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We take your health personally 2015
We take your health personally 2015 Denver Health and Hospital Authority (DHHA) Simple choices. Simple language. Choose the Plan that’s right for you. Your Denver Health Medical Plan Deductibles provides an insurance network of great doctors, clinics, and medical service providers to cover all your health care needs. Choosing a DHMP network of medical care specialists and facilities will fully cover you under the DHMP Plan benefits as outlined on pages 12-21 of this guide. Choosing a benefit package is easy. Here are 6 simple insurance words to know. These words will help you understand and select the best health insurance plan option to fit your needs and save you money in The amount you owe for medical services BEFORE your health insurance plan pays. If you choose a deductible plan, you will pay the full deductible amount toward medical expenses before your health plan pays anything. The deductible does not apply to pharmacy services. Once you have spent that much, your plan will start to cover your expenses based on our list of benefits. 2015. Monthly premium The fixed amount you pay each month for your health insurance plan. Out-of-pocket costs What you pay for medical expenses that aren’t paid back by your health insurance plan. Your out-of-pocket costs include deductibles, copays, and coinsurance for health care services. In other words, any costs you personally pay for covered medical or pharmacy services. See pages 12-21 for your list of DHMP health insurance benefits. See pages 12-21 for your list of DHMP health insurance benefits. Copay A fixed amount that you pay out-of-pocket for a covered medical care service, like when you go to your doctor, get a test or receive medical treatment or pick up a prescription. Coinsurance A percentage of your out-of-pocket cost when you visit your doctor, have tests or recive treatment. For example, if your doctor’s amount for an office visit is $100 (and you’ve met your TOTAL deductible for the year), a 20% coinsurance payment on $100.00 would be only $20.00! Your health insurance pays the rest of the allowed amount…you would save $80.00! At Denver Health Medical Plan, we know that you lead a busy life. We want to make choosing the right health insurance plan easy and uncomplicated. We also recognize that everyone is different and it is important to have options so each of you can choose the plan that best suits your needs and the needs of your family. Option 1 / Traditional HMO Option 2 / If cost is your #1 priority, this is the plan for you. You will pay a lower premium each month and will pay only copays for services when you access care. Because it is a traditional HMO, the network is smaller and uses all Denver Health providers and facilities. Option 3 / Point of Service If you have a need to see a provider at University of Colorado Hospital or Children’s Hospital Colorado, the Expanded HMO may suit your needs. Your premium will be higher than the HMO but you will also have additional options for receiving care.You can also lower out of pocket costs by choosing to access some or all care at Denver Health. When you need a larger network, the Point of Service plan may be a good choice for you. With this plan you can choose to see any provider, any time: A Denver Health provider, a Cofinity provider or even an Out of Network provider — you simply pay the cost share that applies to that tier of service. Your monthly premium is higher but you can lower out of pocket costs by choosing to access select care at Denver Health. Expanded HMO Out-of-pocket maximum The MOST you pay out during a policy period (one calendar year) before your health insurance plan PAYS 100% for your covered health insurance benefits. This limit includes the TOTAL of your deductibles, coinsurance and copay. This DOES NOT INCLUDE your monthly premium. This limit DOES NOT include amounts for non-network providers and other out-of-network cost-sharing, or spending on health services not covered by your benefit plan. 2 Lower Monthly Premium Higher Monthly Premium Higher Monthly Premium Lower Out-of-Pocket Cost Higher Out-of-Pocket Cost Higher Out-of-Pocket Cost 3 Healthy Heroes for Kids Health Coaches A club created by DHMP, Healthy Heroes for Kids is a fun way for you to encourage healthy habits in your kids. Trained professionals who partner with you to identify goals and action plans that are invaluable in helping you achieve your wellness goals. Complementary Health and Wellness classes plus classes for chronic disease management are also available to you. Children receive special promotions such as quarterly kids newsletters, activity sheets and HealthTip postcards in the mail. Health and Wellness also offers healthy cooking recipe books, disease management information and invitions to telephonic seminars. The program is split into three groups so that everyone receives age-appropriate materials. The three groups are: Explorers for children 3-5, Rangers for children 6-9, and X-Kidz for preteens 10-12. Once again, we’ve teamed with Weight Watchers to bring you effective weight management offerings at a special price. A 35% subsidy on the cost of your Weight Watchers program is yours if you take advantage of one of four Weight Watchers options: Care Support Team Having a “medical home” has been proven to have a positive effect on health and wellbeing. That’s why Care Support Services is here, to assist you in navigating within your “medical home.” Care Support Services staff can also assist you with appointments, both primary and specialty care, as well as many other member needs. • • • • At Work Meetings Local Meeting vouchers Online subscription At Home kit You pick the option that best suits your lifestyle and needs. Member Services 303-602-2100 Member Services staff and healthcare navigators are available from 8 AM to 5 PM, Monday through Friday. You can speak to our specially trained representatives to get: Getting a portion of your Curves membership paid for with DHMP is easy. Simply pay your monthly Curves fee as usual, work out at Curves at least eight times in any given month, and the bank account you use to pay your dues will be credited $20. • Answers about your health network and benefits • Information about how to obtain services • Access to a wide variety of information, such as handbooks and provider directories in both electronic and printed formats That’s $20 of savings just for keeping in shape. Each month. Every month. Good health goes beyond a yearly physical or getting cough medicine for a chest cold. Staying healthy and feeling alive is a state of mind. It’s the desire to do the best you can, no matter how big or small the challenge. Denver Health Medical Plan has developed a comprehensive, interactive wellness program for your body and spirit. Each aspect of “Take Control of Your Health” is a fun and rewarding experience for you. You can share positive behaviors and uplifting experiences with like-minded plan members and coaches, as well as your own family and close friends. Try it, you’ll like it! Personal Profile A custom dashboard is developed just for you, to help you learn about and target your health, nutrition and fitness goals. Online Health Risk Assessment (HRA) That’s a few big words for an easy idea. Identify behaviors that may put your health at risk so you can choose a direction for positive change. • Health snapshot–is a daily log of your progress and upcoming events • Rewards tracker–earn points and get prize rewards for your participation and progress • Mobile app–who said you can’t take it with you? • Upload the mobile version on your iPhone®, Droid™, Blackberry®, or Windows® Mobile. Online Social Support We’ve all been there. You don’t have to believe us…through blogs, member forums, even a diet or exercise buddy, you will get encouragement from your peers and have the opportunity to lift another’s spirits when they’re down. Wellness Workshops Team Challenges The week-by-week “how-to” part of the program is a step-by-step guide. Get action items and tips to put you on the road to eating a healthy diet, increasing physical activity, quitting nicotine, managing stress and preventing diabetes and cardio vascular disease. If you like to be social, there’s no better way to get involved in healthy activities than to team up with other Plan members to win prizes for winning a physical activity challenge or celebrate meeting and beating your weight goals. Tracking Tools You don’t have to remember everything every day. Your custom tracking tools can show you how you are managing your weight and offer meal planning options to track your food choices. We can set you up with a progressive strength 4 training and cardio log, even if you are starting from scratch. And, we can even help you track the distance you walk in a day. Here are some examples: Upcoming Events The “Take Control” website is a great way to see what kind of fun activities are going on in the Denver metro area as well as on the Denver Health campus. 5 Community Health Centers From community-based clinic locations to prescription pickup, DHMP offers convenient options. Choose from eight community health centers throughout Denver or be seen at Level One Physicians located in the Webb Center for Primary Care on the main Denver Health campus. The Denver Health Campus The main hospital at 777 Bannock Sreet. It is the home of the Rocky Mountain regional Level I trauma center. Free Parking at all Denver Health facilities The Wellington Webb Center is at 301 W. Sixth Avenue and is the home to the Primary Care Pharmacy and Level One Physicians. Level One Physicians Clinic Denver Health has always offered free parking at the Community Health Center locations. Beginning in September 2014, patients and members can park free on the main Denver Health campus as well. This applies to all patient parking lots between Bannock and Delaware streets and 6th to 8th Avenues. 6 The Level One Physicians Clinic is a primary care clinic serving privately insured patients. With access to on-site laboratory, radiology, and pharmacy services, the Level One Physicians Clinic provides a comfortable, caring atmosphere for you and your family to receive convenient, high quality health care. NurseLine / 303-739-1261 Available 24 hours a day, 7 days a week, the Denver Health NurseLine provides DHMP members with answers, advice and peace of mind without ever leaving home. You will speak directly to a qualified medical professional who has access to your medical history through our electronic medical record system. For certain conditions the NurseLine can even call in a prescription for you. 7 For Moms and Newborns Pavilion for Women and Children Preventive care is very important, especially during pregnancy and the first year of life. DHMP offers programs to help our members in getting preventive care. If you are pregnant or have a baby under one year, you are eligible for one or both of these programs. Call today for your coupon book! Program for Moms-to-be Pregnancy Calendar Ultrasound Photo Frame Umbrella Stroller Ultrasound at 20 weeks After your baby’s four month visit A nurse midwife is a health care professional who specializes in the natural process of pregnancy, childbirth and postpartum care, with as little intervention as possible. Denver Health midwives deliver more than 1,000 babies a year. Many nurse midwives also speak Spanish. After Delivery at Denver Health Two-month Diaper Supply Extra Month Diaper Supply Healthy Baby Kit Activity Gym After Denver Health tour After your baby’s nine month visit Car Seat Baby Monitor After your baby’s six month visit Nurse Midwives Denver Health nurse midwives provide care at three clinic locations in Denver. Diaper Bag After your baby’s two month visit Clinic Visit between 20–30 weeks of pregnancy Denver Health Onesie The Pavilion for Women and Children is an elegant, soothing environment, which offers family-centered care. ALL patient rooms in the Pavilion for Women and Children are PRIVATE with private bathrooms and sleeping spaces for family members. This pavilion includes the new: • OB Screening Room • Labor and Delivery Unit • Neonatal Intensive Care Unit (NICU) • Pediatric Unit • Pediatric Intensive Care Unit After your baby’s three week visit First Prenatal Visit Clinic Visit between 6–10 weeks of pregnancy Mini Spa Kit Pavilion for Women and Children Baby’s First Year Booster Chair One-Month Diaper Supply After your baby’s one year visit After Delivery at Denver Health After your baby’s 15 month visit, if you completed 6 visits, you will get a 2 month supply of Diapers (visits must be at least 14 days apart) 4-week post partum clinic visit Two-Month Diaper Supply To be eligible for all of the benefits above, all care must be received at a Denver Health facility. For more information and to receive your coupon booklet, call DHMP Member Services now at (303) 602-2100. 8 9 Convenient locations N 2015 Pharmacy Discount Prescription List W MONTBELLO GIPSON EASTSIDE LA CASA/QUIGG NEWTON E Some DHMP formulary maintenance medications are eligible for the discount copay program. This program encourages our DHMP members to regularly refill their medications by decreasing their copay. All listed medications require a prescription. Prescriptions must be written by a Denver Health provider to be filled at a Denver Health Pharmacy for a 30-day supply. If your provider allows, a 90-day supply may be filled by the Denver Health Pharmacy by Mail for two copays. Some of the medications listed may require prior authorization, check with your provider. If you have questions regarding whether or not a drug is eligible, call Member Services at 303-602-2100. 70 Generic Name PARK HILL allopurinol Brand Name Zyloprim LOWRY amitriptyline Elavil glyburide micro Glynase nortriptyline Pamelor atenolol Tenormin hydralazine Apresoline paroxetine Paxil atenolol/chlorthalidone Tenoretic hydrochlorothiazide (HCTZ) Hydrodiuril pravastatin Pravachol benazepril Lotensin insulin aspart Novolog prazosin Minipress benazepril / HCTZ Lotensin HCT insulin human Humulin Prenatal Plus bumetanide Bumex insulin human Novolin prenatal vitamin w/ca no.72, fe, fa captopril Capoten insulin lispro Humalog propranolol Inderal carvedilol Coreg labetalol Trandate simvastatin Zocor citalopram Celexa lisinopril Zestril terazosin Hytrin clonidine tabs Catapres lisinopril / HCTZ Zestoretic triamterene / HCTZ Maxzide diltiazem Cardizem lovastatin Mevacor verapamil Calan doxazosin Cardura medroxyprogesterone Provera warfarin Coumadin estradiol tablets Estrace metformin Glucophage fluoxetine Prozac metformin ER folic acid Folic Acid Glucophage XR furosemide Lasix metoprolol Lopressor gemfibrozil Lopid Toprol-XL glimepiride Amaryl metoprolol succinate extrel glipizide Glucotrol nadolol Corgard S SANDOS WESTSIDE HOSPITAL URGENT CARE CLINICS WEBB CENTER FOR PRIMARY CARE 225 Level One Physicians Clinic Adult Medicine Kids Care Clinic WESTWOOD FAMILY HEALTH CENTERS WELLINGTON WEBB CENTER FOR PRIMARY CARE 301 W. 6th Ave. PARK HILL 4995 E. 33rd Ave. LEVEL ONE PHYSICIANS CLINIC (303) 602-8270 ADULT MEDICINE CLINIC Burgundy Green Team (303) 602-8070 (303) 602-8080 KIDS CARE CLINIC (303) 602-8340 Pharmacy (303) 602-8500 GIPSON EASTSIDE 501 28th St Pharmacy LA CASA/QUIGG NEWTON 4545 Navajo Pharmacy SANDOS WESTSIDE 1100 Federal Blvd Pharmacy WESTWOOD 4320 W Alaska Ave (303) 436-4600 (303) 436-4600 (303) 602-6700 (303) 602-6700 Pharmacy MONTBELLO 12600 Albrook Dr. Pharmacy (303) 436-4200 (303) 436-4200 (720) 602-4660 • (303) 436-6000 (303) 602-2822 PEDIATRIC URGENT CARE CLINIC 777 Bannock St. 10 All Formulary Contraceptives - Available at $0 Copay Preventive Medications - Available at $0 Copay 777 Bannock St. (303) 602-4000 (303) 602-4025 nitroglycerin sublingual Brand Name Nitrostat DENVER HEALTH MEDICAL CENTER ADULT URGENT CARE WALK-IN CLINIC (303) 436-4545 (303) 602-4630 glyburide Brand Name Micronase HOSPITAL 777 Bannock St. LOWRY 1001 Yosemite St. Suite 100 (303) 602-3720 Generic Name (303) 602-3300 • • • • Aspirin - all GENERIC oral dosage forms up to 325mg Bowel preparation kits - all generic formulary prescription kits used for colonoscopy preparation Fluoride - all oral dosage forms, age up to 6 years Folic Acid - 0.4mg and 0.8mg tablets, OTC age up to 55 years Iron - all PEDIATRIC oral liquids (Rx or OTC), age up to 1 year Generic Name Smoking Cessation Preventative Medications Available at $0 Copay • • • Bupropion (Zyban) Nicotine – gum, lozenge and patch – covered by prescription or through the Quit Line (1-800-QUITNOW) Chantix – Step Therapy requires previous trial of bupropion All Formulary Vaccines - Available at a $0 Copay If you would like additional information regarding the prescription benefit structure and a list of covered drugs (Drug Formulary and Pharmaceutical Management Procedures), please visit www.denverhealthmedicalplan.org. Here you will also find an explanation of formulary restrictions, limits and quotas, how your provider can request a prior authorization or an exception request, and your plan’s process for generic substitution, therapeutic interchange, and step therapies. 11 Traditional HMO Hospital & Facility Services HMO Plan Name In-Network Out-of-Network Inpatient Hospital Individual No deductible applies. Not applicable. Family No deductible applies. Not applicable. Outpatient/Ambulatory Surgery In-Network Out-of-Network Annual Deductible Annual Out-of-Pocket Maximum Emergency Room Services Emergency Transportation In-Network Out-of-Network $400 copay per hospital stay. * Not covered. $200 copay per surgery. * Not covered. $150 copay per visit. $150 copay per visit. $150 copay per transport. $150 copay per transport. $50 copay per visit. $50 copay per visit. In-Network Out-of-Network $0 copay per test. Not covered. $150 copay per test. $150 copay per test. Not covered. In-Network Out-of-Network $6,350 per year. Not applicable. $12,700 per year. Not applicable. In-Network Out-of-Network No lifetime maximum. Not applicable. Laboratory, X-Ray and CT In-Network Out-of-Network Denver Health and Hospital Authority providers and Denver Health Medical Center. Columbine network for chiropractic. See provider directory for a complete list of current providers. MRI PET scans Not applicable. In-Network Out-of-Network Sleep Study $150 copay per test. Not covered. Primary Care Visit $25 copay per visit. Not covered. Radiation Therapy $10 copay per visit. Not covered. Specialist Visit $30 copay per visit. Not covered. In-Network Out-of-Network Infusion Therapy (includes chemotherapy) $10 copay per visit. Not covered. $10 copay per visit. (Immunizations, allergy shots and any other injections given by a nurse is a $0 copay.) Not covered. No copay (100% covered). Not covered. Individual Family Lifetime Maximum Covered Providers Office Visits Preventive Services Children Adults Prenatal Visit Delivery/Inpatient Prescription Drugs Denver Health Pharmacy Not covered. Non-Denver Health Pharmacy Inpatient Out-of-Network $0 copay per visit. Not covered. $200 copay per admission. Not covered. In-Network Out-of-Network Denver Health Pharmacy by Mail (90-day supply) Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay. Non-Denver Health Pharmacy (30-day supply) Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay. Non-Denver Health Pharmacy (90-day supply) Discount: $16 copay. Generics: $60 copay. Preferred Brand: $80 copay. Non-preferred Brand: $140 copay. Behavioral Health Outpatient In-Network Denver Health Pharmacy (30-day supply) Discount: $4 copay. Generics: $15 copay. Preferred Brand: $20 copay. Non-preferred Brand: $35 copay. Other Diagnostic and Therapeutic Services Renal Dialysis Annual well visit, well women exams, prenatal visits, colonoscopy, mammogram. See USPSTF list on our website at www.denverhealthmedicalplan.org. Maternity Diagnostic Laboratory and Radiology Injections No copay (100% covered). This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF). Urgent Care Center Therapies In-Network Out-of-Network $25 copay per visit. Not covered. $400 copay per admission. Not covered. In-Network Out-of-Network Rehabilitative: Physical, Occupational, and Speech Therapy $10 copay per visit. 20 of each therapy per calendar year. Not covered. Habilitative: Physical, Occupational, and Speech Therapy $10 copay per visit. 20 of each therapy per calendar year. Not covered. Pulmonary Rehabilitation $10 copay per visit. 20 visit limit per calendar year. Not covered. Cardiac Rehabilitation $10 copay per visit. 20 visit limit per calendar year. Not covered. In-Network Out-of-Network 20% coinsurance applies; maximum benefit is $2,000 per calendar year. * Not covered. In-Network Out-of-Network Not covered. Durable Medical Equipment Hearing Aids Adult Not covered. Medically necessary hearing aids prescribed by a DHMP Medical Care Network provider are covered every 5 years in-network. For adults over age 18, there is a $1,500 benefit maximum every 5 years. Charges exceeding the $1,500 hearing aid maximum benefit, are the responsibility of the member. * Not covered. Cochlear implants are now covered. The device is covered at 100%; applicable inpatient/outpatient surgery charges will apply. * Children Children under age 18 are covered at 100%, no maximum benefit applies. Hearing screens and fittings for hearing aids are covered under office visits and the applicable copayment applies. Hearing aids no longer apply to the annual DME limit. * Not covered. Cochlear implants are now covered. The device is covered at 100%; applicable inpatient/outpatient surgery charges will apply. * * Prior authorization required. 12 13 Prosthetics Shoe Orthotics Oxygen/Oxygen Equipment Oxygen Equipment Organ Transplants Out-of-Network 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * Not covered. In-Network Out-of-Network Medically necessary orthotics are reimbursed up to $100 per calendar year. Not covered. In-Network Out-of-Network 100% covered. * Not covered. Individual 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * Not covered. Family In-Network Out-of-Network $400 copay per admission. Only covered at authorized facilities. Coverage no less extensive than for other physical illness. Covered transplants include: cornea, kidney, kidney-pancreas, heart, lung, heart-lung, liver, and bone marrow for Hodgkin’s, aplastic anemia, leukemia, immunodeficiency disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer and Wiskott-Aldrich Syndrome only. Peripheral stem cell support is a covered benefit for the same conditions listed above for bone marrow transplants. * Home Health Care Not covered. In-Network Out-of-Network No copay (100% covered). * Not covered. In-Network Out-of-Network No copay (100% covered). Maximum benefit is 100 days per calendar year at the authorized facility. * Not covered. In-Network Out-of-Network Not covered except for fluoride varnish at PCP visit. Not covered. Vision Care In-Network Out-of-Network Eye Exams $30 copay per visit for routine eye exams (deductible and coinsurance waived). Limit of 1 routine eye exam every 24 months. Self-referral allowed in-network. Not covered. Dental Care Eyewear In-Network Expanded Network Out-of-Network Individual No deductible applies. $500 per year. Not applicable. Family No deductible applies. $1,000 per year. Not applicable. In-Network Expanded Network Out-of-Network $6,350 per year. $2,000 per year. Not applicable. Annual Out-of-Pocket Maximum Lifetime Maximum Office Visits No copay (100% covered) for prescribed medically necessary skilled home health services. * Skilled Nursing Facility Annual Deductible Not covered. Out-of-Network In-Network $20 copay per visit. Maximum 20 visits per calendar year. Services must be provided by Columbine Chiropractic in order to be covered. In-Network 14 No lifetime maximum. Not applicable. In-Network Expanded Network Out-of-Network Denver Health and Hospital Authority providers and Denver Health Medical Center. Columbine network for chiropractic. See provider directory for a complete list of current providers. University of Colorado Hospital and Children’s Hospital of Colorado providers and facilities. Columbine network for chiropractic. See provider directories for a complete list of providers. Not applicable. Out-of-Network Not covered. Specialist Visit $30 copay per visit. $40 copay per visit. Not covered. In-Network Expanded Network Out-of-Network Preventive Services Children Adults No copayment (100% covered). This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF). Maternity Prescription Drugs Denver Health Pharmacy Not covered. Weight Watchers Discount. DHMP will share the cost of Weight Watchers with members. Join Weight Watchers through DHMP and the plan will pay 35% of your cost. Curves Wellness program. DHMP will pay $20 toward the monthly fee for every month that members who join Curves work out at least 8 times per month. eLearning module for parents-to-be. Online childbirth classes, free of charge to members. Take Control of Your Health incentive plan. No lifetime maximum. Expanded Network Out-of-Network Out-of-Network Out-of-Network $30 copay per visit. Note: Massage therapy is not a plan benefit but DHMP offers a discount program through Columbine Chiropractic. Many chiropractic offices offer massage therapy as well. DHMP will not pay for massage therapy received at a Columbine Chiropractic office. Member must pay through discount program. Additional Benefits Not applicable. Expanded Network In-Network $200 toward Lasik surgery once per lifetime. This benefit can be used at any time regardless of whether or not the $350/24 month benefit has been used. Chiropractic $4,000 per year. In-Network $25 copay per visit. Delivery/Inpatient Only one claim can be submitted in a 24 month period, i.e. if you are using the benefit for contacts, you may want to wait until you have accumulated $350 in charges before submitting a claim in order to use full benefit. $12,700 per year. Primary Care Visit Prenatal Visit Plan pays up to $350 one time per 24 month period for prescription eyewear. Expanded HMO Plan Name Covered Providers In-Network Hospice Care Expanded HMO In-Network Non-Denver Health Pharmacy No copayment (100% covered). This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF). Not covered. Annual well visit, well woman exams, prenatal visits; colonoscopy, mammogram. See USPSTF list on our website at www.denverhealthmedicalplan.org Annual well visit, well woman exams, prenatal visits; colonoscopy, mammogram. See USPSTF list on our website at www.denverhealthmedicalplan.org In-Network Expanded Network Out-of-Network $0 copay per visit. $0 copay per visit. Not covered. $200 copay per admission. Deductible and 20% coinsurance apply. Not covered. Out-of-Network In-Network Expanded Network Denver Health Pharmacy (30-day supply) Denver Health Pharmacy (30-day supply) Discount: $4 copay. Generics: $15 copay. Preferred Brand: $20 copay. Non-preferred Brand: $35 copay. Discount: $4 copay. Generics: $15 copay. Preferred Brand: $20 copay. Non-preferred Brand: $35 copay. Denver Health Pharmacy by Mail (90-day supply) Denver Health Pharmacy by Mail (90-day supply) Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay Non-Denver Health Pharmacy (30-day supply) Non-Denver Health Pharmacy (30-day supply) Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay. Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay. Non-Denver Health Pharmacy (90-day supply) Denver Health Pharmacy (90-day supply) Discount: $16 copay. Generics: $60 copay. Preferred Brand: $80 copay. Non-preferred Brand: $140 copay. Discount: $16 copay. Generics: $60 copay. Preferred Brand: $80 copay. Non-preferred Brand: $140 copay. 15 Not covered. Not covered. * Prior authorization required. Hospital & Facility Services In-Network Expanded Network Out-of-Network $400 copay per hospital stay. * Deductible and 20% coinsurance apply. * Not covered. Outpatient/Ambulatory Surgery $200 copay per surgery. * Deductible and 20% coinsurance apply. * Not covered. Emergency Room Services $150 copay per visit. $150 copay per visit. $150 copay per visit. Inpatient Hospital $150 copay per transport. $150 copay per transport. $150 copay per transport. $50 copay per visit. $50 copay per visit. $50 copay per visit. In-Network Expanded Network Out-of-Network $0 copay per test. Deductible and 20% coinsurance apply. Not covered. $150 copay per test. $150 copay per test. $250 copay per test. $150 copay per test. Not covered. In-Network Expanded Network Out-of-Network $150 copay per visit. $250 copay per visit. Not covered. Radiation Therapy $10 copay per visit $10 copay per visit Not covered. Infusion Therapy (includes chemotherapy) $10 copay per visit $10 copay per visit. Not covered. $10 copay per visit (immunizations, allergy shots and any other injection given by a nurse is a $0 copay). $10 copay per visit (immunizations, allergy shots and any other injection given by a nurse is a $0 copay). Not covered. No copay (100% covered) No copay (100% covered) Not covered. In-Network Expanded Network Out-of-Network $25 copay per visit. $30 copay per visit. Not covered. $400 copay per admission. Deductible and 20% coinsurance apply. * Not covered. In-Network Expanded Network Out-of-Network Rehabilitative: Physical, Occupational, and Speech Therapy $10 copay per visit. 20 of each therapy per calendar year. Deductible and 20% coinsurance apply. 20 of each therapy per calendar year. Not covered. Habilitative: Physical, Occupational, and Speech Therapy $10 copay per visit. 20 of each therapy per calendar year. Deductible and 20% coinsurance apply. 20 of each therapy per calendar year. Not covered. Pulmonary Rehabilitation $10 copay per visit. 20 visit limit per calendar year. Deductible and 20% coinsurance apply. 20 visit limit per calendar year. Not covered. Cardiac Rehabilitation $10 copay per visit. 20 visit limit per calendar year. Deductible and 20% coinsurance apply. 20 visit limit per calendar year. Not covered. In-Network Expanded Network Out-of-Network 20% coinsurance applies; maximum benefit is $2,000 per calendar year. * 20% coinsurance applies; maximum benefit is $2,000 per calendar year. * Not covered. In-Network Expanded Network Out-of-Network Emergency Transportation Urgent Care Center Diagnostic Laboratory and Radiology Laboratory, X-Ray and CT MRI PET scans Other Diagnostic and Therapeutic Services Sleep Study Injections Renal Dialysis Behavioral Health Outpatient Inpatient Therapies Durable Medical Equipment Hearing Aids Adult Medically necessary hearing aids prescribed by a DHMP Medical Care Network provider are covered every 5 years in-network. For adults over age 18, there is a $1,500 benefit maximum every 5 years. Charges exceeding the $1,500 hearing aid maximum benefit, are the responsibility of the member. * Prosthetics Children under age 18 are covered at 100%, no maximum benefit applies. Hearing screens and fittings for hearing aids are covered under office visits and the applicable copayment applies. Hearing aids no longer apply to the annual DME limit. * Cochlear implants are now covered. The device is covered at 100%; applicable inpatient/ outpatient surgery charges will apply. * 16 Out-of-Network 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * Not covered. In-Network Expanded Network Out-of-Network Medically necessary orthotics are reimbursed up to $100 per calendar year. Oxygen/Oxygen Equipment Equipment Not covered. In-Network Expanded Network Out-of-Network 100% covered. * 100% covered. * Not covered. 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * Not covered. In-Network Expanded Network Out-of-Network Oxygen Organ Transplants $400 copay per admission. Only covered at authorized facilities. Coverage no less extensive than for other physical illness. Covered transplants include: cornea, kidney, kidney-pancreas, heart, lung, heart-lung, liver, and bone marrow for Hodgkin’s, aplastic anemia, leukemia, immunodeficiency disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer and Wiskott-Aldrich Syndrome only. Peripheral stem cell support is a covered benefit for the same conditions listed above for bone marrow transplants. * Home Health Care Not covered. In-Network Expanded Network Out-of-Network No copay (100% covered) for prescribed medically necessary skilled home health services. * Deductible, then 100% covered for prescribed medically necessary skilled home health services. * Not covered. Hospice Care In-Network Expanded Network Out-of-Network No copay (100% covered). * Deductible, then 100% covered. * Not covered. In-Network Expanded Network Out-of-Network Skilled Nursing Facility No copay (100% covered). Maximum bene- Deductible, then 100% covered. Maximum fit is 100 days per calendar year at authobenefit is 100 days per calendar year at rized facility. * authorized facility. * Dental Care In-Network Expanded Network Not covered. Out-of-Network Not covered except for fluoride varnish at PCP visit. Not covered. Vision Care In-Network Expanded Network Out-of-Network Eye Exams $30 copay per visit for routine eye exams (deductible and coinsurance waived). Limit of 1 routine eye exam every 24 months. Self-referral allowed in-network. $40 copay per visit for routine eye exams (deductible and coinsurance waived). Limit of 1 routine eye exam every 24 months. Self-referral allowed in-network. Not covered. Eyewear Plan pays up to $350 one time per 24 month period for prescription eyewear. Only one claim can be submitted in a 24 month period, i.e. if you are using the benefit for contacts, you may want to wait until you have accumulated $350 in charges before submitting a claim in order to use full benefit. Not covered. $200 toward Lasik surgery once per lifetime. This benefit can be used at any time regardless of whether or not the $350/24 month benefit has been used. Chiropractic Not covered. In-Network Expanded Network Out-of-Network $20 copay per visit. Maximum 20 visits per calendar year. Services must be provided by Columbine Chiropractic in order to be covered. $20 copay per visit. Maximum 20 visits per calendar year. Services must be provided by Columbine Chiropractic in order to be covered. Not covered. Note: Massage therapy is not a plan benefit but DHMP offers a discount program through Columbine Chiropractic. Many chiropractic offices offer massage therapy as well. DHMP will not pay for massage therapy received at a Columbine Chiropractic office. Member must pay through discount program. Additional Benefits Not covered. Expanded Network Shoe Orthotics Cochlear impldants are now covered. The device is covered at 100%; applicable inpatient/outpatient surgery charges will apply. * Children In-Network In-Network Expanded Network Out-of-Network Weight Watchers Discount. DHMP will share the cost of Weight Watchers with members. Join Weight Watchers through DHMP and the plan will pay 35% of your cost. Curves Wellness program. DHMP will pay $20 toward the monthly fee for every month that members who join Curves work out at least 8 times per month. eLearning module for parents-to-be. Online childbirth classes, free of charge to members. Take Control of Your Health incentive plan. 17 * Prior authorization required. Point of Service Point of Service Plan Name Annual Deductible In-Network Cofinity Network Out-of-Network Individual No deductible applies. $500 per year. $1,500 per year. Family No deductible applies. $1,000 per year. $3,000 per year. In-Network Cofinity Network Out-of-Network $6,350 per year. $2,000 per year. $10,000 per year. $12,700 per year. $4,000 per year. $20,000 per year. In-Network Cofinity Network Out-of-Network No lifetime maximum. No lifetime maximum. No lifetime maximum. In-Network Cofinity Network Out-of-Network Denver Health and Hospital Authority providers and Denver Health Medical Center. Columbine network for chiropractic. See provider directory for a complete list of current providers. Cofinity providers and facilities. Columbine network for chiropractic. See provider directories for a complete list of providers. All providers licensed or certified to provide covered benefits in the United States. In-Network Cofinity Network Out-of-Network $25 copay per visit. $30 copay. Deductible, then Plan pays 50% of usual and customary charges. $30 copay per visit. $40 copay. Deductible, then Plan pays 50% of usual and customary charges. Annual Out-of-Pocket Maximum Individual Family Lifetime Maximum Covered Providers Office Visits Specialist Visit Children Adults Maternity In-Network Cofinity Network No copayment (100% covered). No copayment (100% covered). This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF). This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF). Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay. Non-Denver Health Pharmacy (90-day supply) Non-Denver Health Pharmacy (90-day supply) Discount: $16 copay. Generics: $60 copay. Preferred Brand: $80 copay. Non-preferred Brand: $140 copay. Discount: $16 copay. Generics: $60 copay. Preferred Brand: $80 copay. Non-preferred Brand: $140 copay. In-Network Cofinity Network Out-of-Network $400 copay per hospital stay. * Deductible and 20% coinsurance apply. * Deductible, then Plan pays 50% of usual and customary charges. $200 copay per surgery. * Deductible and 20% coinsurance apply. * Deductible, then Plan pays 50% of usual and customary charges. $150 copay per visit. $150 copay per visit. $150 copay per visit. $150 copay per transport. $150 copay per transport. $150 copay per transport. $50 copay per visit. $50 copay per visit. $50 copay per visit. In-Network Cofinity Network Out-of-Network $0 copay per test. Deductible and 20% coinsurance apply. Deductible, then Plan pays 50% of usual and customary charges. $150 copay per test. $150 copay per test. $250 copay per test. $150 copay per test. Deductible, then Plan pays 50% of usual and customary charges. In-Network Cofinity Network Out-of-Network $150 copay per visit. $250 copay per visit. Deductible, then Plan pays 50% of usual and customary charges. Radiation Therapy $10 copay per visit $10 copay per visit Not covered in this tier. Infusion Therapy (includes chemotherapy) $10 copay per visit $10 copay per visit. Not covered in this tier. $10 copay per visit (immunizations, allergy shots and any other injection given by a nurse is a $0 copay). $10 copay per visit (immunizations, allergy shots and any other injection given by a nurse is a $0 copay). Not covered in this tier. No copay (100% covered). No copay (100% covered). Deductible, then Plan pays 50% of usual and customary charges. In-Network Cofinity Network Out-of-Network $25 copay per visit. $30 copay per visit. $0 deductible 20% coinsurance applies. $400 copay per admission. Deductible and 20% coinsurance apply. * Deductible, then Plan pays 50% of usual and customary charges. In-Network Cofinity Network Out-of-Network $10 copay per visit. 20 of each therapy per calendar year. Deductible and 20% coinsurance apply. 20 of each therapy per calendar year. Hospital & Facility Services Out-of-Network Deductible, then Plan pays 50% of usual and customary charges. Immunizations are not covered in this tier. Outpatient/Ambulatory Surgery Emergency Room Services Emergency Transportation Urgent Care Center Diagnostic Laboratory and Radiology Laboratory, X-Ray and CT MRI PET scans Other Diagnostic and Therapeutic Services Sleep Study Annual well visit, well woman exams, prenatal visits; colonoscopy, mammogram. See USPSTF list on our website at www.denverhealthmedicalplan.org In-Network Cofinity Network Out-of-Network $0 copay per visit. $0 copay per visit. Deductible, then Plan pays 50% of usual and customary charges. Injections $200 copay per admission. Deductible and 20% coinsurance apply. Deductible, then Plan pays 50% of usual and customary charges. Renal Dialysis Out-of-Network Delivery/Inpatient Denver Health Pharmacy Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay. Annual well visit, well woman exams, prenatal visits; colonoscopy, mammogram. See USPSTF list on our website at www.denverhealthmedicalplan.org Prenatal Visit Prescription Drugs Non-Denver Health Pharmacy (30-day supply) Inpatient Hospital Primary Care Visit Preventive Services Non-Denver Health Pharmacy (30-day supply) Non-Denver Health Pharmacy In-Network Cofinity Network Denver Health Pharmacy (30-day supply) Denver Health Pharmacy (30-day supply) Discount: $4 copay. Generics: $15 copay. Preferred Brand: $20 copay. Non-preferred Brand: $35 copay. Discount: $4 copay. Generics: $15 copay. Preferred Brand: $20 copay. Non-preferred Brand: $35 copay. Denver Health Pharmacy by Mail (90-day supply) Denver Health Pharmacy by Mail (90-day supply) Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay Discount: $8 copay. Generics: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay 18 Behavioral Health Outpatient Inpatient Not covered in this tier. Therapies Rehabilitative: Physical, Occupational, and Speech Therapy 19 Not covered in this tier. Deductible, then Plan pays 50% of usual and customary charges. 20 of each therapy per calendar year. * Prior authorization required. Habilitative: Physical, Occupational, and Speech Therapy Pulmonary Rehabilitation $10 copay per visit. 20 of each therapy per calendar year. $10 copay per visit. 20 visit limit per calendar year. Deductible and 20% coinsurance apply. 20 visit limit per calendar year.year. $10 copay per visit. 20 visit limit per calendar year. Deductible and 20% coinsurance apply. 20 visit limit per calendar year. Deductible, then Plan pays 50% of usual and customary charges. 20 visit limit per calendar year. In-Network Cofinity Network Out-of-Network 20% coinsurance applies; maximum 20% coinsurance applies; maximum benefit is $2,000 per calendar year. * benefit is $2,000 per calendar year.* Hearing Aids Adult Deductible, then Plan pays 50% of usual and customary charges. 20 of each therapy per calendar year. Deductible, then Plan pays 50% of usual and customary charges. 20 visit limit per calendar year. Cardiac Rehabilitation Durable Medical Equipment Deductible and 20% coinsurance apply. 20 of each therapy per calendar year. In-Network Cofinity Network Hospice Care Shoe Orthotics In-Network Cofinity Network Out-of-Network 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * Not covered in this tier. In-Network Cofinity Network Out-of-Network Medically necessary orthotics are reimbursed up to $100 per calendar year. Oxygen/Oxygen Equipment In-Network Cofinity Network Out-of-Network 100% covered. * 100% covered. * Deductible, then Plan pays 50% of usual and customary charges. 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * 20% coinsurance applies; no maximum benefit, does not apply to DME maximum. * 50% coinsurance, does not apply to DME maximum. * In-Network Cofinity Network Out-of-Network Oxygen Equipment Organ Transplants $400 copay per admission. Only covered at authorized facilities. Coveage no less extensive than for other physical illness. Covered transplants include: cornea, kidney, kidney-pancreas, heart, lung, heart-lung, liver, and bone marrow for Hodgkin’s, aplastic anemia, leukemia, immunodeficiecy disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer and Wiskott-Aldrich Syndrome only. Peripheral stem cell support is a covered benefit for the same conditions listed above for bone marrow transplants. * Home Health Care Deductible, then Plan pays 50% of usual and customary charges. In-Network Cofinity Network Out-of-Network No copay (100% covered). Maximum benefit is 100 days per calendar year at authorized facility. * Deductible, then 100% covered. Maximum benefit is 100 days per calendar year at authorized facility. * Deductible, then Plan pays 50% of usual and customary charges. In-Network Cofinity Network Out-of-Network Cofinity Network Out-of-Network No copay (100% covered) for prescribed medically necessary skilled home health services. * Deductible, then 100% covered for prescribed medically necessary skilled home health services. * Deductible, then Plan pays 50% of usual and customary charges. Not covered in this tier. In-Network Cofinity Network Out-of-Network Eye Exams $30 copay per visit for routine eye exams (deductible and coinsurance waived). Limit of 1 routine eye exam every 24 months. Self-referral allowed in-network. $40 copay per visit for routine eye exams (deductible and coinsurance waived). Limit of 1 routine eye exam every 24 months. Self-referral allowed in-network. Not covered in this tier. In-Network Cofinity Network Out-of-Network Eyewear Plan pays up to $350 one time per 24 month period for prescription eyewear. Only one claim can be submitted in a 24 month period, i.e. if you are using the benefit for contacts, you may want to wait until you have accumulated $350 in charges before submitting a claim in order to use full benefit. $200 toward Lasik surgery once per lifetime. This benefit can be used at any time regardless of whether or not the $350/24 month benefit has been used. Chiropractic In-Network $20 copay per visit. Maximum 20 visits per calendar year. Services must be provided by Columbine Chiropractic in order to be covered. Cofinity Network $20 copay per visit. Maximum 20 visits per calendar year. Services must be provided by Columbine Chiropractic in order to be covered. Out-of-Network Not covered in this tier. Note: Massage therapy is not a plan benefit but DHMP offers a discount program through Columbine Chiropractic. Many chiropractic offices offer massage therapy as well. DHMP will not pay for massage therapy received at a Columbine Chiropractic office. Member must pay through discount program. Additional Benefits In-Network Cofinity Network Out-of-Network Weight Watchers Discount. DHMP will share the cost of Weight Watchers with members. Join Weight Watchers through DHMP and the plan will pay 35% of your cost. Curves Wellness program. DHMP will pay $20 toward the monthly fee for every month that members who join Curves work out at least 8 times per month. eLearning module for parents-to-be. Online childbirth classes, free of charge to members. Take Control of Your Health incentive plan. * Prior authorization required. Not covered in this tier. In-Network 20 Deductible, then 100% covered. * Not covered except for fluoride varnish at PCP visit. Cochlear implants are now covered. The device is covered at 100%; applicable inpatient/outpatient surgery charges will apply. * Prosthetics No copay (100% covered). * Vision Care Medically necessary hearing aids prescribed by a DHMP Medical Care Network provider are covered every 5 years in-network. For adults over age 18, there is a $1,500 benefit maximum every 5 years. Charges exceeding the $1,500 hearing aid maximum benefit, are the responsibility of the member. * Children under age 18 are covered at 100%, no maximum benefit applies. Hearing screens and fittings for hearing aids are covered under office visits and the applicable copayment applies. Hearing aids no longer apply to the annual DME limit. * Out-of-Network Dental Care Cochlear impldants are now covered. The device is covered at 100%; applicable inpatient/outpatient surgery charges will apply. * Children Cofinity Network Skilled Nursing Facility Not covered in this tier. Out-of-Network In-Network 21 777 Bannock Sreet, MC 6000 Denver, Colorado 80204 LG_PLM_2015DHHAenroll_v1 22
