8,000 two person $11,250 per family
Prostate Specific Antigen (PSA) Screening - one per Endoscopic Exams - one per Well Child Care 7 visits, birth through 12 months 3 visits, 13 months through 36 months 2 visits, 37 months through 47 months 1 visit per year thereafter through age 17 Immunizations -Pediatric & Adult Routine Hearing Exam One per Physician Office Services Office Visits Includes: Primary care and specialist physicians Presurgical consultations Initial visit to determine pregnancy Tier 1 Covered - 80% after Covered - 80% after Covered - 60% after Emergency Medical Care Hospital Emergency Room Qualified medical emergency Covered - 100% after $75 copay; copay waived if admitted Covered - 100% after $75 copay; copay waived if admitted Covered - 100% after $75 copay; copay waived if admitted Non-Emergency use of the Emergency Room Covered- $75 copay, 90% after Covered- $75 copay, 80% after Covered- $75 copay, 60% after Urgent Care Services Covered - 90% after Covered - 80% after Covered - 60% after Ambulance Services - Medically Necessary Transport Covered - 100% Covered - 80% after Covered - 80% after Facility Diagnostic and Therapeutic Services MRI,MRA, PET and CAT Covered - 100% Covered - 80% after Covered - 60% after Scans and Nuclear Medicine Diagnostic Tests, X-rays, Covered -100% Covered - 80% after Covered - 60% after Laboratory & Pathology Radiation Therapy and Chemotherapy Covered -100% Covered - 80% after Covered - 60% after Professional Diagnostic and Therapeutic Services MRI,MRA, PET and CAT Scans and Nuclear Medicine Diagnostic Tests, X-rays, Laboratory & Pathology Radiation Therapy and Chemotherapy Covered - 80% after Covered - 80% after Covered - 60% after Covered - 80% after Covered - 80% after Covered - 60% after Covered - 80% after Covered - 80% after Covered - 60% after
Tier 1 Maternity Services Provided by a Physician Prenatal and Postnatal Care Covered 100% Covered 100% Covered - 60% after Delivery and Nursery Care Covered - 80% after Covered - 80% after Covered - 60% after Hospital Care Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies Covered - 100% Covered - $250 copay then; 80% after Covered - $500 copay then; 60% after Inpatient Medical Care Covered - 80% after Covered - 80% after Covered - 60% after Alternatives to Hospital Care Hospice Care Covered - 100% Covered - 100% Covered - 60% after Home Health Care Covered - 100% Covered - 80% after Covered - 60% after Skilled Nursing Limited to 120 days per Surgical Services Surgery (includes related facility surgical Sterilization males only excludes reversal sterilization Sterilization female only excludes reversal sterilization Human Organ Transplants Specified Organ Transplants in designated facilities only, when coordinated through BCBSM Human Organ Transplant Program (800-242-3504) Kidney, Cornea, Bone Marrow and Skin Covered - 100% Covered - $250 copay, then 80% after Covered - $500 copay, then 60% after Covered - 100% Covered - $75 copay then; 80% after Covered - $150 copay then; 60% after Not Covered Not Covered Not Covered Covered - 100% Covered - 100% Not covered Covered - 100% Covered - 100% Not covered Covered - 100% Covered - 80% after Covered - 60% after Mental Health and Substance Abuse Services Inpatient Mental Health and Inpatient Substance Abuse Care Covered - 100% Covered - $250 copay then; 80% after Covered - $500 copay then; 60% after Outpatient Mental Health and Covered - 80% after Covered - 80% after Covered - 60% after Substance Abuse Care Other Services Cardiac Rehabilitation Covered - 100% Covered - 80% after Covered - 60% after Maximum of 36 visits in a 12 week period Chiropractic Services Covered - 80% after Covered - 80% after Covered - 60% after 20 visit maximum per benefit period Durable Medical Equipment Covered - 100% Covered - 80% after Covered - 60% after Prosthetic and Orthotic Devices Covered - 100% Covered - 80% after Covered - 60% after Private Duty Nursing Covered - 100% Covered - 80% after Covered - 60% after Allergy Testing Covered - 80% after Covered - 80% after Covered - 60% after Allergy Therapy Covered - 80% after Covered - 80% after Covered - 60% after
Tier 1 Therapy Services Physical, Occupational and Covered - 100% Covered - 80% after Covered - 60% after Speech Therapy Limited to 60 visits maximum per Independent Physical Therapist Covered - 80% after Covered - 80% after Covered - 60% after Limited to 60 visits maximum per combined with outpatient physical therapy The information in this document is based on BCBSM s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA becomes available. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusio ns may apply. Payment amounts are based on BCBSM s approved amount, less any applicable and/or copay. For a complete description of benefits please see the applicable BCBSM certificates a nd riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-At-A-Glance and any applicable plan document, the plan document will control. Non-Surgical Weight Loss Therapy Along with the existing benefits for bariatric surgery, the plan will cover additional services for non-surgical weight loss treatment. Benefits are payable 100% up to an annual benefit maximum of $500 and include: Outpatient counseling or therapy, Office visits rendered by a licensed physician for the treatment of weight loss Lab services performed during a course of treatment, and Services for weight loss rendered by a Trinity Health Ministry Organization or national recognized programs such as Jenny Craig, Weight Watchers and LA Weight Loss. Weight-loss expenses that are not covered are: Services administered exclusively through an Internet-based forum, Medication or injection expenses for weight loss, unless otherwise covered for an unrelated medical condition Charges for food or nutritional supplements, unless included in the initial program fee, Charges for over-the counter diet aids, Health clubs or exercise equipment, Services or programs that are not approved in the United States, and Charges in connection with acupuncture, hypnotism or biofeedback training.
Case Management / Disease Management Incentive Program If you and/or your covered spouse complete a disease management or case management program, you will receive $50 Visa gift c ard for each program completed.* Baby Steps Program If you agree to participate a BCBSM nurse case manager will administer an assessment and an individualized plan that includes condition and goals based on your assessment results. The nurse will work with you via telephone to address your specific health concerns and goals. Once you have completed the program you will receive a case closure letter via mail and a call explaining that you have completed your program. Upon your case being closed, you will be awarded a $50 Visa gift card that will be issued in the calendar quarter following the program completion date. If you (or your covered spouse) enroll in the Baby Steps program, you will be eligible for a $50 Visa gift card that will be issued in the calendar quarter following the date in which you enroll in the Baby Steps program.* The Baby Steps program connects you with a BCBSM registered nurse who provides information to support the health of your baby and to address your questions or concerns. The nurse can help by: Conducting a confidential health assessment questionnaire Offering suggestions on how to reduce risks during pregnancy Addressing any questions or concerns following the birth of your child Helping you get access to free online materials and self-help books *Please note that gift card incentives are considered taxable income. Selecting a Provider Trinity Health Facilities When you use Trinity Health facilities and satellite locations, you receive the highest benefit payment level. A listing of eligible facilities is available online at bsbsm.com. Network Providers Network providers have signed agreements with BCBS, which means they agree to accept our approved payment for a covered benefit as payment in full. You will only pay for the s, copayments and coinsurances required by your coverage. Ask your physician if he or she participates with the BCBS PPO network in your plan area. If you need help locating a network provider, please call the phone number to locate a BCBS network provider or visit the Web site listed on the inside front cover of this handbook. When you go to network providers, you do not have to send a claim to us. Network providers submit claims to BCBS for you, and they are paid directly by BCBS. Nonparticipating (Out-of-Network) Providers Nonparticipating providers have not signed agreements with BCBS. This means they may or may not choose to accept the BCBS approved amount as payment in full for your health care services.
If your present providers do not participate with BCBS, ask if they will accept the amount we approve as payment i n full for the services you need. This is called participating on a "per claim" basis and means that the providers will accept the approved amount as payment in full for the specific services. You are responsible for any s, copayments, and coinsurances required by your plan along with charges for non-covered services. Prescription Drugs Administered directly by CVS Caremark Retail 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name Ministry Organization on-site pharmacies 90-day supply Generic Formulary Brand Name Non-Formulary Brand Name Mail Order 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name 100% after $10 copay 20% with $30 minimum and $80 maximum 40% with $60 minimum and $100 maximum 100% after $30 copay* 20% with $90 minimum and $240 maximum* 40% with $180 minimum and $300 maximum* * Not inclusive of associate discount 100% after $25 copay 20% with $75 minimum and $200 maximum 40% with $150 minimum and $250 maximum If the brand drug has a specific equivalent generic drug available and the plan participant receives the brand, then in addition to the copay, the plan participant must also pay the difference between the ingredient cost of the brand drug and the generic dr ug.