Virginia Plan Guide. for the individual market. Effective January 1, 2014

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Transcription:

Virginia Plan Guide for the individual market Effective January 1, 2014 This brochure is intended for broker use only and should not be distributed to consumers or employer groups. 38204VABENAHK Rev. 11/13

On-Exchange Plans Bronze DirectAccess with HSA cacd (ORUS) Bronze DirectAccess cabw (ORUQ) Bronze DirectAccess with Child Dental cdbw (ORV2) Bronze DirectAccess caam (ORUL) Network Name Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Individual Deductible (Family is 2 x Individual amount) Individual OOP Limit (Includes deductible, copays, coinsurance & Rx. Family is 2 x Individual amount) $3,750 $4,500 $4,500 $5,500 $6,200 $6,350 $6,350 $6,350 Coinsurance 25% 35% 35% 25% Office Visit: PCP Office Visit: Specialist Outpatient Diagnostic Tests (Examples: X-ray, EKG) Outpatient Advanced Diagnostic Tests (Examples: MRI, CT scan) and and $40 copay per visit for first 2 office visits, then deductible and Preventive Care No cost to you No cost to you No cost to you No cost to you Urgent Care Emergency Room Care 45% coinsurance applies 45% coinsurance applies Inpatient Admission 25% (tier 1) 35% (tier 1) 35% (tier 1) 25% (tier 1) Outpatient Surgery Hospital Facility 25% (tier 1) 35% (tier 1) 35% (tier 1) 25% (tier 1) RX Tier 1 (Retail) RX Tier 2 (Retail) RX Tier 3 (Retail) RX Tier 4 (Retail) Dental Vision Maternity Outpatient Mental Health and Substance Abuse Inpatient Mental Health and Substance Abuse* Chiropractic Physical Therapy deductible then 25% (tier 1) deductible then 35% (tier 1) deductible then 35% (tier 1) deductible then 25% (tier 1) * Costs may vary by site of service

2 Bronze DirectAccess with HSA caas (ORUN) Silver DirectAccess cbky (ORVM) Silver DirectAccess cbjs (ORVG) Silver DirectAccess cbfs (ORVB) Silver DirectAccess cbau (ORV6) Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital $6,000 $1,500 $2,250 $2,600 $3,350 $6,350 $5,500 $6,350 $6,000 $5,500 15% 30% 20% 20% 15% and 3 3 3 $35 copay, unlimited and $45 copay, unlimited 3 No cost to you No cost to you No cost to you No cost to you No cost to you deductible then 3 4 30% (tier 1) 30% (tier 1) 3 20% (tier 1) 20% (tier 1) 3 20% (tier 1) 20% (tier 1) 15% (tier 1) or 45% (tier 2) coinsurance 15% (tier 1) or 45% (tier 2) coinsurance $15 copay $15 copay $15 copay $15 copay $40 copay $40 copay $40 copay $40 copay 3 3 deductible then 30% (tier 1) 3 3 3 3 deductible then 15% (tier 1) or 45% (tier 2) coinsurance

On-Exchange Plans Gold DirectAccess ccam (ORWC) Gold DirectAccess with Child Dental cdda (ORWG) Catastrophic DirectAccess (ORWL) Network Name Pathway X Tiered Hospital Pathway X Tiered Hospital Pathway X Tiered Hospital Individual Deductible (Family is 2 x Individual amount) Individual OOP Limit (Includes deductible, copays, coinsurance & Rx. Family is 2 x Individual amount) $750 $750 $6,350 $3,500 $3,500 $6,350 Coinsurance 20% 20% 0% Office Visit: PCP $30 copay, unlimited $30 copay, unlimited Office Visit: Specialist Outpatient Diagnostic Tests (Examples: X-ray, EKG) Outpatient Advanced Diagnostic Tests (Examples: MRI, CT scan) $40 copay per visit for first and Preventive Care No cost to you No cost to you No cost to you Urgent Care Emergency Room Care Inpatient Admission Outpatient Surgery Hospital Facility 30% coinsurance apply 20% (tier 1) 20% (tier 1) 30% coinsurance apply 20% (tier 1) 20% (tier 1) RX Tier 1 (Retail) $15 copay $15 copay RX Tier 2 (Retail) $40 copay $40 copay RX Tier 3 (Retail) RX Tier 4 (Retail) Dental Vision Maternity Outpatient Mental Health and Substance Abuse Inpatient Mental Health and Substance Abuse* Chiropractic Physical Therapy deductible then * Costs may vary by site of service

Notes 4

Off-Exchange Plans Core DirectAccess with HSA cacd (ORUT) Core DirectAccess cabw (ORUR) Core DirectAccess with Child Dental cdbw (ORV3) Core DirectAccess caam (ORUM) Network Name Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Individual Deductible (Family is 2 x Individual amount) Individual OOP Limit (Includes deductible, copays, coinsurance & Rx. Family is 2 x Individual amount) $3,750 $4,500 $4,500 $5,500 $6,200 $6,350 $6,350 $6,350 Coinsurance 25% 35% 35% 25% Office Visit: PCP Office Visit: Specialist Outpatient Diagnostic Tests (Examples: X-ray, EKG) Outpatient Advanced Diagnostic Tests (Examples: MRI, CT scan) and and $40 copay per visit for first 2 office visits, then deductible and Preventive Care No cost to you No cost to you No cost to you No cost to you Urgent Care Emergency Room Care 45% coinsurance applies 45% coinsurance applies Inpatient Admission 25% (tier 1) 35% (tier 1) 35% (tier 1) 25% (tier 1) Outpatient Surgery Hospital Facility 25% (tier 1) 35% (tier 1) 35% (tier 1) 25% (tier 1) RX Tier 1 (Retail) RX Tier 2 (Retail) RX Tier 3 (Retail) RX Tier 4 (Retail) Dental Vision Maternity deductible then 25% (tier 1) deductible then 35% (tier 1) deductible then 35% (tier 1) deductible then 25% (tier 1) Outpatient Mental Health and Substance Abuse Inpatient Mental Health and Substance Abuse* Chiropractic Physical Therapy * Costs may vary by site of service

6 Core DirectAccess with HSA caas (ORUP) Essential DirectAccess cbky (ORVN) Essential DirectAccess cbjs (ORVH) Essential DirectAccess cbfs (ORVC) Essential DirectAccess cbau (ORV7) Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital $6,000 $1,500 $2,250 $2,600 $3,350 $6,350 $5,500 $6,350 $6,000 $5,500 15% 30% 20% 20% 15% and 3 3 3 $35 copay, unlimited and $45 copay, unlimited 3 No cost to you No cost to you No cost to you No cost to you No cost to you deductible then 3 4 30% (tier 1) 30% (tier 1) 20% coinsurance apply 3 20% (tier 1) 20% (tier 1) 20% coinsurance apply 3 20% (tier 1) 20% (tier 1) 15% coinsurance apply 15% (tier 1) or 45% (tier 2) coinsurance 15% (tier 1) or 45% (tier 2) coinsurance $15 copay $15 copay $15 copay $15 copay $40 copay $40 copay $40 copay $40 copay 3 3 deductible then 30% (tier 1) 3 3 3 3 deductible then 15% (tier 1) or 45% (tier 2) coinsurance

Off-Exchange Plans Preferred DirectAccess ccam (ORWD) Preferred DirectAccess with Child Dental cdda (ORWH) Catastrophic DirectAccess (ORWM) Network Name Pathway Tiered Hospital Pathway Tiered Hospital Pathway Tiered Hospital Individual Deductible (Family is 2 x Individual amount) Individual OOP Limit (Includes deductible, copays, coinsurance & Rx. Family is 2 x Individual amount) $750 $750 $6,350 $3,500 $3,500 $6,350 Coinsurance 20% 20% 0% Office Visit: PCP $30 copay, unlimited $30 copay, unlimited Office Visit: Specialist Outpatient Diagnostic Tests (Examples: X-ray, EKG) Outpatient Advanced Diagnostic Tests (Examples: MRI, CT scan) $40 copay per visit for first and Preventive Care No cost to you No cost to you No cost to you Urgent Care Emergency Room Care Inpatient Admission Outpatient Surgery Hospital Facility 20% coinsurance apply 3 20% (tier 1) 20% (tier 1) 20% coinsurance apply 3 20% (tier 1) 20% (tier 1) RX Tier 1 (Retail) $15 copay $15 copay RX Tier 2 (Retail) $40 copay $40 copay RX Tier 3 (Retail) RX Tier 4 (Retail) Dental Vision Maternity Outpatient Mental Health and Substance Abuse Inpatient Mental Health and Substance Abuse* Chiropractic Physical Therapy * Costs may vary by site of service deductible then

Notes 8

Exclusions and Limitations Exclusions This list includes some of the more common services not covered by these plans: Acupuncture Allergy tests and treatment, except as spelled out in your Evidence of Coverage Artificial insemination, fertilization, infertility drugs or sterilization reversal Artificial and mechanical hearts Alternative or complementary medicine Bariatric surgery, unless optional benefit rider has been purchased Benefits covered by Medicare or a governmental program Breast reduction or augmentation mammoplasty is excluded unless associated with breast reconstruction surgery following a medically necessary mastectomy resulting from cancer Care provided by a member of your family Care received in an emergency room that is not emergency care, except as specified in your Evidence of Coverage Charges incurred prior to the effective date of coverage or after the termination date of coverage Charges greater than the maximum allowable amount (charges exceeding the amount HealthKeepers recognizes for services) Comfort and/or convenience items Cosmetic surgery and/or treatment that s primarily intended to improve your appearance Custodial care Dental, except as described in your Evidence of Coverage Educational services, except as mandated Experimental or investigative treatment Non-chemical additions such as gambling, spending, religious Nutritional and dietary supplements Over-the-counter drugs, devices or products Pharmacy except as spelled out in your Evidence of Coverage Routine foot care Sclerotherapy (a medical procedure used to eliminate varicose veins and spider veins) Services we determine aren t medically necessary Sex transformation surgery TMJ and Craniomandibular Joint Disorder. Covered services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings) or prosthetics (crown, bridges, dentures). Vision except as described in your Evidence of Coverage Weight loss programs or treatment of obesity except as mandated Workers compensation Limitations These services are limited as described below: Therapy services Physical/Occupational therapy 30 combined visits per member per year Speech therapy 30 visits per member per year Chiropractic 30 visits for manipulation per member per year Home health care 100 visits per member per year Private duty nursing provided in a home care setting 16 hours per member per year Skilled nursing facility 100 days per stay *All plans available with optional bariatric surgery coverage for an additional premium. Preventive care services consist of services recommended by the United States Preventive Services Task Force, including well-child care, immunizations, PSA screenings, Pap tests, mammograms and more.

Notes 10

This piece refers to Policy form #s VA_HMHS(1/14), VA_HMHS(1/14)ONHIX. Schedule of benefits forms VA_SB_BRZ_3750_ORUT_(1/14), VA_SB_BRZ_4500_ORUR_(1/14), VA_SB_BRZ_5500_0RUM_(1/14), VA_SB_BRZ_6000_0RUP_(1/14), VA_SB_SLV_1500_0RVN_(1/14), VA_SB_SLV_2250_0RVH_(1/14), VA_SB_SLV_2600_0RVC_(1/14), VA_SB_SLV_3350_0RV7_(1/14),VA_SB_GLD_750_0RWD_(1/14), VA_SB_GLD_750_PD_0RWH_(1/14), VA_SB_CAT_6350_0RWM_(1/14), VA_SB_BRZ_3750_0RUS_(1/14)_ONHIX, VA_SB_BRZ_4500_0RUQ_(1/14)_ONHIX, VA_SB_BRZ_4500_PD_0RV2_(1/14)_ONHIX, VA_SB_BRZ_5500_0RUL_(1/14)_ONHIX, VA_SB_BRZ_6000_0RUN_(1/14)_ONHIX, VA_SB_SLV_1500_0RVM_(1/14)_ONHIX, VA_SB_SLV_2250_0RVG_(1/14)_ONHIX, VA_SB_SLV_2600_0RVB_(1/14)_ONHIX, VA_SB_SLV_3350_0RV6_(1/14)_ONHIX, VA_SB_GLD_750_0RWC_(1/14)_ONHIX, VA_SB_GLD_750_PD_0RWG_(1/14)_ONHIX, VA_SB_CAT_6350_0RWL_(1/14)_ONHIX and rider form VA_Bariatric_(1/14). HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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