HomeMy WebLinkAboutRES.2229.12-18-2006BILL NO. 06-265
RESOLUTION NO.
A RESOLUTION AUTHORIZING THE CITY MANAGER TO
EXECUTE A CONTRACT WITH ANTHEM BLUE CROSS
FOR EMPLOYEE HEALTH INSURANCE SERVICES, IN
THE CITY OF CAPE GIRARDEAU, MISSOURI
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF CAPE
GIRARDEAU, MISSOURI, AS FOLLOWS:
ARTICLE 1. The City Manager, for and on behalf of the City
of Cape Girardeau, Missouri, is hereby authorized to execute a
Contract with Anthem Blue Cross for employee health insurance
services, in the City of Cape Girardeau. Said Contract shall
contain the terms set out in the proposal from Anthem Blue
Cross.
A copy of the proposal information is attached hereto and
made a part hereof.
PASSED AND ADOPTED THIS I0DAY OF 20 ``i
01/
< :: Jay Knudtson, Mayor
City Clerk
CBIZ Benefits & Insurance Services, Inc.
11440 Tomahawk Creek Parkway
Leawood, Kansas 66211
Main: (913) 234-1000
Toll Free: (800) 530-5866
Fax: (913) 234-1100
December 7, 2006
Mr. David Milam
Human Resources and Risk Manager
City of Cape Girardeau
401 Independence Street
P.O. Box 617
Cape Girardeau, MO 63702
Re: Dental and Medical Plan Renewal
Dear David:
Your dental and medical plan renewals will renew effective January 1, 2007. The following
information will discuss those plans.
Dental Plan
As you know, the City's dental plan is self funded with Delta Dental Plan of Missouri. As such, you
set your own conventional equivalent rates to gather enough premiums to cover administrative costs
and claims.
The expenses for the past year on this plan have been within those projected at renewal last year.
Delta has requested a slight increase in administrative costs for the next year. Even with a slight
increase, and the projected claims for 2007, your current rates should provide adequate funding for
the plan. We would recommend renewing the plan with Delta Dental with no increase in premium
rates.
Medical Plan
Your paid claims have increased by 23% over the prior 12 month period, from $1,882,170 for
10/01/04 — 09/30/05 to $2,315,716 for 10/01/05 — 09/30/06. In the last 12 months, there were 20
claims over $25,000 for a total of $1,092,790.68. This is equivalent to 47% of your claims on 3% of
your members.
11440 TOMAHAWK CREEK PARKWAY . LEAWOOD, KANSAS 66211 • 913-234-1000 • FAx: 913-234-1100
Mr. David Milam
City of Cape Girardeau
December 7, 2006
Page Two
The contract in place with Anthem (in place prior to the City contracting with CBIZ) is a hybrid self-
funded plan. As such, while there is potential to realize savings if claims are lower than expected,
any deficits developed are carried forward, and are funds owed to Anthem, regardless of the City's
actions (termination, etc.). Additionally, if there is a deficit carried forward, Anthem will include a
specific component in the renewal rating formula for deficit recovery.
2007 Plan Year Renewal
As discussed, your claim experience has deteriorated this year. However, Anthem's renewal
philosophy is to utilize the past three years of claims experience in the rating formula. As such, you
have benefited from your positive claims experience from 2005.
As part of the renewal process, Anthem would normally increase all fixed expenses, increase claim
maximums and include a component for deficit recovery. After negotiations, Anthem has agreed not
to increase individual stop loss costs, administrative costs, nor include a specific component for
reduction of the deficit. After these reductions, Anthem proposed an overall increase of 43% on the
Enriched Plan and 41.6% on the Base (City paid) plan.
These increases would develop about $3,146,086 in premium for 2007, vs. an approximate collected
premium of $2,183,027, based on current enrollment, and rates charged by the City to employees.
Possible Plan Changes
Anthem has developed some possible plan design options to mitigate this increase. The first
suggested change is to remove the two plans and keep one plan in place. This develops a credit of
approximately 3%.
The plan that would be provided to all employees and retirees will include benefit changes. Some of
those changes are as follows:
Deductible:
Coinsurance limit:
Maximum Out-of-pocket:
Office Visit Copay:
Prescription Drugs:
Mr. David Milam
City of Cape Girardeau
December 7, 2006
Page Three
$2,500 / person (3x family) In -network
$2,500 (2x family) In -network
$5,000 (2x family) In -network
$30 Primary Care / $50 Specialist
$10 Generic / $35 Tier 2 / $75 Tier 3 / Specialty
Drugs (Tier 4) 25% Copay to Annual Max of $2,500
11440 TOMAHAWK CREEK PARKWAY • LEAWOOD, KANSAS 66211 •913-234-1000 • FAx: 913-234-1100
While these are changes from your current plans, Physician office visits and Prescription Drugs
remain covered subject to copays. Additionally, you will see some enhancements to benefits as
illustrated in the side by side comparison which is attached. One of those enhancements is that
office surgery is now covered under the office visit copay, where it was covered subject to deductible
and coinsurance. Also, emergency room visits were subject to deductible and coinsurance, where
now they are covered at 80% after a $150 copay, no deductible. Preventive care services, which
were covered at a maximum of $150, will now have no limit.
This develops an increase of 25% over last years Base Plan Rates. Those rates are attached.
If we can provide any further information, please let us know.
Sincerely,
David J. Johnson, CEBS
Senior Benefits Consultant
/dlr
Enc.
11440 TOMAHAWK CREEK PARKWAY • LEAWOOD, KANSAS 66211 •913-234-1000 • FAx: 913-234-1100
Anthem.0. 9
The
Network
Non -Network
Network Non -Network
Lifetime Maximum
Unlimited
Unlimited
Deductible (Single/Family)
$1,000
$2,000
$2,500
$2,500
Charges applied to the Network deductible will
$2,000
$4,000
$7,500
$7,500
not apply towards the Non -network deductible
and vice versa.
4th quarter deductible carry over credit is no
longer standard,
Out-of-pocket Maximums
(Single/Family)
$2,000
$4,000
$5,000
$10,000
$5,000
$10,000
$10,000
The deductible is included in out-of-pocket
$20,000
maximum. This was tracked as coinsurance
(deductible not
(deductible not
(deductible
(deductible
maximums without the deductible.
Included)
included)
included)
included)
Network and non -network maximums do not
cross apply.
Cost Share
20%
50%
20%
50%
Physician Home and
Office Services (includes
Office surgery is now covered under the
PCP and SCP)
office -visit copay, It was deductible and
coinsurance.
Office visit
$30 PCP/
Deductible/ 50%
$30 PCP/
Deductible/ 50%
There is a $5 allergy injection copayment per
$30 SPC
$50 SPC
visit in the network office setting only if billed
without an office visit charge. If there is an
Office Surgery
Deductible/ 20%
Deductible/ 50%
$30
Deductible/ 50%
office -visit charge with the injection charge,
the member pays the office -visit copay and
Allergy serum
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
not the allergy injection copay. If allergy
serum is the only charge as a result of a
network office visit, the member pays
Allergyinjections
1
Deductible/ 20 /°
Deductible/ 50%
$5
Deductible/ 50%
deductible/ cost share instead of a copay,
WAS, MRIs, CT -scans, PETS, nuclear
cardiology imaging studies, stress tests, and
Allergy testing
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
non -routine maternity ultrasounds now are
subject to the Other Outpatient Services cost
Routine and non routine
Covered in full
Deductible/ 50%
$30
°
Deductible/ 50%
share regardless of where services are
received.
mammograms
Other Outpatient Services cost share will
apply to all DME, DME vendor medical
Diabetic education
Deductible/ 20%
Deductible/ 50%
$30
°
Deductible/ 50%
supplies, and prosthetic devices/appliances
obtained in the office visit, urgent care, other
outpatient setting, or home care setting,
MRAs, MRIs, PETS,
CT -scans, nuclear
Covered in full
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
cardiology imaging studies
and non -maternity related
ultrasounds
information
included here rs simply an overview of key benefit changes in our standard product lines. Itis not an exhaustive list of changes and is nota legal document. For
complete details on all benefits, limitations and exclusions, please refer to the benefit contract. In the event of a conflict between this document and the contract, the contract will control.
Anthem Blue Cross and Blue Shield is the trade name RightCHOICEe Managed Care, Inc. (RIT),
Healthy AhianceaLife Insurance Company (HALIC) and HMO Missouri, Inc. use to do business
PPO Product Comparison - PI/6 (4106) in most of Missouri. RIT and certain affiliates administer non -HMO benefits underwritten by
HALIC and HMO benefits by HMO Missouri, Inc. RIT and certain affiliates only provide adminis alive
services for self-funded plans and do not underwrite benefits. RIT, HMO Missouri, Inc. and HALIC
are independent licensees of the Blue Cross Blue Shield Association.
Benefit
s
Preventive dare Services
Thele I. no cafe»dar-yearbenefit maximum.
Sernce� irrdude but are not
There was a $150 calendar -year maximum for
limited to: routine exams,
well adult.
pelvic exams, Pap testing,
Vision Exams/Refractions covered under new
PSA tests, immunizations,
plan,
annual diabetic eye exam,
routine vision and hearing
exams
Physician home and office
$30
Deductible/ 50%
$30
Deductible/ 50%
visits
Other outpatient services at
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
hospital/altemative care
facility
Immunizations
Covered in full
Covered in full
Covered in full
Covered in full
through age 5
Emergency and Urgent
ER charges are paid at copay and now
Care
include separately billed doctor charges.
Emergency room services at
Deductible/ 20%
Deductible/ 50%
$150/20%
$150/20%
There now is an urgent care center copay
hospital (facility/other
covered services)
copayment waived if
admitted
Urgent care center services
Deductible/ 20%
Deductible/ 50%
.$50
Deductible/ 50%
Emergency ambulance
Deductible/ 20%
Network
Deductible/ 20%
In Network
services
Deductible/ 20%
Deductible/ 20%
Inpatient and Outpatient
Professional Services
Included but are not limited
to:
Medical care visits (1 per
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
day) intensive medical care,
concurrent care,
consultation, surgery,
administration of general
anesthesia and newborn
exams
PPO Product comparison - P216 (4/06)
Benefit
Blue Cross
Inpatient Facility Services
Now there is a 60-day limit per bbnefitperiod
Unlimited days except for
for inpatient physical medicine/rehab.
Previously we did not track inpatient physical
60 days Network/Non-
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
medicine/rehab,
network combined for
Skilled Nursing now has a 90-day limit per
physical medicine/rehab
benefit period. The limit was 100 day.
(limit includes day
rehabilitation therapy
services on an outpatient
basis)
90 days Network/Non-
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
network combined for skilled
nursing facility
Outpatient Surgery
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
(Hospital/Alternative Care
Facility)
Other Outpatient Services
Breast prosthesis is covered whether internal
(including but not limited to):
or external following a mastectomy and four
surgical bras per benefit period. Breast
Non-surgical outpatient
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
prosthesis is not subject to the maximum for
prosthetic devices.
services such MRIs,
CT-scans, chemotherapy,
Foot orthotics now are covered under the
ultrasounds, and other
plan,
diagnostic outpatient
HHC now is limited to 90 visits per benefit
services
period vs. 100 visits current plan.
Private duty nursing is covered under home
Home health care services
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
care and has a separate limit of $50,000 per
(Network and Non-network
benefit period and $100,000 per lifetime. The
combined) 90 visits per
dollar limits are combined Network and Non-
benefit series (excludes IV
network.
therapy)
When provided in the home,
Durable medical equipment,
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
physical/manipulation therapy (excluding
chiropractic services), occupational therapy,
orthotics (Network and Non-
network combined $4,000
and speech therapy will accumulate towards
benefit period maximum)
the home care services limit only.
DME & orthotics now have a benefit period
Prosthetics (network and
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
maximum.
Non-network combined
Prosthetics now have a benefit period
$4,000 benefit period
maximum
maximum.)
Non-emergency ambulance now subject to
network deductible and network cost-share.
Physical medicine therapy
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
day rehabilitation programs
Hospice care
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
Non-emergency ambulance
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
services
PPO Product Cornpanson - P3/6 (4/06)
PPO Product Comparison - P416 (4/66)
Blue Cross
New
Change
Outpatient Therapy
Speech therapy visits now are unlimited.
Services
All occupational therapy, physical therapy and
(Combined Network and
speech therapy in the office is covered under
Non -network limits apply)
the office -visit copay, It was covered under
deductible/coinsurance after the member paid
Physician home and office
$30 Office and
Deductible/ 50%
$30/$50
Deductible/ 50%
the copay for the office -visit charge.
visits (PCP/SCP)
Deductible/ 20%
for therapy
Other outpatient services at
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
hospital/ altemative care
facility
Limits apply to:
Physical/manipulation
therapy excluding
Chiropractic services: 20
visits
Occupational therapy: 20
visits
Chiropractic services: 26
visits network only
Speech therapy unlimited
Behavioral Health Services
There now is no limit to Non -network services
(Network& Non -network)
for substance abuse rehabilitation programs.
Mental Health
There was a $5,000 lifetime maximum for
Non -network services for substance abuse.
Inpatient facility services
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
Physician home and office
$30
Deductible/ 50%
$30/$50
Deductible/ 50%
visits (PCP/SCP)
Other outpatient services
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
(hospital/ alternative care
facility)
Substance Abuse
Inpatient 21 days/6 detox
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
Outpatient facility: 30 days
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
Outpatient office visits: 30
$30
Deductible/ 50%
$30/$50
Deductible/ 50%
visits (PCP/SCP)
(Substance abuse rehab
programs are limited to 10
episodes per lifetime
Network and Non -network
combined.)
PPO Product Comparison - P416 (4/66)
Benefit•
Anthem
New Change
Human Organ and Tissue
Deductible/ 20%
Deductible/ 50%°
Covered in full
Deductible/ 30% Cornea and kidney transplants are covered
Transplants
A set list of
A set list of
the same as any other medical condition;
Acquisition and transplant
transplant
transplant
other transplants are included under the
procedures, harvest and
procedures
procedures
HOTT benefits.
storage
(including
(including
No cost share for HOTT services received
cornea and
cornea and
from a Network transplant provider.
kidney) and
covered
kidney) and
covered
Non-network/non-participating (not
services are
services are
participating in the transplant Network): the
HOTT admission is subject to 30% cost share
subject to the
subject to the
and does not accumulate to the Non -
same cost
shares as other
same cost
shares as other
network/non-participating OPL
surgeries.
surgeries.
HOTT benefits do not apply to a covered
service (related to a covered transplant
procedure) received prior to or after the
transplant benefit period.
Transplant benefit period is defined as the
period starting one day prior to the transplant
and covered by the case rate/global fee
arrangement for Network transplants, or
continuing until the discharge date for Non -
network transplants.
HOTT services apply to the medical lifetime
maximum.
Eliminated EPO for ABMT — now treated
same as other HOTT
Prescription Drugs
Self injectables (01 Tier) now are 25% cost
share with a $2,500 out-of-pocket maximum
Network Retail Pharmacy
Tier 1, 2 and 3:
Tier 1, 2 and 3:
Tier 1, 2 and 3:
Tier 1, 2 and 3:
per benefit period.
.30 -da supply includes
y PP y (
$8/$25/$45
is appropriate
$10/$35/$75
50%
Diabetic test strips are copay
diabetic test strip)
°
Tier 4: 20 /° up
to a $100
tier copay plus
f ll P
30% of allowed
°
Tier 4:25 /° up
to $2,500 out -of-
cost share with
a minimum $45
Non -network pharmacy charges are paid at
coinsurance
amount plus
pocket
per prescription
50% with a minimum dollar amount.
maximum per
P
difference
maximum per
°
Tier 4: 50% cost
The mail order vendor will continue to be
prescription,
between the
benefit period
share with a
Precision Rx.
with a $2,000
retail charge
minimum $45
coinsurance
and allowed
per prescription
maximum per
amount
calendar year
Tier 4 is
30% of allowed
amount plus
difference
between the
retail charge
and allowed
-
amount
Precision Rx Mail -Order
Tier 1, 2 and 3:
Not available
Tier 1, 2 and 3:
Not available
Services
$16/$30/$50
$20/$90/$190
(90 -day supply (includes
Tier 4: 20% up
Tier 4: 25% up
diabetic test strip)
to a $200
to $2,500 out -of -
coinsurance
pocket
maximum per
maximum per
prescription,
benefit period
with a $2,000
calendar
maximum
PPO Product Companson - P5/6 (4/06)
Y*
Administrative a -s
Blue Cross Current
Anthem
L
Network tVame Changes
Alliance
Blue Access PPO
A simple name change.
Pharmacy Vendors
Wellpoint Pharmacy
WellNextRx for Retail and
A simple name change.
Management for Retail and
Precision Rx for Mail Order
Precision Rx for Mail Order
Laboratory Services
For Alliance, the member
No additional cost share for
cost share is based on
plans with office visit
setting and if services are
copayment designs if
received from an
performed during a
independent lab in the
network, no copayment is
Network office visit or at a
required.
Network laboratory.
For lab services at any
other place of service, the
applicable Network or Non -
network cost shares apply
according to the place of
service where rendered.
E•bill functionality
Have the ability to pull up
Will not have this
Excel -document report with
functionality for several
current employees enrolled
months.
on plan.
Dependent Child Ages
23/23 end of calendar year
23/23 end of calendar year
Pre-existing (PPO products only)
Currently have a six month
New Hires, Special and Late
look back & an 18 month
Enrollees: 12 month pre -
wait after enrollment for
existing wait with a 6 month
coverage of pre-existing to
look back. Late enrollees
late enrollees.
must wait until open
enrollment to come on the
plan.
Precertification
Currently have a penalty for
While precertification is
non -participating providers of
required; there is no penalty
20% that is the member's
to a member when
responsibility.
precertification is not
obtained.
Maternity Coverage
Employee or spouse
Employee or spouse or
dependent daughter
PPO Product comparison - P616 (4106)
"%�Uuu AMUr;IICe Rates
Effectfye Janaary 1, 2006
Health Insurance
Monthly Costs
Active Employees and Retirees underage 65
Core Plan
E-°— vee Unl�' Emn & Snause
$370.16* $285.46 Em & Children Emn & Family
$214.10 $499.60
*Paid by the City based on Maximum Claims Premiums
Buy -Up Plan
Employee Only Emn &Spouse _
$107.90* ------- Emp & Children Emn & Fanny
$433.02 $350.54 $670.15
*Cost of Retiree Only Core Plan paid by the City. All other tiers paid by employees
COBRA hates
Core Plan
m loyee Ow Emn &Spouse &Children
$370.67 $668.83 Emn Emn & Family
$596.05 $887. 6 --
Buy-Up Plan
EmpIovee Only Emn &Spouse
$487,72 Emp &Children
$819.35 Ems'— &family
$735 22 $1,061.22
The responsible party(ies) pays all monthly cost. All monthly premiums
Claims premiums, plus 2% administrative fees, based on lviaximum
Dental Insurance
(Monthly Costs)
Active Employees and Retirees under age 65
EmnIovee Only Emp &Spouse
$23.34* $17.70 4A Chfldren Emn & Fa..&
$15.18 $32.38
!Paid by the City includes $5.11
Dependent Tiers paid by monthly to ee nt yPeradditional yee Delta Dental Admini
A strati
Fee. All
directly for the City' re y dministration Fee. Retirees that retired
Plan Tiers.gardless of age, are treated the same in the Dental Plan that
as the Health
COBRA Rates -
Employee Only Emp &Spouse
$ 23.80 $41.86 Emp & Children E„Mm r& Fami1Y
$39.30 $56 84
The responsible party(ies) pays all monthly costs. The 2% administrative fee is included in
listed above, rates
2007 Health and Dental Insurance Rates
Effective January 1, 2007
Health Insurance
Monthly Costs
Active Employees and Retirees underage 65
Employee Only Employee & Spouse Employee & Child(ren) Employee &Family
$462.70* $356.83 $267.63 $624.50
*Cost of Employee Only plan paid by the City. All other tiers paid by employees.
COBRA Rates
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$471.95 $835.92 $744.94 $1,108.94
The responsible party(ies) pays all monthly cost. All monthly premiums based on premiums, plus
2% administrative fees.
Dental Insurance
(Monthly Costs)
Active Employees and Retirees under age 65
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$23.24* $17.70 $15.18 $32.38
*Cost of Employee Only plan paid by the City. All other tiers paid by employees.
COBRA Rates
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$23.80 $41.86 $39.30 $56.84
The responsible party(ies) pays all monthly cost. All monthly premiums based on premiums, plus
2% administrative fees.
Cite of Cape Girardeau — Stand Alone Plan
Blue AccesssM
Summary of Benefits, Effective January 1, 2007
Physician Home and Office Services (PCP/SCF
Primary Care Physician (PCP)/Specialty Care
Physician (SCP)
Including Office Surgeries and allergy serum:
• allergy in(PCP and SCP)
• allergy testing
• routine and non -routine mammograms
(regardless of outpatient setting)
• diabetic education (regardless of outpatient setting)
• certain medical nutritional therapy (regardless of
outpatient setting)
• MRAs, MRIs, PETS, C -Scans, Nuclear Cardiology Imaging
Studies and n—atrelated Ultrasounds
Preventive Care Services
Services include but are not limited to:
Routine Exams, Pelvic Exams, Pap testing, PSA
tests, Immunizations, Annual diabetic eye exam,
Routine Vision and Hearing exams
• Physician Home and Office Visits (PCP/SCP)
• Other Outpatient Services @ Hospital/Alternative
Care Facility
• Immunizations through age 5
Emergency and Urgent Care
• Emergency Room Services @ Hospital (facility/other
covered services) (copayment waived if admifted)
• Urgent Care Center Services
• Emergency Ambulance Services
Inpatient and Outpatient Professional Services
Include but are not limited to:
• Medical Care visits (1 per day), Intensive Medical Care,
Concurrent Care, Consultations, Surgery and administration
f1{nnn. f----tL--"--1_11,, .
Unlimited days except for:
• 60 days Network/Non-Network combined for physical
medicine/rehab (limit includes Day Rehabilitation Therapy
Services on an outpatient basis)
• 90 days Network/Non-Network combined for skilled
---1 11.1
$5
Deductible/20%
$30
$30
$30
Deductible/20%
$30/$50
Deductible/20%
$150/20%
$50
Deductible/20%
–t--Lungery and administration of general anesthesia
Other Outpatient ervices (inclu Ing ut not invited to): Deductibl 20�
• Non Surgical Ou anent Services
For example: MRIs, C -Scans, Chemotherapy, Ultrasounds,
and other diagnostic outpatient services.
• Nome Care Services ((NetworkMon-network combined)
90 visits (excludes IV'fherapy)
• Durable Medical Equipment and Orthotics
(Network/Non-network combined)
,000 benefft maximum (excluding Prosthetic Devices and
Medical Supplies)
• Prosthetic Devices $4,000 benefit maximum
• Physical Medicine Therapy Day Rehabilitation programs
• Hospice Care
Nnn Finarnnnnv ,&-k�JDeductible/20%
• .,...... o,.—a___
ANTHEM
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
No cooavfnent/winmimnrp
$150/20%
50%
Deductible/20%
Deductible/50%
and F4fB0 Cross end Blue $Wd AUssoud IN i�se Is
lin �tor�R11endM, a hManaod ales ad�ids n *10 beau underm&nn iy 1W and I
MO WE 3.1 PPO LG SOB Rev. 406 HMO benefits underwdden by l# O m issoie, Inc. RIT; WO Missouri, Inc. and FiALIC are Wependent kevAes of the Blue cross and Blue shield AssWabon.
OR09WO ed marks Blue Cross and Blue Shield AssoMon.
Notes:
• Flat dollar copayments and Non Network Human Organ and Tissue Transplants are excluded from the out-of-pocket limits. Also Prescription Drug deductibles/copaymenal
coinsurance are excluded from the out-of-pocket limits.
• Deductible(s) apply only to covered medical services listed with a percentage I`%) coinsurance. However, the deductible does not apply to Emergency Room Services where a
copayment and a percentage r1oo) coinsurance applies.
• Network and Non-neavork deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other.
• DgxwdauAgeto the end of the calendar year which the child attains age 13 or to the end of the calendar year which the child attains age 23 or if qualifies as a full-time student.
• Specialist copayment is applicable to all Specialists excluding General Physicians, Internist Pediatricians, OB/GYN's and Geriatrics or any other Network Provider as
allowed by theplan.
• Physicians Home and office visit copayment applies if the office visit is billed with allergy injections.
• No copayment/coinsurance means no deductiblelcopaymenticoinsurance up to the maximum allowable amount. 01% means no coinsurance up to the maximum allowable amount.
However, when choosing a Non -network provider, the member is responsible for any balance due after the plan payment.
• PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics; obsteirics/gynecologv, geriatrics or any other
Network provider as allowed by the plan.
• SCP is a Network Provider, other than a Primary Care Physician, who provides servicer within a designated specialty area ofpracdce.
• Certain diabetic and asthmatic supplies have no dedudiblelcopayment/coinsurance up to the maximum allowable amount at netw rk pharmacies, except diabetic test strips.
• Benefitperiod = calendaryear
• Elective abortions are not covered.
1 Kidney and cornea are treated the same as any other illness and subject to the medical benefits.
If applicable; all prescrlpdon drug expenses except tier 1, (NetworkWon-network RetaiUMail-service combined) apply to the per individual RXdeductible. Once the RXdedudible is
m4 the appropriate copayment applies. Also if applicable, the Prescription Drug out ofpocket maximum applies to Network Retail and M 11 ervice combined.
Rx non-networkdiabetidasthmatic supplies not covered except diabetic test strips.
Pracriptlon Drugs do not accumulate toward the Medical Lifetime Maximum (ifapplicable). However, once the Medical Lifetime Maximum is met (ifapplicable), no additional
Prescription Drug claims will be paid.
PrecetdlfeWon:
• Members are encouraged to always obtain prior approval when using non -network providers. Precertification will help avoid any unnecessary reduction in benefits
for non -covered or non -medically necessary services.
Anthem Blue Cross and Blue Shield is the trade name RIghtCHOKa Managed Care, Inc. (RM, Healthy Alflanoe® Ufa Insurance Companyy (HALIc)
and HMO Missouri. Inc. use to do business in nest of Misscud. RIT and mWn ates administer non•HMO benefits underwdten by ILLI and
HMO benefits undenmilten by HMO Wssoui, Inc, RR, HMO ftoud, W. and HACK are Indeperdentkensees of the Blue Cross and 81ue Shield Association.
MO BLUE 3.1 PPD LG 08 Rev. 4106 ®ROslered marks Blue Cross and Blue Shkld Association.
Covered Benefits
Outpa ent Therapy ervices
Network•
• rk
(Combined Network & Non -Network limits apply)
• Physician Home and Office Visits (PCP/SCP)
$30/$50
Deductible/50%
• Other Outpatient Services @ Hospital/Alternative Care
Deductible/20%
Deductible/50%
Facility
Limits apply to
• Physical/Manipulation therapy excluding Chiropractic
Services; 20 visits
• Occupational therapy: 20 visits
• Chiropractic Services: 26 visits (Network)
Non -Network Not Covered
• Speech thera : Unlimited visits
Behavioral Health Services: (Network and Non -Network)
Mental Health and Substance Abuse
• Inpatient Facility Services
• Physician Home and Office Visits (PCP/SCP)
Deductible/20%
$30/$50
Deductible/50%
Deductible/50%
• Other Outpatient Services @ Hospital/Alternative Care
Deductible/20%
Deductible/50%
Facility
Substance Abuse limits
• Inpatient: 21 days/6 detox
• Outpatient Facility: 30 visits
• Outpatient Office Visits: 30 visits
(Substance Abuse rehabilitation programs are limited to 10
episodes per lifetime Network and Non -Network combined.
Human Organ and Tissue Transplants'
No copayment/coinsurance
30%
• Acquisition and trans lant procedures, harvest and storage.
Prescription Drugs
Network Tier structure equals 1/2/3 (and 4, if applicable)
•
ysl it Pharmacies:
$10/$35/$75
I3dasupp
41h Tieris25% up to an annual OOP maximum
50% minus $75
Includes diabetic test strip
Maximum of $2,500
• Anthem Rx Direct Mail Service:
(90 -day supply)
$20/$90/$190
Includes diabetic test strip
4th Tier is 25% up to an annual OOP Maximum
Not covered
`Member may be responsible for additional cost when not
Of $2,500
selecting the available genetic drug.
Medicare Rx - Wrap
fetime aximum Combined Network and Non -network
Unlimited
Unlimited
Notes:
• Flat dollar copayments and Non Network Human Organ and Tissue Transplants are excluded from the out-of-pocket limits. Also Prescription Drug deductibles/copaymenal
coinsurance are excluded from the out-of-pocket limits.
• Deductible(s) apply only to covered medical services listed with a percentage I`%) coinsurance. However, the deductible does not apply to Emergency Room Services where a
copayment and a percentage r1oo) coinsurance applies.
• Network and Non-neavork deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other.
• DgxwdauAgeto the end of the calendar year which the child attains age 13 or to the end of the calendar year which the child attains age 23 or if qualifies as a full-time student.
• Specialist copayment is applicable to all Specialists excluding General Physicians, Internist Pediatricians, OB/GYN's and Geriatrics or any other Network Provider as
allowed by theplan.
• Physicians Home and office visit copayment applies if the office visit is billed with allergy injections.
• No copayment/coinsurance means no deductiblelcopaymenticoinsurance up to the maximum allowable amount. 01% means no coinsurance up to the maximum allowable amount.
However, when choosing a Non -network provider, the member is responsible for any balance due after the plan payment.
• PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics; obsteirics/gynecologv, geriatrics or any other
Network provider as allowed by the plan.
• SCP is a Network Provider, other than a Primary Care Physician, who provides servicer within a designated specialty area ofpracdce.
• Certain diabetic and asthmatic supplies have no dedudiblelcopayment/coinsurance up to the maximum allowable amount at netw rk pharmacies, except diabetic test strips.
• Benefitperiod = calendaryear
• Elective abortions are not covered.
1 Kidney and cornea are treated the same as any other illness and subject to the medical benefits.
If applicable; all prescrlpdon drug expenses except tier 1, (NetworkWon-network RetaiUMail-service combined) apply to the per individual RXdeductible. Once the RXdedudible is
m4 the appropriate copayment applies. Also if applicable, the Prescription Drug out ofpocket maximum applies to Network Retail and M 11 ervice combined.
Rx non-networkdiabetidasthmatic supplies not covered except diabetic test strips.
Pracriptlon Drugs do not accumulate toward the Medical Lifetime Maximum (ifapplicable). However, once the Medical Lifetime Maximum is met (ifapplicable), no additional
Prescription Drug claims will be paid.
PrecetdlfeWon:
• Members are encouraged to always obtain prior approval when using non -network providers. Precertification will help avoid any unnecessary reduction in benefits
for non -covered or non -medically necessary services.
Anthem Blue Cross and Blue Shield is the trade name RIghtCHOKa Managed Care, Inc. (RM, Healthy Alflanoe® Ufa Insurance Companyy (HALIc)
and HMO Missouri. Inc. use to do business in nest of Misscud. RIT and mWn ates administer non•HMO benefits underwdten by ILLI and
HMO benefits undenmilten by HMO Wssoui, Inc, RR, HMO ftoud, W. and HACK are Indeperdentkensees of the Blue Cross and 81ue Shield Association.
MO BLUE 3.1 PPD LG 08 Rev. 4106 ®ROslered marks Blue Cross and Blue Shkld Association.