MEDICAL COST SHARE OPTIONS Individual Deductible PCY (Family deductible 2X Individual) Coinsurance (Member's percentage of costs after deductible based on allowable charges) Individual Out of Pocket Maximum PCY, includes deductible, coinsurance and copay if applicable (Family OOP max 2X Individual) Office Visit Cost Share PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION $5,000 PCY Shared with In-Network 20% /40% Hospital/CD & Professional: 60%; ARP: Same as In-Network Cost Share (highest benefit $6,350 PCY Not Applicable 40% 1 Preventive Office Visit () Immunizations () Health Education (HE) () 1 Community Wellness, Prevention and Safety Programs (CW) ($250 PCY) 1 1-2FJDIZ Rev #1 Q 4/2/2014 10:39 AM Page 1 of 7
Diabetes Health Education (DE) () PROFESSIONAL CARE Professional Office Visit Including Urgent Care Inpatient Professional Services Contraceptive Management Services () DIAGNOSTIC SERVICE OPTIONS Preventive Professional Diagnostic Imaging and Laboratory Services - Including Mammogram and PAP/PSA Other Professional Diagnostic Imaging Other Professional Diagnostic Laboratory/Pathology Diagnostic Mammography 1 40% 1-2FJDIZ Rev #1 Q 4/2/2014 10:39 AM Page 2 of 7
FACILITY CARE OPTIONS Inpatient Facility Outpatient Surgery Facility Skilled Nursing Facility (60 days PCY) Hospice Inpatient Facility (Inpatient: ; Respite: 240 hours; 6 month limit) EMERGENCY CARE OPTIONS Emergency Care (If applicable, waive copay if admitted to inpatient facility) Emergency Room Physician Ambulance Transportation () Non-Emergent Ground Ambulance () Air Ambulance () Non-Emergent Air Ambulance () $150 Copay, applies to the Out of Pocket Deductible, then 20% /40% Deductible, then 20% Deductible, then 60% Transportation - Air or Surface (High Option 3 round trips PCY for patient (includes 3 round trips PCY for parent or guardian if pt. under 18 yrs of age)) OTHER SERVICES Allergy/Therapeutic Injections Deductible, then 20% Deductible, then 20% 1-2FJDIZ Rev #1 Q 4/2/2014 10:39 AM Page 3 of 7
Mental Health Inpatient Facility Care () Mental Health Outpatient Professional Care () Chemical Dependency Inpatient Facility Care () Chemical Dependency Outpatient Professional Care () Rehab Inpatient Facility (30 days PCY) Deductible, then 20% of Pocket Maximum Deductible, then 20% of Pocket Maximum Rehab Outpatient Care, Including Physical, Occupational, Speech and Massage Therapy; Cardiac & Pulmonary Rehab.; and Chronic Pain (45 visits PCY) Medical Supplies, Equipment, Prosthetics (MS:, ME:, Pro: ) Foot Orthotics, Orthopedic Shoes and Accessories ($300 PCY ( Diabetes Related)) Home Health Visits (130 visits PCY) Hospice Care (Home Health and Respite) (Hospice Home Visits: ; Respite: 240 hours; within the 6 month lifetime maximum) 40% * * 1-2FJDIZ Rev #1 Q 4/2/2014 10:39 AM Page 4 of 7
Transplants ( up to the member annual maximum; $75,000 donor and $7,500 travel and lodging limits) Autism () ALTERNATIVE CARE Manipulations (Spinal and other) (12 visits PCY) Acupuncture (12 visits PCY) Nutritional Therapy () SUPPLEMENTAL BENEFITS Routine Vision Exam (1 PCY) Vision Hardware ($150 PCY) Pediatric Vision Exam (1 PCY Under age 19) Pediatric Vision Hardware (Under age 19: 1 pair lenses PCY, 1 pair of frames PCY) ANNUAL PLAN MAXIMUM Annual Plan Maximum Covered as any other service Covered as anyother service 40% 40% $25 Copay of Pocket Maximum Not Covered Covered as anyother service of Pocket Maximum 1-2FJDIZ Rev #1 Q 4/2/2014 10:39 AM Page 5 of 7
¹Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance. Seasonal immunizations provided at a pharmacy will be covered in full up to maximum allowable amount. *Massage therapy must be billed by a licensed physician. Autism: Mental Health, Psychological & Neuropsychological Testing, Outpatient Professional & Facility Care covered as any other service. Copays are not subject to the deductible unless otherwise noted. Prior Authorization is required for many services to be covered. For more information please refer to your benefit booklet. PCY = Per Calendar Year. Balance billing may apply if a provider is not contracted with Premera Blue Cross Blue Shield of Alaska. Members are responsible for amounts in excess of the allowable charge. This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight is not a contract For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service. 1-2FJDIZ Rev #1 Q 4/2/2014 10:39 AM Page 6 of 7
9001274 Pharmacy Benefits Tier 1 = Generic Tier 2 = Brand Name Tier 3 = Non Brand Name Below is a brief overview of what you can expect to pay for a prescription drug, depending on which "tier" category it falls under in the Drug List for your plan when using an In-Network Pharmacy. For more information on your pharmacy benefits, including Out-of-Network benefits, see your benefit booklet. To find out what tier applies to a specific medication, see out Drug List in your pharmacy packet or at www.premera.com. Effective Date: 05/01/2014 PHARMACY PLAN PRESCRIPTION DRUGS Retail Cost Shares Mail Cost Shares Day Supply Individual Deductible PCY Out of Network (Non-participating retail pharmacies) Out of Pocket Maximum Annual Benefit Maximum Drug List Specialty Pharmacy 2014 RX $15/$25/$50 2.5XMO PREFERRED Cost Share Category Tier1/Tier2/Tier3 $15/$25/$50 $37/$62/$125 Retail: 90 Days; Mail: 90 Days; Specialty: 30 Days $0 Same as in-network Mandatory This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight is not a contract For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service. 1-2FJDIZ Rev #1 Q 4/2/2014 10:39 AM Page 7 of 7