HomeMy WebLinkAboutRES.2230.12-18-2006BILL NO. 06-266
RESOLUTION NO.
A RESOLUTION AUTHORIZING THE CITY MANAGER TO
EXECUTE A CONTRACT WITH DELTA DENTAL FOR
EMPLOYEE DENTAL 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 Delta Dental for employee dental insurance
services, in the City of Cape Girardeau. Said Contract shall
contain no changes in plan design or premium structure from the
current city plan with Delta Dental. A copy of the proposal is
attached hereto and made a part hereof.
PASSED AND ADOPTED THIS DAY OF )ffetaj , 20
Gayle L.Abnrad, City Clerk
oe
Jay Knudtson, Mayor
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 9 LEAWOOD, KANSAS 66211 .913-234-1000 9 FAx: 913-234-1100
Physician Home and
Network
Non -Network
Network
Non -Network
Lifetime Maximum
Unlimited
Unlimited
Deductible (Single/Family)
$1,000
$2,000
$2,000
$2,500
$2,500
Charges applied to the Network deductible will
office -visit copay. It was deductible and
$4,000
$7,500
$7,500
not apply towards the Non -network deductible
coinsurance.
Office visit
$30 PCP/
Deductible/ 50%
$30 PCP/
and vice versa.
There is a $5 allergy injection copayment per
$30 SPC
$50 SPC
4th quarter deductible carry over credit is no
visit in the network office setting only if billed
longer standard,
The deductible is included in out-of-pocket
Out-of-pocket Maximums
(Single/Family)
$2,000
$4,000
$5,000
$10,000
$5,000
$10,000
$10,000
Deductible/ 50%
office -visit charge with the injection charge,
$20,000
maximum. This was tracked as coinsurance
(deductible not
(deductible not
(deductible
(deductible
maximums without the deductible.
Deductible/ 50%
included)
Included)
included)
included)
Network and non -network maximums do not
network office visit, the member pays
Allergyinjections
i
Deductible/ 20%
Deductible/ 50%
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
i
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.
WAS, MRIs, PETS,
Covered in full
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
CT -scans, nuclear
cardiology imaging studies
and non -maternity related
ultrasounds
The information included here is simply an overview of key benefit changes in our standard product lines. It is not an exhaustive list of changes and is not a 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 RightCHOICE° Managed Care, Inc. (RIT),
Healthy Alliance°Life Insurance Companyy (HALIC) and HMO Missouri, Inc. use to do business
PPO Product Comparison - Pt/6 (4106) in most of Missouri. RIT and certain affliates administer non•HMO benefits underwritten by
HALIC and HMO benefits by HMO Missouri, Inc. RIT and certain affiliates only provide administrative
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
Blue CrossAnthem
New
Change
Preventive Care Services
There is no caiendar-year benefit maximum.
Services include 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 dopay and now
Care
include separately billed doctor charges.
Emergency room services at
Deductible! 20%
Deductible/ 50%
$150/20%
$150120%
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 Compariso • P2/6 (4/06)
Benefit
Inpatient Facility Services
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
nursing facility
Blue Cross AnthemChange
Deductible/ 20% Deductible/ 50% Deductible/ 20% Deductible/ 50%
Deductible/ 20% Deductible/ 50% Deductible/ 20% Deductible/ 50%
Now there is a 60-day limit per benefit.period
for inpatient physical medicine/rehab,
Previously we did not track inpatient physical
medicine/rehab.
Skilled Nursing now has a 90-day limit per
benefit period. The limit was 100 day.
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
PIan,
diagnostic outpatient
HHC now is limited to 90 visits per benefit
services
period vs. 100 visits current plan.
Home health care services
Deductible/ 20%
Deductible/ 50%
Deductible/ 20%
Deductible/ 50%
Private duty nursing is covered under home
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 Cornpadw - P3/6 (4/06)
I
Benefit
Blue Cross
Current
Anthem
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/ alternative 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 - P4/6 (4/06)
4
PPO Product Comparison - P5/6 (4/06).
GrossAnthem
New Change
Human Organ and Tissue
Transplants
Deductible/ 20%
Deductible/ 50%
Covered in full
Deductible/ 30% Comea and kidney transplants are covered
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
comes and
cornea and
from a Network transplant provider.
kidney) and
covered
kidney) and
covered
Non-networklnon-participating (not
services are
services are
participating in the transplant Network): the
subject to the
subject to the
HOTT admission is subject to 30% cost share
same cost
same cost
and does not accumulate to the Non -
shares as other
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 (41� Tier) now are 25% cost
Network Retail Pharmacy
Tier 1, 2 and 3:
Tier 1, 2 and 3:
Tier 1, 2 and 3:
Tier 1, 2 and 3:
share with a $2,500 out-of-pocket maximum
per benefit period.
<30 -day supply (includes
$$/$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
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.
maximumer
p
difference
maximum per
o
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 Comparison - P5/6 (4/06).
Administrative • -Cross
A simple name change.
Network Name Changes
Alliance
Blue Access PPO
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.
N
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 (4/06)
yam— imurance rates
Effectfye Janaary 1, 2006
� Health Ins
uranee
Monthly Costs
Active Employees and Retirees under age 65
Core Plan
Employee Onlj Emn & Snause
$285.46
$370.16* Ema &` Children Emn & Family
$214.10 $499.60
*Paid by the City based on Maximum Claims Premiums
Buy -Up Plan
Emnlovee Onli Emn &Snouse
$107.90* Emu &Children F, &Family
$433.02 $350.54 $670.15
*Cost: of Retiree Only Core plan paid by the City. All other tiers paid by employees.
COBRA Rates
Core PIan
mloyee Only EmEmn &
p &Snouse
$370.67 $668.83 ChildrenFmp &Family
$596.05 $887-26
Buy -Up Plan
'1 '0
()niy Ema_ & Spouse Emp &Cdren
$487.— 7` $819.35 4. & Family
$735.22 $1,061.22
The responsible Party(ies) pays all monthly cost. All monthly
Claims premiums, plus 2% administrative fees. premiums based on Maximum
Dental Insurance
(Monthly Costs)
Active Employees and Retirees under age 65
Employee Only Emp &Spouse
$23.34* $17.70 Emn &Children Emn & Famih
$15.18 $32.38
`Paid by the City includes $5.11 monthly
Dependent Tiers aid b Per employee Delta Dental Administration Fee, All
P Y employee, no additional Administration Fee. Retirees that retired
directly for the City, regardless of age, are treated the same in the Dental plan Tiers as the Health
Plan Tiers.
COBRA Rates
Emnlovee Only Em4 &—Sn
$23.80 — Emn & Chflciren EmL& F�
$41.86 $39,30 $5694
The responsible pares) 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 Onlv 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
Suni ntary of Benefits, Effective January 1, 2007
Physician Home and Office Services (PCP/SCF
Primary Care Physician (PCP)/Specialty Care
Ldn
ian (SCP)
g Office Surgeries and allergy serum:
gy injections (PCP and SCP)
gy testing
ne and non -routine mammograms
rdless of outpatient setting)
etic education (regardless of outpatient setting)
in medical nutritional therapy (regardless of
tient setting)
s, MRIs, PETS, C -Scans, Nuclear Cardiology Imaging
ies and non-maternit related Ultrasounds
reventive 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 @ HospitallAltemative
Care Fadtity
• Immunizations through age 5
• Emergency Room Services @ Hospital (faciifty/other
covered services) (copayment waived if admitted)
• Urgent Care Center Services
• Emerpenc(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
of general anesthesia and Newborn exams
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
$5
Deductible/20%
$30
$30
$30
Deductible/20%
$30/$50
Deductible/20%
$150/20%
$50
Deductible/20%
• (ion Surgical Outpatient Services 1111 wl. UwucUDle/LU`,
For example: MRIs, C -Scans, Chemotherapy, Ultrasounds,
and other diagnostic outpatient services,
• Home Care Services ((NetworldNon-network combined)
90 visits (excludes 13herapy)
• Durable Medical Equipment and Orthotics
0(Network/Non-network combined)
,000 benefit maximum (excluding Prosthetic Devices and
Medical •
Prosthetic supplies)
$4,000 benefit maximum
• Physical Medicine Therapy Day Rehabilitation programs
• Hospice Care Deductible/20%
• Mn Finarncnnv A -f-1 ..... c--.:___
ANTHEM
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
Deductible/50%
No cooavment/r.
$150/20%
50%
Deductible/20%
Anthem Blue Cross and Blue SWd k the trade nepne Rkh(CHOION Manned care, Inc. (Rrr) Heahhy Manod Lae Insurance Camp (HgLIC)
and HMO AUssoui, hrc. use to do business In most of is w. RIT end certain aflillates administer non.NMO benefits under%I*A by 1 0 and
MO 9LLE 3.1 PPO LG SOB Rev. 496 HMO benefits underxdden by HMO MssoA Inc, RiT; HMO "Mud, Inc. and WC we krdePendeM kensees of the Blue Cross and Blue ShWdAsaodation.
ORepls eW marks Blue Cross and Blue shield AswWon
wtpaucuL nrctapy Qt!JVit;@S
(Combined Network& Non -Network limits apply)
• Physician Home and Office Visits (PCP/SCP)
• Other Outpatient Services @ Hospital/Alternative Care
Facility
Limits apply to:
$30/$50
Deductible/20%
—
Deductible/50%
Deductible/50%
• Physical/Manipulation therapy excluding Chiropractic
Services: 20 visits
• Occupational therapy, 20 visits
• Chiropractic Services: 26 visits (Network)
Non -Network Not Covered
• Speech therapy: Unlimited visits
Behavioral Health Services: (Network and Non -Network)
Mental Health and Substance Abuse
• Inpatient Facility Services
Deductible/20%
Deductible/50%
• Physician Home and Office Visits (PCP/SCP)
$30/$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
e /sodes el lifetime Network and Non -Network ced.
ombin
Human Organ and Tissue Transplants'
No copaymenticoinsurance
30%
• Acquisition and trans lant procedures, harvest and storage,
Prescription Drugs
Network Tier structure equals 1/2/3 (and 4, If applicable)
• Network it Pharmacies:
$10/$35/$75
uppRetl
Includes
4th Tier is 25% up to an annual OOP maximum
50% minus $75
diabetic test strip
Maximum of $2,500
• Anthem Rx Direct Mail Service:
day supply)
$20/$90/$190
ncl
Includes diabetic test strip
4thTier is 25% uP to an annual OOP Maximum
Not covered
`Member maybe responsible for additional cost when not
Of $2500
selecting the available generic drug.
Medicare Rx - Wrap
fetime Maximum Combined Network and Non -n I
Unlimited
Unlimited
Notes:
• Flat dollar copayments and Non Network Human Organ and 114sue Transplants are excluded from the out-of-pocket limits. Also Prescription Drug deducublesleopaymenisl
coinsurance are excluded from the out-of-pocket limits.
• Deductiblefs) apply only to covered medical services listed with a percentage ("/) coinsurance. However, the deductible does not apply to Emergency Room Services where a
copayment and a percentage (%) coinsurance applies.
• Network and Non -network deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other.
• DgxwdmrAge• to the end of the calendaryear which the child attains age 23 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, OBIGIN's and Geriatrics or any other Network Provider as
allowed bytheplan.
• Physicians Home and office visit copayment applies f the office visit is billed with allergy injections.
• No copaymenilcoir surance means no deductiblelcopaymenticoinsurance up to the maximum allowable amount. 0116 means no coinsurance up to the maximum allowable amount.
However, when choosing a Non-networkprovider, the member is responsible for any balance due after the plan payment.
• PCP is a Network Provider who is a practitioner that specializes in familypractice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other
Network provider as allowed by the plan.
• SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area o(practice.
• Certain diabetic and asthmatic supplies have no deductible/copayment/coinsurance uP to the maximum allowable amount at network pharmacies, except diabetic test strips.
• Benefit period = calendaryear
• Elective abortions are not covered.
'Kidney and cornea are treated the same as any other illness and subject to the medical benefits.
IfaPplicaable, all prescription drug expenses except tier 1, (NetworklAron-network RetailMail-service combined) apply to the per individual RXdeductiblc Once the RXdeductible is
the appropriate copayment applies. Also ifapplicable, the Prescription Drug out ofpocket maximum applies to Network Retail and Mail,Service combined
Ax non-networkdiabetir/asthmatic supplies not covered except diabetic test strips.
Prescription Drugs do not accumulate toward the Medical Lifetime Maximum rf applicable). However, once the Medical Lifetime Maximum is stet (f applicable), no additional
Prescription Drug claims will be paid.
Precertification:
• Members are encouraged to always obtain prior approval when using non -network providers. Precertiftcation will help avoid any unnecessary reduction in benefits
for non -covered or non -medically necessary services.
Angcem Blue Cross and Blue Shield is Bre We name RlghtCHOM Managed Care, Inc. (RIT), Healthy Aliens@ Life Insurance Company �p� IC)
and HMO Missouri, Inc. use to do business in nw of Missoud. Rrr and certrdn affllabesadmfdsler non•HMO benefits underwdben by HALIC and
HMO benefds underwritten by HMO Missouri, Inc. RR, HMO Missouri, krc. and HAM are Independentkensees ofthe Blue Cross and Blue shield Association,
MO BLUE 3.1 NPO LG SOB Rev. 40e ®Registered marks Blue Goss and Blue S%d Association.