For Employees - UAB and VIVA

2016
For
Employees
Coverage
you deserve.
Choices
you demand.
Access to all participating Viva Health Providers
No referrals required to see specialists
Viva UAB Access 2016
Effective Dates: January 1, 2016 – December 31, 2016
Attachment A to Certificate of Coverage
The Plan’s services and benefits, with their copayments, coinsurance, and some of the limitations, are listed below. Please remember that this is only a
brief listing. For further information, plan guidelines, and exclusions, please see the Certificate of Coverage.
BENEFITS
Please keep this Attachment A for your records.
CALENDAR YEAR OUT-OF-POCKET MAXIMUM: The most a Member will pay
per Calendar Year for qualified medical, mental, and substance abuse
services, prescription drugs, and specialty drugs. The maximum includes
deductibles, copayments, and coinsurance paid by the Member for qualified
services but does not include premiums or out-of-network charges over the
maximum payment allowance. See the Certificate of Coverage for details.
PREVENTIVE CARE:
 Well Baby Care (Children under age 3)
 Routine Physicals (One per Calendar Year for ages 3+)
 Covered Immunizations
 Preventive Prenatal Care (As defined in the Certificate of Coverage)
 OB/GYN Preventive Visit (One per Calendar Year)
 Other preventive items and services. See Certificate of Coverage for
recommendations and guidelines.
OTHER PRIMARY CARE SERVICES:
 Medical Physician Services
 Illness and Injury
 Hearing Exams
 X-Ray and Laboratory Procedures
o
Covered Genetic Testing
SPECIALTY CARE: (No PCP Referral Required)
 Medical Physician Services
 Illness and Injury
 OB/GYN Services
 X-Ray and Laboratory Procedures
o Covered Genetic Testing
URGENT CARE CENTER SERVICES:
 Medical Physician Services
 Illness and Injury
VISION CARE: (No PCP Referral Required)
 One routine vision exam per Calendar Year
 Other eye care office visits
ALLERGY SERVICES: (No PCP Referral Required)
 Physician Services
 Testing
DIAGNOSTIC SERVICES: (Including but not limited to CT Scan, MRI,
PET/SPECT, ERCP)
OUTPATIENT SERVICES:
 Surgery and Other Outpatient Services
HOSPITAL INPATIENT SERVICES:
 Physician Services
 Semi-Private Room
MATERNITY SERVICES: (Covered for employee and employee’s spouse; not
covered for dependent children except as provided under Preventive Care)
 Physician Services (Prenatal, delivery, and postnatal care)
 Maternity Hospitalization
Eligible baby must be enrolled in plan within 30 days of birth or adoption
for baby’s care to be covered.
EMERGENCY ROOM SERVICES:
EMERGENCY AMBULANCE SERVICES:(Must be Medically Necessary)
COVERAGE
(Tier 1) UAB Network*
COVERAGE
(Tier 2) VIVA HEALTH Network*
$6,600 per individual;
$13,200 per family
100% Coverage
100% Coverage
$15 Copayment per visit
$20 Copayment per visit
80% Coverage
80% Coverage
$30 Copayment per visit
$40 Copayment per visit
80% Coverage
80% Coverage
$30 Copayment per visit
$40 Copayment per visit
$30 Copayment per visit
$30 Copayment per visit
$30 Copayment per visit
$30 Copayment per visit
$30 Copayment per visit
80% Coverage
$40 Copayment per visit
80% Coverage
$100 Copayment per service
$200 Copayment per service
$150 Copayment per visit
$250 Copayment per visit
100% Coverage
$250 Copayment per admission
100% Coverage
$250 Copayment per day (Days 1-5)
$30 Copayment per delivery
$250 Copayment per admission
$40 Copayment per delivery
$250 Copayment per day (Days 1-5)
$100 Copayment per visit (waived if
admitted within 24 hours)
$200 Copayment per visit (waived if
admitted within 24 hours)
80% Coverage
80% Coverage
DURABLE MEDICAL EQUIPMENT AND PROSTHETIC DEVICES:
80% Coverage
80% Coverage
SKILLED NURSING FACILITY SERVICES: (Limited to 60 days per Calendar Year)
80% Coverage
80% Coverage
DIABETIC SUPPLIES: Insulin covered under CAREMARK prescription plan. For
Diabetic Supplies call VIVA HEALTH.
100% Coverage
100% Coverage
$30 Copayment per visit;
$250 Copayment per admission
$40 Copayment per visit;
$250 Copayment per day (Days 1-5)
80% Coverage
80% Coverage
REHABILITIATION SERVICES: Physical, Speech, and Occupational Therapy
HOME HEALTH CARE SERVICES: (Limited to 60 visits per Calendar Year)
UAB Access (2016) 10/2015
BENEFITS
Effective Dates: January 1, 2016 – December 31, 2016
Attachment A to Certificate of Coverage
CHIROPRACTIC SERVICES: (No PCP Referral Required)
 Treatment for manual manipulation of subluxations only
TEMPOROMANDIBULAR JOINT DISORDER:
($3,500 maximum benefit per Lifetime)
SLEEP DISORDERS:
(2 Sleep Studies per Member per Lifetime)
TRANSPLANT SERVICES:
MENTAL HEALTH & SUBSTANCE ABUSE SERVICES1:
 Inpatient Services
 Outpatient Services
Residential treatment and certain diagnoses are excluded. See your Certificate
of Coverage for details.
PHARMACY DEDUCTIBLE:
Applies to all drugs except for generic oral contraceptives and other preventive
drugs required by the Affordable Care Act.
COVERED PRESCRIPTION DRUGS2:
 Generic Drugs
o From a Participating Pharmacy
o Mail-order
o Participating Pharmacy
1
COVERAGE
*
(Tier 1) UAB Network
COVERAGE
*
(Tier 2) VIVA HEALTH Network
$40 Copayment per visit
$30 Copayment per visit
$40 Copayment per visit
$30 Copayment per visit;
$150 Copayment per service
100% Coverage after $250 Hospital
Copayment
$40 Copayment per visit;
$250 Copayment per service
100% Coverage after $250
Copayment per day (Days 1-5)
100% Coverage after $250
Copayment per admission
$30 Copayment per visit
100% Coverage after $250
Copayment per day (Days 1-5)
$40 Copayment per visit
$100 per individual; $200 aggregate amount per family
$15 Copayment per 31-day supply
$30 Copayment per 90-day supply
$45 Copayment per 90-day supply

Preferred Brand Drugs
o From a Participating Pharmacy
o Mail-order
o Participating Pharmacy
$35 Copayment per 31-day supply
$88 Copayment per 90-day supply
$105 Copayment per 90-day supply

Non-Preferred Brand Drugs
o From a Participating Pharmacy
o Mail-order
o Participating Pharmacy
$60 Copayment per 31-day supply
$150 Copayment per 90-day supply
$180 Copayment per 90-day supply

Oral Contraceptives
$0 Copayment for generic drugs; Applicable Copayment for brand-name
drugs

Biological Drugs, Biotechnical Drugs, and Specialty Pharmaceuticals3
80% Coverage
2
Some medications may require prior authorization from VIVA HEALTH. For further information, please contact Customer Service at the phone number listed
below. 3May be administered in the home, physician’s office or on an outpatient basis. When these medications are received from CAREMARK, they must be
ordered by calling 1-800-237-2767. For a list of medications in this category, please refer to http://www.vivaemployer.com/Members/Default.aspx.
When generic is available, Member pays difference between generic and Brand Name price, plus Copayment.
Check with your participating pharmacy to learn if it is eligible to offer a 90-day supply at retail.
SMOKING CESSATION PRODUCTS:
Two, 12-week treatment courses total per Calendar Year. Prescription
required. [Generic nicotine replacement products (including the patch,
lozenge, gum, inhaler, or nasal spray), or Nicotrol (inhaler), or Nicotrol NS
(nasal spray), or Generic Zyban, or Varenicline tartrate (Chantix).]
DEPENDENT STUDENT BENEFITS:
(Emergencies and in-area care are covered under the appropriate sections set
forth in the Certificate of Coverage.)
$0 Copayment
Services to treat an illness or injury for Covered Dependents will be covered
while they are full-time students at an accredited educational institution
out of the Service Area, subject to the Copayments described herein and a
$1,500 maximum benefit per Calendar Year.
SABBATICAL:
Services to treat an illness or injury for Subscribers and Covered
(Sabbatical leave is a period of paid leave granted to faculty members by the
Dependents on Sabbatical Leave will be covered while they are out of the
Employer to pursue professional development, a program of investigation,
Service Area, subject to the Copayments described herein and a $1,500
creative writing, or artistry, and the like.)
maximum benefit per Calendar Year.
VIVA HEALTH Customer Service: (205) 558-7474 or 1-800-294-7780
Visit our Website at www.vivahealth.com
Eligible Dependent:
To be eligible to enroll as a Covered Dependent, a person must be listed on the enrollment application completed by the
Subscriber, reside in the Service Area or with the Subscriber (exceptions apply), and meet additional qualifying criteria. For
exceptions and additional qualifying criteria, please refer to the Certificate of Coverage.
Pre-Existing Condition Policy:
No pre-existing condition exclusions or waiting period.
*
Tier 1 coverage applies to all pediatric care for dependents under age 18 regardless of whether those dependents receive their pediatric care in the VIVA HEALTH
network or the UAB network. The Tier 2 network includes hospitals and health centers within the VIVA HEALTH network but outside of UAB. UAB means University
Hospital, UAB Women and Infants Center, UAB Highlands, The Kirklin Clinic, and all UAB satellite clinics.
UAB Access (2016) 10/2015
VIVA UAB & UAB Access Wellness Benefits
This schedule outlines preventive services and items that VIVA HEALTH will pay at 100 % for the non-grandfathered VIVA UAB & UAB Access
plans. Many of the services are provided as part of an annual physical, which is covered at 100%. In some cases, an office visit or facility
copayment or coinsurance may apply if the preventive service or item is billed separately from the visit. A copayment or coinsurance may
also apply if the primary purpose of your visit is not routine, preventive care. All services must be performed by a provider in your network.
This list does not apply to all VIVA HEALTH plans. Please refer to your Certificate of Coverage to determine the terms of your health plan. “As
recommended per guidelines” means as recommended under the federal health reform law.
PREVENTIVE SERVICE
FREQUENCY
Well Child Visits (Age 3-17) (Must be part of the annual well child visit for
coverage at 100%)
Routine screenings, tests, & immunizations
HIV screening & Counseling
Obesity Screening
Hepatitis B virus screening
Sexually transmitted infection counseling
Skin cancer behavioral counseling (Beginning at age 10)
One per year at PCP2
Routine Physical (Age 18+) (Must be part of your annual physical or
OB/GYN visit for coverage at 100%)
Alcohol misuse screening & counseling
Blood pressure screening
Cholesterol screening
Depression screening
Diabetes screening
Hepatitis B and C Virus Screening
HIV screening & counseling
Obesity screening
Sexually transmitted infection counseling
Syphilis screening
Skin cancer behavioral counseling (Up to age 24)
One per year at PCP
Well Woman Visit (Adolescents & Adults) (Must be part of your annual
physical or OB/GYN visit for coverage at 100%)
Pap smear/cervical cancer screening
Chlamydia screening
Contraception counseling
Domestic violence screening & counseling
Gonorrhea screening
HPV DNA testing
One per year at PCP or OB/GYN
Maternity Care (Pregnant Women)
Prenatal Services (Up to 6 visits per pregnancy depending on diagnosis for
the following services):
 Anemia screening

 Bacteriuria screening

 Chlamydia screening

 Gestational diabetes mellitus screening

As recommended per guidelines
As recommended per guidelines1
As recommended per guidelines
Well Baby Visits (Age 0-2)
Routine Screenings, tests, & immunizations




Gonorrhea screening
Hepatitis B screening
HIV screening
Rh incompatibility screening
 Syphilis screening
Breast feeding counseling
Breast pump purchase3
Tobacco counseling
As recommended per guidelines
As recommended per guidelines
As recommended per guidelines
As recommended per guidelines
Annually
As recommended per guidelines
Annually
Annually
As recommended per guidelines
Annually
As recommended per guidelines
As recommended per guidelines
As recommended per guidelines
As recommended per guidelines
Annually
As recommended per guidelines
As recommended per guidelines
Annually
As recommended per guidelines
Annually
Annually
As recommended per guidelines
Women 30+, every three years





As recommended per guidelines
One at 12-16 weeks’ gestation
One per pregnancy for at-risk women
First prenatal visit if high-risk; after 24 weeks of gestation for
all women
One per pregnancy for at-risk women
First Prenatal visit
One per pregnancy
First prenatal visit for all women; repeated testing at 24-28
weeks’ gestation if at-risk
One per pregnancy
Two per pregnancy
One electric pump selected by VIVA HEALTH every four years
Three per pregnancy for women who smoke
UABpreventserv2016R | 10/2015
VIVA UAB & UAB Access Wellness Benefits
PREVENTIVE SERVICE
FREQUENCY
o
oGenerics only; Prescription required
One every three years; Performed in physician’s office
oOne every three months
oOne every three years; Performed in physician’s office
oOne per year
oGeneric only; Prescription required; Quantity limits apply
based on method
oOne procedure per lifetime
 Sterilization
oThree per month
 Contraceptive Patch
oOne per month
 Contraceptive Vaginal Ring
Osteoporosis screening (All women age 65+ and at-risk women of all ages)
As recommended per guidelines
Screening mammography (Women age 40+)
One per year
BRCA risk assessment and genetic counseling/testing (Women at risk)
Per medical/family history
Lung cancer screening (Very heavy smokers, ages 55-80)
One per year, as recommended per guidelines
Colorectal cancer screening (Age 50-75)
o
One per year
 Fecal occult blood testing or
One every five years
 Sigmoidoscopy or
One every 10 years
 Screening colonoscopy
Abdominal aortic aneurysm screening (Men age 65-75 w/ smoking history)
One per lifetime
Dental caries prevention (Infants and children from birth through age 5)
Four per year at physician’s office
Routine immunizations (Not travel related); Includes, but not limited to:
As recommended by CDC
One per year
 Influenza (Age 6 months-adult)
3 doses per lifetime
 HPV (Starting age 11-12)
As recommended by PCP
 Pneumococcal
oOne per lifetime
 Zoster (Shingles) (Age 60+)
For a full list of covered immunizations, please visit www.vivahealth.com or call V IVA HEALTH Customer Service at 1-800-294-7780 and ask a
representative to mail you a copy.
Diet Counseling (Adults with high cholesterol or other risks for heart or dietThree visits per year with PCP
related chronic disease)
Obesity counseling (Clinically obese children and adults: BMI > 30)
Six visits per lifetime with PCP
Tobacco counseling
One visit per year with PCP or specialist
Contraception (Females)
 Oral Contraceptives4
 Implant (Implanon)
 Injection (Depo-Provera shot)
 I.U.D.
 Diaphragm or cervical cap
 Over the counter contraceptives (Females)5
PHARMACY BENEFITS4
Aspirin to prevent heart disease (Age 45+)
Folic acid supplements (Women 55 & younger)
Iron supplements (12 months & younger)
Oral contraceptives (Females)
Over the counter contraceptives (Females)
Oral fluoride supplements (6 years & younger)
Vitamin D (At-risk 65+)
Tobacco cessation products6
Breast Cancer Preventive Drugs (Women)7
Generic only
Generic only
For babies at risk for anemia
Generic only
Generic only
For children whose water source is fluoride deficient
Generic only; for those at increased risk for falls
Two, 12-week treatment courses total per Calendar
Year. Prescription required.
 Generic nicotine replacement products (including
the patch, lozenge, gum, inhaler, or nasal spray), or
 Nicotrol (inhaler), or
 Nicotrol NS (nasal spray), or
 Generic Zyban, or
 Varenicline tartrate (Chantix)
Tamoxifen and raloxifene (generic only)
As recommended per guidelines means as recommended by your physician and in accordance with guidelines issued under the Affordable Care Act. 2PCP means
personal care provider or primary care physician and is generally an internist, family practitioner, general practitioner, pediatrician, and sometimes an obstetrician/
gynecologist. 3To order a breast pump, member must be within 30 days of due date or actively breastfeeding. Call MedSouth Medical Supplies at 1-800-423-8677.
4
Must have prescription coverage through VIVA HEALTH to access this benefit. Prescription required for coverage, even for over-the-counter products. Quantity limits
may apply. 5Exceptions may apply based on medical necessity. 6Prior Authorization must be obtained in order to access additional courses of treatment covered at
100%. 7Must complete and return to VIVA HEALTH an exception form to be eligible to receive at $0 copayment. Go to www.vivaprovider.com/Resources/Forms.aspx to
download the form, or call Customer Service.
1
UABpreventserv2016R | 10/2015
Coverage
& Choices
Coverage you deserve.
Choices you demand.
The Viva Access Plan offers you:
• Access to all participating Viva Health providers!
• No referrals needed. You may use any participating
Viva Health Specialist or Primary Care Physician
without a referral.
Worldwide Emergency and Urgent Care Coverage.
If you are outside the service area and have an urgent
and unforeseen need for care that can’t wait until you
return home, you are covered. This includes care in a
physician’s office for an unexpected illness or injury
that would not be classified as an emergency, but does
require immediate attention. Of course this does not include routine or elective medical services, and you must return to the service area for any follow-up care. Still, if you’re on a weekend trip or an
extended vacation, you can relax knowing that you are covered. Care in an Emergency Room is only covered for treatment of emergency medical conditions.
Customer Service
(205) 558-7474 or (800) 294-7780 or
[email protected]
Viva Access for UAB Employees
A Product of
A Member of the
Health System
www.VivaHealth.com
417 20th Street North , Suite 1100 Birmingham, Alabama 35203