2015 CBC PPO-HRA Medical Plan Summary of

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2015 CBC PPO-HRA Medical Plan Summary of
Air Products Medical Plan
1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2015 – 12/31/2015
Coverage for: All | Plan Type: Consumer PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy document
at www.capbluecross.com or by calling 1-800-597-5154. For the Plan document call the Employee Help Center at the number below.
Note: The Uniform Glossary can be accessed at: www.dol.gov/ebsa/healthreform and www.cciio.cms.gov.
For expatriates, all covered medical services incurred while you are outside the U.S. are considered at the Participating Provider level.
Important Questions
Answers
What is the overall
deductible?
$ 1,300/person/$2,000/2-Party/ $2,600/
family.1 Does not apply to network
preventive services or prescription
medications.
Are there other
deductibles for specific
services?
No.
Yes. $2,150/person/$3,325/2-party/$4,400
family for participating providers $3,400/
person/ $5,000/2-Party/$6,600/family nonparticipating providers for medical services.1
What is not included in This Plan does not cover balance-billed
charges, premium, pre-authorization penalties
the out–of–pocket
expenses. Prescriptions have a separate limit.
limit?
Is there an overall
No.
annual limit on what
the Plan pays?
Is there an out–of–
pocket limit on my
expenses?
Why this Matters:
You must pay all the costs up to the deductible amount before this Plan
begins to pay for covered services you use. Check your policy or Plan
document to see when the deductible starts over (usually, but not
always, January 1st). See the chart starting on page 2 for how much you
pay for covered services after you meet the deductible.
You do not have to meet deductibles for specific services, but see the
chart starting on page 2 for other costs for services this Plan covers.
The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses. See page 3 for Rx.
Even though you pay these expenses, they do not count toward the outof-pocket limit.
The chart starting on page 2 describes any limits on what the Plan will
pay for specific covered services, such as office visits.
Does this Plan use a
network of providers?
Yes. For a list of participating providers, see
www.capbluecross.com or call 1-800-5975154.
If you use an in-network doctor or other health care provider, this Plan
will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some
services. Plans use the term in-network, preferred, or participating for
providers in their network. See the chart starting on page 2 for how this
Plan pays for different kinds of providers.
Do I need a referral to
see a specialist?
No. You do not need a referral to see a
specialist.
You can see the specialist you choose without permission from this Plan.
Are there services this
Plan does not cover?
Yes.
Some of the services this Plan does not cover are listed on page 5. See
your policy or Plan document for additional information about excluded
services.
For eligibility: Employee Help Center 1-800-272-5442 or [email protected] For medical benefits: Capital BlueCross
1-800-597-5154 or www.capbluecross.com. For behavioral health: Magellan 1-866-322-1657. For employee assistance program: Magellan
1-800-327-0205 or www.magellanhealth.com/member. For prescriptions: Express Scripts 1-800-283-8609 or www.express-scripts.com.
1 of 8
Air Products Medical Plan
1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2015 – 12/31/2015
Coverage for: All | Plan Type: Consumer PPO
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example,
if the Plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may
change if you haven’t met your deductible.
• The amount the Plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay
and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This Plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
Your Cost If You Use a
Services You May Need
Primary care visit to treat an
injury or illness
Specialist visit
If you visit a health
care provider’s
office or clinic
If you have a test
Participating
Provider
Non-participating
Provider
Limitations & Exceptions
20% coinsurance
40% coinsurance
---------------none---------------
20% coinsurance
20% coinsurance
for chiropractic
40% coinsurance
40% coinsurance
for chiropractic
Preventive care/screening/
immunization/Employee
Assistance Program
No charge
Not covered
---------------none--------------Acupuncture not covered. Chiropractic not covered
after 10 visits.
Certain preventive services are covered at no
charge. Deductible does not apply to services at
participating providers.
For Employee Assistance Program – Brief
counseling, limited to 5 face-to-face sessions per
year (individually or as a group).
Diagnostic test (x-ray, blood
work)
20% coinsurance
for lab and tests.
20% coinsurance
for outpatient
radiology.
40% coinsurance
---------------none---------------
Imaging (CT/PET scans,
MRIs)
20% coinsurance
40% coinsurance
---------------none---------------
Other practitioner office visit
For eligibility: Employee Help Center 1-800-272-5442 or [email protected] For medical benefits: Capital BlueCross
1-800-597-5154 or www.capbluecross.com. For behavioral health: Magellan 1-866-322-1657. For employee assistance program: Magellan
1-800-327-0205 or www.magellanhealth.com/member. For prescriptions: Express Scripts 1-800-283-8609 or www.express-scripts.com.
2 of 8
Air Products Medical Plan
1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Your Cost If You Use a
Common
Medical Event
Services You May Need
Prescription
Medication Out-ofPocket Limit
$4,000/person;$8,000/family
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.expressscripts.com.
Limitations & Exceptions
Participating
Non-participating
Provider
Provider
Not included in this limit are: costs that exceed allowable amount from a non-participating
pharmacy, the difference in cost between a brand name and generic medication equivalent,
additional costs if you use a non-preferred medication, a non-designated specialty pharmacy
or receive medications in excess of the quantity, dose or coverage provisions of the program.
Generic drugs
20% coinsurance
(mail and retail)
Preferred brand drugs
20% coinsurance
(mail and retail)
20% coinsurance
Non-preferred brand drugs
40% coinsurance
(mail and retail)
40% coinsurance
Note: Walgreens
pharmacy is no
longer a participating
provider.
20% coinsurance
For additional limitations for all medications.2
Mail - up to 90 day supply - $10 min. - $100 max.
Retail - up to 30 day supply - $5 min. - $50 max.
For additional limitations for all medications.2
Mail - up to 90 day supply - $25 min. - $250 max.
Retail - up to 30 day supply - $10 min. - $200 max.
For additional limitations for all medications.2
Mail - up to 90 day supply - $50 min. - $500 max.
Retail - up to 30 day supply - $25 min. - $400 max.
For additional limitations for all medications.2
Specialty drugs must be purchased through mail
order to be eligible (unless unavailable by mail).
Specialty drugs
If you have
outpatient surgery
Coverage Period: 01/01/2015 – 12/31/2015
Coverage for: All | Plan Type: Consumer PPO
Facility fee (e.g., ambulatory
surgery center)
Preferred – 20%
coinsurance
Non-preferred –
40% coinsurance
20% coinsurance
Not covered
40% coinsurance
Preferred Mail - up to 90 day supply - $25 min. $250 max.
Non-Preferred Mail - up to 90 day supply - $50
min. - $500 max.
Preferred Retail - up to 30 day supply - $10 min. $200 max.
Non-preferred Retail - up to 30 day supply - $25
min. - $400 max.
---------------none---------------
For eligibility: Employee Help Center 1-800-272-5442 or [email protected] For medical benefits: Capital BlueCross
1-800-597-5154 or www.capbluecross.com. For behavioral health: Magellan 1-866-322-1657. For employee assistance program: Magellan
1-800-327-0205 or www.magellanhealth.com/member. For prescriptions: Express Scripts 1-800-283-8609 or www.express-scripts.com.
3 of 8
Air Products Medical Plan
1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you need
immediate medical
attention
If you have a
hospital stay
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
Coverage Period: 01/01/2015 – 12/31/2015
Coverage for: All | Plan Type: Consumer PPO
Your Cost If You Use a
Services You May Need
Participating
Provider
Non-participating
Provider
Limitations & Exceptions
Physician/surgeon fees
20% coinsurance
40% coinsurance
Preauthorization is required. 3
Emergency room services
20% coinsurance
20% coinsurance
---------------none---------------
Emergency medical
transportation
20% coinsurance
20% coinsurance
---------------none---------------
Urgent care
20% coinsurance
40% coinsurance
---------------none--------------Preauthorization is required. 3
Facility fee (e.g., hospital
room)
20% coinsurance
40% coinsurance
Acute Inpatient Rehab – 60 day limit per benefit
period.
Physician/surgeon fee
20% coinsurance
40% coinsurance
---------------none---------------
Mental/Behavioral health
outpatient services
20% coinsurance
40% coinsurance
---------------none---------------
Mental/Behavioral health
inpatient services
20% coinsurance
40% coinsurance
---------------none---------------
Substance use disorder
outpatient services
20% coinsurance
40% coinsurance
---------------none---------------
Substance use disorder
inpatient services
20% coinsurance
40% coinsurance
---------------none---------------
Prenatal and postnatal care
20% coinsurance
40% coinsurance
---------------none---------------
Delivery and all inpatient
services
20% coinsurance
40% coinsurance
---------------none---------------
For eligibility: Employee Help Center 1-800-272-5442 or [email protected] For medical benefits: Capital BlueCross
1-800-597-5154 or www.capbluecross.com. For behavioral health: Magellan 1-866-322-1657. For employee assistance program: Magellan
1-800-327-0205 or www.magellanhealth.com/member. For prescriptions: Express Scripts 1-800-283-8609 or www.express-scripts.com.
4 of 8
Air Products Medical Plan
1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Coverage Period: 01/01/2015 – 12/31/2015
Coverage for: All | Plan Type: Consumer PPO
Your Cost If You Use a
Services You May Need
Limitations & Exceptions
Non-participating
Provider
Home health care
40% coinsurance
Non-participating not covered after 50 visits.
Therapy visit limit: speech 30, physical and
Rehabilitation services
20% coinsurance 40% coinsurance
occupational 30 (combined).3
If you need help
Habilitation services
Not covered
Not covered
---------------none--------------recovering or have
other special health
Skilled nursing care
20% coinsurance 40% coinsurance
After 120 days, not covered.
needs
Preauthorization is required on items greater than
Durable medical equipment
20% coinsurance 40% coinsurance
or equal to $500.3
Hospice service
20% coinsurance 40% coinsurance
---------------none--------------Eye exam
Not covered
Not covered
---------------none--------------If your child needs
Glasses
Not covered
Not covered
---------------none--------------dental or eye care
Dental check-up
Not covered
Not covered
---------------none--------------1
Member cost share may be reduced by employer participation in an HRA (Health Reimbursement Account). Air Products’ HRA
allocation is $700/person/$1,050/2-party and $1,400/family. Rollover HRA funds can be applied to employee deductible responsibility only.
Participating
Provider
20% coinsurance
2
Deductible does not apply. Certain drugs require preauthorization/coverage review in order to be eligible. Certain coverage limits may
apply. If a non-participating pharmacy charges more than the allowed amount, you may have to pay the difference. Medications taken on
an ongoing basis must be ordered through Express Scripts by mail order. You may use a participating retail pharmacy for an initial fill (up
to 30 days) and one refill.
3
Preauthorization may apply. See your policy for a list of services requiring Preauthorization and penalties for failure to obtain
Preauthorization.
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or Plan document for other excluded services.)
• Acupuncture
• Glasses
• Private Duty Nursing
• Bariatric surgery (unless medically necessary) • Habilitation services
• Routine eye care
• Cosmetic surgery
• Hearing aids
• Routine foot care
• Dental care
• Long-term care
• Weight loss programs
For eligibility: Employee Help Center 1-800-272-5442 or [email protected] For medical benefits: Capital BlueCross
1-800-597-5154 or www.capbluecross.com. For behavioral health: Magellan 1-866-322-1657. For employee assistance program: Magellan
1-800-327-0205 or www.magellanhealth.com/member. For prescriptions: Express Scripts 1-800-283-8609 or www.express-scripts.com.
5 of 8
Air Products Medical Plan
Coverage Period: 01/01/2015 – 12/31/2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: All | Plan Type: Consumer PPO
Other Covered Services (This isn’t a complete list. Check your policy or Plan document for other covered services and your costs for these
services.)
• Chiropractic care
• Non-emergency care when traveling outside the United States
• Infertility treatment
• Routine maternity
• Most coverage provided outside the United States. See
www.bcbs.com/shop-for-health-insurance/coverage-home-and-away.html
1
Your Rights to Continue Coverage:
If you lose coverage under the Plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep
health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the
premium you pay while covered under the Plan. Other limitations on your rights to continue coverage may also apply.
For more information on the rights to continue coverage, contact the claims administrator at the phone number below. You may also contact your
state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or
the U.S. Department of Health and Human Services at 1-877-267-2323 or www.cciio.com.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under the Plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact the claims administrator at the phone number below. You may also contact the
Pennsylvania Insurance Department 1-877-881-6338 or www.insurance.pa.gov. You may also contact the Department of Labor Employee Benefits
Security Administration 1-866-444-3272 or www.dol.gov/ebsa/healthreform. For additional assistance, you may contact the Pennsylvania Consumer
Assistance Line 1-877-881-6388 or [email protected]
Language Access Services:
Para obtener asistencia en Espanol, llame al 1-800-962-2242. Contact Capital BlueCross or other claims administrators at the phone numbers below.
中文: 如果需要中文的帮助,请拨打这个号码 1-800-962-2242. Contact Capital BlueCross or other claims administrators at the phone numbers
below.
Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care
coverage that qualifies as “minimum essential coverage.” This health coverage option does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard? In order for certain types of health coverage (for example, individually
purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed
charges for covered services. This is called the “minimum value standard”. This health coverage option does meet the minimum value standard for
the benefits it provides.
––––––––––––––––––––––To see examples of how this Plan might cover costs for a sample medical situation, see the next page.––––––––––––––––
For eligibility: Employee Help Center 1-800-272-5442 or [email protected] For medical benefits: Capital BlueCross
1-800-597-5154 or www.capbluecross.com. For behavioral health: Magellan 1-866-322-1657. For employee assistance program: Magellan
1-800-327-0205 or www.magellanhealth.com/member. For prescriptions: Express Scripts 1-800-283-8609 or www.express-scripts.com.
6 of 8
Air Products Medical Plan
Coverage Period: 01/01/2015 – 12/31/2015
Coverage for: All | Plan Type: Consumer PPO
Coverage Examples
About these Coverage
Examples:
These examples show how this Plan might
cover medical care in given situations. Use
these examples to see, in general, how much
financial protection a sample patient might get
if they are covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this Plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
4
Having a baby
Managing Type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $5,840
 Patient pays $1,700
 Amount owed to providers: $5,400
 Plan pays $3,720
 Patient pays $1,680
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles4
Copays
Coinsurance
Limits or exclusions
Total
$600
$0
$1,000
$80
$1,680
Patient pays:
Deductibles4
Copays
Coinsurance
Limits or exclusions
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$600
$0
$900
$200
$1,700
Employee deductible responsibility has been reduced by Company-paid HRA allocation.
For eligibility: Employee Help Center 1-800-272-5442 or [email protected] For medical benefits: Capital BlueCross
1-800-597-5154 or www.capbluecross.com. For behavioral health: Magellan 1-866-322-1657. For employee assistance program: Magellan
1-800-327-0205 or www.magellanhealth.com/member. For prescriptions: Express Scripts 1-800-283-8609 or www.express-scripts.com.
7 of 8
Air Products Medical Plan
Coverage Examples
Coverage Period: 01/01/2015 – 12/31/2015
Coverage for: All | Plan Type: Consumer PPO
Questions and answers about the Coverage Examples:
What are some of the assumptions
behind the Coverage Examples?
•
•
•
•
•
•
•
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health
plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under the Plan.
Out-of-pocket expenses are based only
on treating the condition in the
example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been
higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up.
It also helps you see what expenses might be
left up to you to pay because the service or
treatment isn’t covered or payment is
limited.
Does the Coverage Example predict
my own care needs?
 No. Treatments shown are just
examples. The care you would receive for
this condition could be different based on
your doctor’s advice, your age, how
serious your condition is, and many other
factors.
Does the Coverage Example predict
my future expenses?
No. Coverage Examples are not cost
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the Plan provides.
Are there other costs I should
consider when comparing plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as flexible spending
arrangements (FSAs) or health
reimbursement accounts (HRAs) that
help you pay out-of-pocket expenses.
estimators. You can’t use the examples to
estimate costs for an actual condition.
They are for comparative purposes only.
Your own costs will be different
depending on the care you receive, the
prices your providers charge, and the
reimbursement the Plan allows.
For eligibility: Employee Help Center 1-800-272-5442 or [email protected] For medical benefits: Capital BlueCross
1-800-597-5154 or www.capbluecross.com. For behavioral health: Magellan 1-866-322-1657. For employee assistance program: Magellan
1-800-327-0205 or www.magellanhealth.com/member. For prescriptions: Express Scripts 1-800-283-8609 or www.express-scripts.com.
8 of 8

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