1. Healthcare

2015 Health Plans
2-50 Employees
Platinum
Gold
Silver
Bronze
Table of contents
Blue Solutions for small business employers �������������������������������������������� 1
Your 2015 Blue Solutions plan guide ������������������������������������������������������� 2
What’s new and important for 2015�������������������������������������������������������� 3
Flexible health plan options to meet your needs ���������������������������������������� 4
Learn about affordable and innovative plan options���������������������������������� 5
More ways your employees can save on health care costs�������������������������� 8
Prescription drug coverage���������������������������������������������������������������������� 9
Vision coverage������������������������������������������������������������������������������������ 11
Pediatric dental coverage ��������������������������������������������������������������������� 12
Making health insurance easier for you and your employees �������������������� 13
2015 Benefits at a Glance......................................................................15
Platinum���������������������������������������������������������������������������������������������� 16
Gold���������������������������������������������������������������������������������������������������� 20
Silver��������������������������������������������������������������������������������������������������� 26
Bronze������������������������������������������������������������������������������������������������� 32
Important plan details ������������������������������������������������������������������������� 35
Underwriting information �������������������������������������������������������������������� 36
Blue Solutions for small
business employers
®
Your employees are your most valuable asset, and providing health insurance
is one of the most important things you can do for them and their families.
With Blue Solutions, you can choose from a suite of products specially
designed for small businesses. And because no two businesses are alike, we
give you a wide range of options to choose from so you can find the health
plans that meet your needs at the price that’s right for your business.
Everything you need to get started is here. With this brochure, you’ll be able to:
• Find
out what’s new and important for 2015
• Learn
about our most innovative and affordable health plans
• Understand
• Discover
how our health plans work
the details of our health plans
• Read
important information about our health plans and
underwriting process
1
Your 2015 Blue Solutions
plan guide
As your partner in health care, Independence Blue Cross (IBC) is committed
to providing innovative solutions that enhance the health and wellness of
you and your employees. Part of that commitment is to help you navigate
through health care reform.
Comprehensive
coverage
Regardless of the
metallic levels, all
products cover
essential health
benefits like doctor
visits, prescription
drugs, X-rays, and
hospital stays.
For 2015, our comprehensive Blue Solutions health plans have been updated
to comply with the most recent Affordable Care Act (ACA) requirements.
All plans will continue to be arranged by metallic levels of coverage (platinum,
gold, silver, and bronze), which makes it easier to find plans that are right
for your business and your budget.
The chart below shows how the metallic levels compare on coverage and costs.
P
G
S
B
Platinum
Gold
Silver
Bronze
Monthly cost
$$$$
$$$
$$
$
Cost of care
$
$$
$$$
$$$$
plan to use a
lot of health
care services
want to save
on monthly
premiums
while keeping
out-of-pocket
costs low
need to balance
monthly premium
with out-ofpocket costs
don’t plan
to need a lot
of health
care services
Good option if you …
2
What’s new and important
for 2015
• Deductible
limitations have been removed. This means that deductible
amounts on certain plans have changed. See specific plan details which
begin on page 15.
• Out-of-pocket
maximum limits have been updated. In-network out-ofpocket maximums have been raised to $6,600/$13,200 on certain non
HSA-qualified plans. For HSA-qualified plans, in-network out-of-pocket
maximums have been raised to $6,450/$12,900. Once this limit is
reached, all covered benefits are covered in-network 100 percent by
the health plan. All coinsurance, copays, and deductibles for essential
health benefits accrue to the plan’s overall out-of-pocket maximum.
See specific plan details which begin on page 15.
• New
low-cost health plan available. If you’re looking to continue offering
your employees a plan with comprehensive benefits that fits within your
budget, take a look at our new HMO Bronze Basic plan. The plan is
ACA-compliant and offers full access to our Keystone HMO network at
an affordable price. Note: This health plan does not include coverage for
routine adult vision exams or eyewear.
• Access
to low-cost retail generic prescription drugs. For most plans,
$7 is the most your employees will pay for generic prescription drugs.
For select health plans, your employees must meet their deductible
first before the copay applies. For Keystone HMO Proactive plans, the
copay for generic drugs is $4 for preferred generics and $15 for all
other generic drugs. No cost sharing is required at participating retail
and mail order pharmacies for certain designated preventive drugs,
prescription and over the counter (with a doctor’s prescription). For
more information about our comprehensive prescription drug plans,
see page 9.
• More
dollars to spend at Visionworks.1 Your employees get even more
dollars to spend when they purchase frames at a Visionworks store.
See page 11 for more details.
• HRA
plans with $0 employer contribution no longer offered. We will
continue to offer plans that can be paired with HRAs. However, we
will no longer offer the following plans that do not include an employer
contribution amount – PPO Gold HRA, PPO Silver HRA, PPO Bronze
Premier HRA, and PPO Bronze HRA. If you offered your employees
one of these plans in 2014, we will assist you in selecting a comparable
plan for 2015.
1. An affiliate of Independence Blue Cross has a financial interest in Visionworks.
3
Flexible health plan options
to meet your needs
PPO, Direct POS, and HMO plans
There are three main types of plans you can choose from – PPO, Direct POS,
and HMO. Each product type is offered across metallic levels at various price
points, so your choice is all about how much flexibility you want to give your
employees when they receive covered services.
• Personal
Choice® PPO plans provide the ultimate in flexibility. Your
employees get in-network coverage across the country when using
participating BlueCard® PPO providers and coverage out-of-network.
Plus, your employees won’t need referrals to visit specialists.
• Keystone
Direct POS provides both in and out-of-network coverage,
but your employees select a primary care physician (PCP) and only
need referrals for certain services, which helps keep costs down.
• Keystone
HMO plans require employees to select a PCP to coordinate
all of their care with network providers.
Take a look at how the plans compare.
KEYSTONE
HMO
KEYSTONE
DIRECT POS
PERSONAL
CHOICE
Access to network of more
than 60,000 physicians
and specialists
X
X
X
Selection of a PCP required
X
X
No referrals needed to visit
in-network specialists
X2
In-network benefits coast-tocoast through BlueCard PPO
X
X
Away from Home Care®
program for employees who
temporarily reside outside
the service area
X
X
Emergency and urgent
care access across the
country and around the world
through BlueCard PPO and
BlueCard Worldwide
X
X
X
2. D
irect POS employees need a referral from their PCP for spinal manipulations, routine X-rays, and physical/occupational therapy.
For lab work, employees should use the facility recommended by their PCP for the lowest out-of-pocket costs.
4
Learn about affordable and
innovative plan options
While our bronze plans work well for employees who want a more affordable
“just in case” plan, we also have a number of cost-saving options across all
metallic levels so your employees can choose the amount of coverage they
need. You can select from plans that include health spending accounts, like a
Health Savings Account (HSA) or a Health Reimbursement Account (HRA),
or try Keystone HMO Proactive – our plans with a tiered network.
Lower your costs and take advantage of tax savings with
HSA and HRA plans
Blue Solutions HSA and HRA plans give you flexible options when you’re
looking to lower health care costs and offer your employees top-quality
health coverage. They help you:
• Save
on premium. High-deductible health plans offer access to our
Personal Choice PPO network at a lower premium.
• Save on taxes. There are potential tax advantages for you and employees
because contributions to an HSA or HRA are not treated as taxable
income if used for qualified medical expenses.
• Encourage
employees to become savvy health care consumers.
Employees play a greater role in managing their health care purchases
and using covered services appropriately.
Managing your spending
accounts has never
been easier
For employers
• Integrated, streamlined
enrollment process
• Easy access to account
information including
online reporting
• Convenient funding options
• No monthly account fee
• No pre-funding for HRA
For employees
• Direct-pay-to-provider
• Automated reimbursements
• Pay claims quickly
• Pharmacy-only debit cards
for covered members
The BlueSaver℠ HSA through Bank of America™
Our BlueSaver HSA offers employees all of the advantages of an HSA through
Bank of America, and independent company, along with claim and payment
integration to make account management easy. The interest-bearing account
includes a wide variety of investment options once the balance reaches $500 to
help maximize savings year after year. And, there is no monthly account fee
for as long as employees remain enrolled in a qualified IBC plan.
5
Comparing Blue Solutions HSA and HRA plans
HSA
HRA
What is it?
A bank account which is
paired with a qualified high
deductible health plan, to help
employees save money to pay
for future qualified medical
expenses on a tax-free basis.
An employer-funded medical
reimbursement account used to
pay current qualified medical
expenses and save for future
qualified medical expenses.
How is it funded?
Employee and/or employer
Employer only
What are the employer
contribution amounts?
Please refer to Benefits at a
Glance section beginning on
page 15 for plan details.
Please refer to Benefits at a
Glance section beginning on
page 15 for plan details.
How much can employees
contribute to the account?
The total annual contributions
from all sources cannot exceed
IRS guidelines.3 For 2015,
the maximum contribution
is $3,350 for self only,
$6,650 for family. There is
also an optional “catch-up”
contribution of $1,000 for
individuals 55 or older.
N/A
Who owns the account?
Employee
Employer. Any balances left
at the end of the plan year
or when an employee leaves
the company remain with
the employer.
Do funds carry over?
Yes, funds and any interest
or investment earnings
roll over to use for qualified
medical expenses in
subsequent years.
No
What are the tax
implications?4
Contributions are generally
excluded from an employee’s
gross income. Interest and
earnings from investments are
tax-free. Future withdrawals
are tax-free provided that
they are for qualified medical
expenses. Taxes and penalties
apply for non-qualified
reimbursements.
Employer contributions are
tax deductible to the employer
and generally excluded from
an employee’s gross income.
What type of deductible
does the plan have?
Aggregate deductible: For
family coverage, the entire
family annual deductible
must be met before
copayments or coinsurance
is applied for any individual
family member.
Embedded deductible: Each
covered family member only
needs to satisfy his or her
individual deductible, not the
entire family deductible, prior
to receiving plan benefits.
3. Details available at www.irs.gov.
4. IBC does not provide legal or tax advice. You should consult with your own legal
and/or tax advisor regarding the tax advantages of an HRA or HSA.
6
Tiered network plans – Keystone HMO Proactive
Keystone HMO Gold and Silver Proactive, our tiered network plans, offer
your employees full access to the Keystone network at a lower premium.
As with any HMO plan, the member will select a PCP who will refer them
to specialists. Your employees can save even more money by choosing certain
health care providers when they seek care.
Online Provider Finder
Your employees can find out
which tier their doctor is in by
using the online Provider Finder.
ibx.com/providerfinder
How Keystone HMO Proactive works
All Keystone HMO providers are grouped into one of three tiers based
on cost and, in many cases, quality measures. The three tiers are:
Tier 1 – Preferred, Tier 2 – Enhanced, and Tier 3 – Standard. All doctors and
hospitals in the Keystone HMO network are accessible in the Proactive plans.
When your employees choose providers in Tier 1 – Preferred or Tier 2 – Enhanced,
they will save on out-of-pocket costs each time they receive care for certain
services. While all of the doctors and hospitals in our Keystone HMO network
must meet high quality standards, some are able to offer the same services
at a lower cost. The good news is that more than 50 percent of doctors and
hospitals in the Keystone HMO provider network are in Tier 1 – Preferred, so
your employees will have plenty of choices.
Employees pay the same cost for select services
Even though your employees can save money on certain health services by
choosing Tier 1 – Preferred or Tier 2 – Enhanced providers, there are some
health services that cost the same across all tiers, such as:
• Preventive
care
• Emergency room
• Emergency ambulance
• Urgent care
• Outpatient labs
• Prescription drugs
• Pediatric
dental and vision
• Mental health
• Physical and occupational therapy
• Outpatient lab and pathology
• Routine radiology
• Spinal manipulations
Remember:
All doctors and hospitals in the
Keystone HMO network are
accessible in the Proactive plans.
Save on quality care
The cost of covered services varies
across tiers. Your employees will
have access to quality care at a
lower cost when they choose a
provider in Tier 1 - Preferred or
Tier 2 – Enhanced.
Is Keystone HMO Proactive right for your business and your employees?
Before you decide to purchase one of the Proactive plans, you may want
to consider a few key questions.
1. D
o your employees live within our five-county service area or the
contiguous counties? These plans are only available to employees who
reside in our service area.
2. Are most of the Tier 1 – Preferred or Tier 2 – Enhanced hospitals conveniently
located near your employees? Visit www.ibx.com/proactivehospitals to see
a list of hospitals and their tiers.
3. Are your employees willing to change doctors if it will save them money?
If you answered yes to these questions, Keystone HMO Proactive may be right
for you and your employees.
To see the Keystone HMO Proactive plan details, please refer to the Benefits
at a Glance section beginning on page 15.
7
More ways your employees
can save on health care costs
Many of our health plans encourage employees to make more cost-effective
choices when spending their health care dollars. Your employees can save
on out-of-pocket costs when they visit certain providers for select services.
$0 outpatient laboratory services at freestanding labs
When your employees need blood work or other covered laboratory services,
they will be covered in full as long as they use a freestanding lab in our
network. If they choose to use a hospital-based lab, they will pay the costsharing designated in their Benefits at a Glance. To find an in-network
freestanding lab, visit ibx.com/providerfinder. Note: This feature applies
to PPO Platinum Premier, PPO Platinum, PPO Gold Premier, PPO Gold,
and PPO Silver.
$0 preventive colonoscopies from Preventive Plus designated providers
Colorectal cancer is highly treatable when it’s detected early, which is why
we cover preventive colonoscopies at $0 cost-sharing when your employees
use one of our Preventive Plus designated providers. Our Preventive Plus
providers are chosen based on cost and quality measures so that it’s easy
for your employees to get high-quality care. In addition to $0 cost-sharing,
Preventive Plus offers more convenience for employees, with sameday preliminary screening results and nearby screening centers. To find a
Preventive Plus provider, visit ibx.com/providerfinder.
Lower cost-sharing for outpatient surgery
For certain plans, your employees will pay less by visiting in-network
ambulatory surgical centers (ASC) when they require an outpatient surgical
procedure. But as with any important health care matter, decisions should
not be based on cost alone. Your employees should work with their health
care providers to determine the best setting for the care they need. To see
specific plan details, please reference Benefits at a Glance beginning on
page 15. Both in-network ASCs and hospitals can be found by visiting
ibx.com/providerfinder.
8
Prescription drug coverage
Promoting better health
Your Blue Solutions medical benefits include IBC Prescription Drug coverage.5
Your employees’ prescription drug benefit program provides many
advantages to help your employees have access to covered prescription drugs
prescribed by their doctor at an affordable cost. All Blue Solutions plans
are designed to incent your employees to use the most cost-effective
medications available.
Convenient mail order pharmacy
If your employee’s doctor has prescribed a medication that they’ll need
to take regularly over a long period of time, the mail-order service is an
excellent way to get a long-lasting supply and reduce out-of-pocket costs.
Mail order is convenient and safe to use. If your employee chooses mail order,
their doctor can prescribe a supply that will last up to 90 days. Employees
can get three times as many doses of their maintenance medication at one
time through mail order.
Specialty Pharmacy Program
Rx
Online services
Your employees can log on
to ibxpress.com and click
Manage My Prescription
Drugs to take advantage of
convenient features, such as:
• Network pharmacy search
• Formulary search
• Claims information
• Mail-order refill requests
The Specialty Pharmacy Program is a convenient delivery system for
specialty medications. Since specialty drugs require special handling,
administration, and monitoring, these complex and costly medications may
not be readily available at local pharmacies. With the Specialty Pharmacy
Program, your employees’ medications will be delivered directly to their
homes or to their doctors. In addition, your employees will have 24/7 access
to clinical staff who will answer questions about specialty medications.
Mandatory Generic
Mandatory generic is featured in all Silver and Bronze Blue Solutions plans
and our Keystone HMO Proactive plans as a way of providing coverage to
your employees at a lower cost. Generic drugs are as effective as brand drugs
and can save your employees money. If your employees choose to purchase
a brand drug that is available in a generic form, they will be responsible
for paying the dispensing pharmacy the difference between the negotiated
discount price for the generic drug and the brand drug plus the appropriate
cost-sharing for the brand drug.
5. Pharmacy benefits are administered by Futurescripts, a Catamaran company, an independent company providing pharmacy benefit management services.
9
Pharmacy Networks
Participating pharmacies
The FutureScripts® network includes more than 68,000 retail pharmacies.
When traveling, your employees will find that most of the pharmacies in all
50 states accept their ID card and can fill their prescription for the same
cost-sharing they pay at home, as long as they use a participating pharmacy.
There is no need for employees to select just one pharmacy for their
prescription needs. To locate a participating pharmacy, visit ibx.com and
select Find a Pharmacy.
FutureScripts Preferred Pharmacy Network
Use of the preferred pharmacy network is required for all Silver and Bronze
Blue Solutions plans and our Keystone HMO Proactive plans in order to
provide coverage at a lower cost. This network is a subset of the national retail
pharmacy network and includes over 50,000 pharmacies, including most
major chains and local pharmacies, except Walgreens and Rite Aid stores.
Non-participating pharmacies
Out-of-network benefits apply to prescriptions filled at non-participating
pharmacies. The employee must pay the full retail price for their prescription,
then file a paper claim for partial reimbursement.
10
Vision coverage
IBC Vision Care: The clear solution to your vision care needs6
When your employees visit their vision provider, they are getting more than
just their eyes checked. Eye exams can help detect more serious medical
conditions like diabetes, hypertension, or heart disease. Vision benefits
could help reduce your company’s overall health care spending and increase
employee productivity.
To help your employees maximize their coverage, we provide enhanced adult
vision benefits in most of our Blue Solutions plans. Now your employees can
get an even richer benefit when visiting a Visionworks location, with a $150
frame allowance, while at other participating providers the frame allowance is
$100. Visionworks and other providers provide a $100 contact lens allowance,
as well as an annual routine eye exam at no cost.
Conveniently located providers and value-added services
The network includes more than 40,000 ophthalmologists, optometrists, and
regional and national retailers, including Visionworks optical retail centers.
Visionworks retail centers are conveniently located across the Philadelphia
five-county area and surrounding states.
With adult vision coverage, your employees can take advantage of:
• No frame limitations. They have the freedom to use their frame allowance
at any network location toward any frame on the market today.
• Fully covered designer brands. They can select any frame from the
Exclusive Frame Collection of over 200 of the latest, stylish, contemporary
frames covered in full, or with a minimal copay.
• One-year
warranty. Every frame or lens purchased at a participating
provider is backed by an unconditional one-year breakage warranty for
repair or replacement.
Your employees get even more through value-added services such as:
• Contact
lenses replacement. LENS123® will ship replacement contact
lenses or solution anywhere the same day and employees are guaranteed
low prices.
• Vision
correction discounts. Laser Vision Correction gives employees up
to 25 percent off the participating provider’s usual and customary fees,
or 5 percent off any participating provider’s advertised specials on laser
vision corrections services.
Pediatric Vision benefits
Pediatric vision, an essential health benefit, is covered for your employees’
dependents up to age 19. These benefits include yearly eye care visits and
a pair of eyeglasses every calendar year. These benefits can be used at
Visionworks, which has one of the largest selections of eyeglasses especially
designed for children.
6. IBC Vision Care is administered by Davis Vision, an independent company.
11
Pediatric dental coverage
Pediatric Dental 7 is considered an essential health benefit. When you buy
a Blue Solutions plan8 from IBC, it will include pediatric dental coverage
for enrolled dependents up to age 19. Coverage includes preventive
and diagnostic treatment that can help reduce the frequency and cost
of expensive procedures.
Pediatric Dental PPO included with PPO plans
If you offer your employees a PPO plan — including plans with an HRA or
HSA — those plans also include IBC Personal Choice pediatric dental
coverage. The plan fully covers in-network dental exams and cleanings every
six months to help maintain a child’s oral health. Your employees can
choose a dental provider from the nationwide Concordia Advantage network.
Dental options for adults
Pediatric DHMO included with HMO and DPOS plans
Visit www.ibx.com/sgdental
to learn about your options for
providing comprehensive dental
coverage for adults.
If you offer your employees an HMO or DPOS plan, those plans also include
Keystone Health Plan East (KHPE) pediatric dental coverage. To obtain
services, your employees will need to select a Primary Dental Office (PDO)
from the KHPE DHMO network. PDO referral is required for specialist
services. Diagnostic and preventive services, like exams and cleanings, are
fully covered once every six months.
More information on Pediatric Dental Benefits
Pediatric dental benefits are in-network only and also include basic and
major services, and medically necessary orthodontia. All coinsurance,
deductibles, and copayments used for pediatric dental services will contribute
toward the employee’s medical out-of-pocket expense.
Network dentists can be found using the online dental directory at www.ibx.com.
You can find descriptions of covered Pediatric Dental services and how much
your employees have to pay for them by visiting www.ibx.com/sgdental.
7. Benefits administered by United Concordia, an independent company.
8. P
lans offered through the small business health options program (SHOP) do not include pediatric dental coverage.
12
Making health insurance easier
for you and your employees
ibxpress.com for employers
Running a small business means that you have a lot of responsibilities to
juggle, so we make managing your health benefits as easy as possible.
Whether you’re looking for account information or online billing, you get
24/7 access through ibxpress.com.
Account Management features:
• Add
or delete an employee
• Change
• View
employee or dependent information
coverage history
• Download
• View
forms
your daily work log and transaction history
eBilling and epayment features:
• View
current and prior invoices
• Review
• Get
billing and payment history
monthly billing reminders
• Receive
and pay invoices online
ibxpress.com and IBX smartphone app for your employees
Your employees can also access ibxpress.com, which is loaded with wellness
tools and information to help your employees stay healthy. Whether they
want to research symptoms, complete a health assessment, engage in an
online lifestyle improvement program, or record and track important health
information, ibxpress.com can help.
Employees can use ibxpress.com to review their benefits, find a doctor or
hospital, and check the status of claims. It’s free, secure, and convenient.
IBX app makes it easy for employees to manage their health on the go
Even if they aren’t near a computer, your employees can still access their
benefits. They can download the free IBX app for their iPhone or Android
to help them make the most of their health plan. The IBX app gives your
employees easy access to their health care coverage 24/7, so they can:
• View
benefits and claim information
• View
temporary ID card information
• View
open referrals
• View
their Personal Health Record
• Find
a doctor
• Estimate
• Call
Log in with the same
username and password
used for ibxpress.com
the price of a drug
customer service
13
Helping your employees make the most of their coverage
We’re making it easier for your employees to get started using the online and
mobile tools and resources that are available to help them maximize their
benefits and save time.
Your employees will receive an insert with their member ID card that
directs them to visit www.ibx.com/start, where they can register or log
in to ibxpress. A short video helps them learn about tools and resources
at ibxpress to manage their benefits, estimate care costs, track spending,
and make informed decisions about their health.
The website also walks them through some of the most important ways
they can start to make the most of their coverage, including how to find
in-network doctors, learn what their plan covers, get covered services
and use prescription drug benefits, and receive free, customized messages
about their benefits on their smartphone.
To deliver the most rewarding and positive member experience, we will
regularly engage your employees through timely, relevant communications
to help them understand their benefits and how to use them effectively.
14
2015 Benefits at a Glance
Platinum health plans
PPO Platinum Premier2
Benefits per contract year1
You pay in-network
You pay out-of-network7
Deductible, individual/family
$0
$2,000/$4,000
Coinsurance
0%
50%
Out-of-pocket maximum, individual/family includes:
$1,500/$3,000
coinsurance and copays
$5,000/$10,000
coinsurance and ded
Preventive care for adults and children
$0
50% no ded
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0
N/A
Preventive colonoscopy for colorectal cancer screening - All other providers
$750
50% no ded
Primary care office visit/retail clinic
$10
50% after ded
Specialist office visit
$20
50% after ded
Urgent care
$70
50% after ded
Spinal manipulations (20 visits per year)9
$20
50% after ded
$20
50% after ded
Inpatient hospital services (includes maternity)
$0
50% after ded
Inpatient professional services (includes maternity)
$0
50% after ded
Emergency room (not waived if admitted)
$100
$100 no ded
Routine radiology/diagnostic
$20
50% after ded
MRI/MRA, CT/CTA scan, PET scan
$175
50% after ded
Biotech/specialty injectables
$50
50% after ded
Durable medical equipment/prosthetics
30%
50% after ded
Mental health, serious mental illness & substance abuse - outpatient
$20
50% after ded
Mental health, serious mental illness & substance abuse - inpatient
$0
50% after ded
Ambulatory surgical facility
$0
50% after ded
Hospital-based
$0
50% after ded
Freestanding
$0
50% after ded
Hospital-based
50%
50% after ded
Rx deductible (individual/family)
$0
$0
Retail generic
$7
Member pays 70% of retail
Retail brand
$40
Member pays 70% of retail
Retail non-formulary brand
$70
Member pays 70% of retail
Pediatric routine eye exam25, 26
$0
Not covered
Pediatric glasses
$0
Not covered
Adult routine eye exam26
$0
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
$50
Not covered
$0 no ded
Not covered
50% after ded
Not covered
Preventive services8
Physician services
Physical/occupational therapy (30 visits per year)
9
Hospital/other medical services
Outpatient surgery
Outpatient lab/pathology
Prescription drugs16, 17, 18, 19, 20
Additional benefits
Vision24
25, 27
Adult eyewear (glasses or contacts)
28
Dental29
Pediatric dental deductible (per individual)30
Pediatric exams and cleanings
30, 31
Pediatric basic, major and orthodontia services
30, 32, 33
16
PPO Platinum2
DPOS Platinum Premier2
DPOS Platinum2
You pay in-network
You pay
out-of-network7
You pay in-network
You pay
out-of-network5
You pay
in-network
You pay
out-of-network5
$0
$2,000/$4,000
$0
$2,000/$4,000
$0
$2,000/$4,000
0%
50%
0%
50%
0%
50%
$2,000/$4,000
coinsurance and copays
$5,000/$10,000
coinsurance and ded
$2,000/$4,000
coinsurance and copays
$5,000/$10,000
coinsurance and ded
$3,000/$6,000
coinsurance and copays
$5,000/$10,000
coinsurance and ded
$0
50% no ded
$0
50% no ded
$0
50% no ded
$0
N/A
$0
N/A
$0
N/A
$750
50% no ded
$750
50% no ded
$750
50% no ded
$15
50% after ded
$10
50% after ded
$15
50% after ded
$30
50% after ded
$20
50% after ded
$30
50% after ded
$70
50% after ded
$70
50% after ded
$70
50% after ded
$30
50% after ded
$2010
50% after ded
$3010
50% after ded
$30
50% after ded
$20
50% after ded
$30
50% after ded
$100 per day11
50% after ded
$0
50% after ded
$100 per day11
50% after ded
$0
50% after ded
$0
50% after ded
$0
50% after ded
$100
$100 no ded
$100
$100 no ded
$100
$100 no ded
$30
50% after ded
$20
50% after ded
$30
50% after ded
$175
50% after ded
$40
50% after ded
$60
50% after ded
$75
50% after ded
$50
50% after ded
$75
50% after ded
30%
50% after ded
50%
50% after ded
50%
50% after ded
50% after ded
$20
50% after ded
$30
$100 per day
50% after ded
$0
50% after ded
$100 per day
50% after ded
$25
50% after ded
$0
50% after ded
$25
50% after ded
$125
50% after ded
$0
50% after ded
$125
50% after ded
$0
50% after ded
$0
50% after ded
$0
50% after ded
50%
50% after ded
$0
50% after ded
$0
50% after ded
$0
$0
$0
$0
$0
$0
$7
Member pays 70% of retail
$7
Member pays 70% of retail
$7
Member pays 70% of retail
$45
Member pays 70% of retail
$40
Member pays 70% of retail
$45
Member pays 70% of retail
$75
Member pays 70% of retail
$70
Member pays 70% of retail
$75
Member pays 70% of retail
$0
Not covered
$0
Not covered
$0
Not covered
$0
Not covered
$0
Not covered
$0
Not covered
$0
Not covered
$0
Not covered
$0
Not covered
Allowance up to $150 for
frames or $100 for contact
lenses at Visionworks stores
Not covered
Allowance up to $150 for
frames or $100 for contact
lenses at Visionworks stores
Not covered
Allowance up to $150 for
frames or $100 for contact
lenses at Visionworks stores
Not covered
$50
Not covered
$0
Not covered
$0
Not covered
$0 no ded
Not covered
$0
Not covered
$0
Not covered
50% after ded
Not covered
Copay varies
Not covered
Copay varies
Not covered
$30
11
10
12
10
10
50% after ded
11
All footnotes listed on page 35
ded = Deductible
17
Platinum health plans (cont.)
HMO Platinum Premier3
HMO Platinum3
Benefits per contract year1
You pay in-network6
You pay in-network6
Deductible, individual/family
$0
$0
Coinsurance
0%
0%
Out-of-pocket maximum, individual/family includes:
$2,000/$4,000
coinsurance and copays
$3,000/$6,000
coinsurance and copays
Preventive care for adults and children
$0
$0
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0
$0
Preventive colonoscopy for colorectal cancer screening - All other providers
$750
$750
Primary care office visit/retail clinic
$10
$15
Specialist office visit
$20
$30
Urgent care
$70
$70
Spinal manipulations (20 visits per year)9
$20
$30
$20
$30
Inpatient hospital services (includes maternity)
$0
$100 per day11
Inpatient professional services (includes maternity)
$0
$0
Emergency room (not waived if admitted)
$100
$100
Routine radiology/diagnostic
$20
$30
MRI/MRA, CT/CTA scan, PET scan
$40
$60
Biotech/specialty injectables
$50
$75
Durable medical equipment/prosthetics
50%
50%
Mental health, serious mental illness & substance abuse - outpatient
$20
$30
Mental health, serious mental illness & substance abuse - inpatient
$0
$100 per day11
Ambulatory surgical facility
$0
$25
Hospital-based
$0
$125
Freestanding
$0
$0
Hospital-based
$0
$0
Rx deductible (individual/family)
$0
$0
Retail generic
$7
$7
Retail brand
$40
$45
Retail non-formulary brand
$70
$75
Pediatric routine eye exam25, 26
$0
$0
Pediatric glasses25, 27
$0
$0
$0
$0
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Pediatric dental deductible (per individual)30
$0
$0
Pediatric exams and cleanings
$0
$0
Pediatric basic, major and orthodontia services30, 32, 33
Copay varies
Copay varies
Preventive services8
Physician services
Physical/occupational therapy (30 visits per year)
9
Hospital/other medical services
Outpatient surgery
Outpatient lab/pathology
Prescription drugs16, 17, 18, 19, 20
Additional benefits
Vision24
Adult routine eye exam
26
Adult eyewear (glasses or contacts)
28
Dental29
30, 31
18
PPO Platinum HSA 50
PPO Platinum HRA 50
Employer Contribution - $750 individual/$1,500 family4
You pay in-network
Employer Contribution - $750 individual/$1,500 family4
You pay out-of-network7
You pay in-network
You pay out-of-network7
$1,500/$3,000
$10,000/$20,000
$1,500/$3,000
$10,000/$20,000
0%
50%
0%
50%
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
$0 no ded
50% no ded
$0 no ded
50% no ded
$0 no ded
N/A
$0 no ded
N/A
$750 no ded
50% no ded
$750 no ded
50% no ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
$0 after in-network ded
$0 after ded
$0 after in-network ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
$0 after ded
50% after ded
Integrated
Integrated
Integrated
Integrated
$7 after ded
50% after ded
$7 after ded
50% after ded
$40 after ded
50% after ded
$40 after ded
50% after ded
$60 after ded
50% after ded
$60 after ded
50% after ded
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores after ded
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores after ded
Not covered
Integrated
Not covered
Integrated
Not covered
$0 no ded
Not covered
$0 no ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
All footnotes listed on page 35
ded = Deductible
19
Gold health plans
PPO Gold Premier2
Benefits per contract year1
You pay in-network
You pay out-of-network7
Deductible, individual/family
$0
$6,000/$12,000
Coinsurance
0%
50%
Out-of-pocket maximum, individual/family includes:
$5,000/$10,000
coinsurance and copays
$18,000/$36,000
coinsurance and ded
Preventive care for adults and children
0%
50% no ded
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0
N/A
Preventive colonoscopy for colorectal cancer screening - All other providers
$750
50% no ded
Primary care office visit/retail clinic
$35
50% after ded
Specialist office visit
$70
50% after ded
Urgent care
$105
50% after ded
Spinal manipulations (20 visits per year)
$70
50% after ded
Physical/occupational therapy (30 visits per year)9
$70
50% after ded
Inpatient hospital services (includes maternity)
$600 per day11
50% after ded
Inpatient professional services (includes maternity)
$0
50% after ded
Emergency room (not waived if admitted)
$150
$150 no ded
Routine radiology/diagnostic
$70
50% after ded
MRI/MRA, CT/CTA scan, PET scan
$175
50% after ded
Biotech/specialty injectables
$125
50% after ded
Durable medical equipment/prosthetics
50%
50% after ded
Mental health, serious mental illness & substance abuse - outpatient
$70
50% after ded
Mental health, serious mental illness & substance abuse - inpatient
$600 per day11
50% after ded
Ambulatory surgical facility
$300
50% after ded
Hospital-based
$700
50% after ded
$0
50% after ded
50%
50% after ded
Rx deductible (individual/family)
$0
$0
Retail generic
$7
Member pays 70% of retail
Retail brand
$50
Member pays 70% of retail
Retail non-formulary brand
$75
Member pays 70% of retail
Pediatric routine eye exam25, 26
$0
Not covered
Pediatric glasses
$0
Not covered
Adult routine eye exam
$0
Not covered
Adult eyewear (glasses or contacts)28
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
$50
Not covered
$0 no ded
Not covered
50% after ded
Not covered
Preventive services8
Physician services
9
Hospital/other medical services
Outpatient surgery
Outpatient lab/pathology
Freestanding
Hospital-based
Prescription drugs
16, 17, 18, 19, 20
Additional benefits
Vision24
25, 27
26
Dental29
Pediatric dental deductible (per individual)30
Pediatric exams and cleanings
30, 31
Pediatric basic, major and orthodontia services
30, 32, 33
20
PPO Gold2
DPOS Gold Premier2
You pay in-network
You pay out-of-network7
You pay in-network
You pay out-of-network5
$1,000/$2,000
$7,500/$15,000
$0
$5,000/$10,000
10%
50%
0%
50%
$5,000/$10,000
coinsurance and copays
$25,000/$50,000
coinsurance and ded
$6,600/$13,200
coinsurance and copays
$15,000/$30,000
coinsurance and ded
$0 no ded
50% no ded
$0
50% no ded
$0 no ded
N/A
$0
N/A
$750 no ded
50% no ded
$750
50% no ded
$25 no ded
50% after ded
$30
50% after ded
$50 no ded
50% after ded
$60
50% after ded
10% after ded
50% after ded
$87
50% after ded
$50 no ded
$50 no ded
50% after ded
$60
10
50% after ded
50% after ded
$6010
50% after ded
10% after ded
50% after ded
$500 per day11
50% after ded
10% after ded
50% after ded
$0
50% after ded
10% after ded
10% after in-network ded
$300
$300 no ded
10% after ded
50% after ded
$6010
50% after ded
10% after ded
50% after ded
$250
50% after ded
$100 no ded
50% after ded
$125
50% after ded
50% after ded
50% after ded
50%
50% after ded
$50 no ded
50% after ded
$60
50% after ded
10% after ded
50% after ded
$500 per day11
50% after ded
10% after ded
50% after ded
$300
50% after ded
10% after ded
50% after ded
$500
50% after ded
$0 no ded
50% after ded
$0
50% after ded
50% after ded
50% after ded
$0
50% after ded
$0
$0
$0
$0
$7
Member pays 70% of retail
$7
Member pays 70% of retail
$50
Member pays 70% of retail
$50
Member pays 70% of retail
$75
Member pays 70% of retail
$75
Member pays 70% of retail
$0 no ded
Not covered
$0
Not covered
$0 no ded
Not covered
$0
Not covered
$0 no ded
Not covered
$0
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
$50
Not covered
$0
Not covered
$0 no ded
Not covered
$0
Not covered
50% after ded
Not covered
Copay varies
Not covered
All footnotes listed on page 35
ded = Deductible
21
Gold health plans (cont.)
DPOS Gold2
Benefits per contract year1
You pay in-network
You pay out-of-network5
Deductible, individual/family
$1,000/$2,000
$7,500/$15,000
Coinsurance
10%
50%
$6,600/$13,200
coinsurance, copays, and ded
$25,000/$50,000
coinsurance and ded
Preventive care for adults and children
$0 no ded
50% no ded
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0 no ded
N/A
Preventive colonoscopy for colorectal cancer screening - All other providers
$750 no ded
50% no ded
Primary care office visit/retail clinic13
$25 no ded
50% after ded
Specialist office visit
$50 no ded
50% after ded
Urgent care
10% after ded
50% after ded
Spinal manipulations (20 visits per year)9
$50 no ded10
50% after ded
$50 no ded
50% after ded
Inpatient hospital services (includes maternity)
10% after ded
50% after ded
Inpatient professional services (includes maternity)
10% after ded
50% after ded
Emergency room (not waived if admitted)14
10% after ded
10% after in-network ded
Routine radiology/diagnostic
$40 no ded
50% after ded
MRI/MRA, CT/CTA scan, PET scan
$80 no ded
50% after ded
Biotech/specialty injectables
$100 no ded
50% after ded
Durable medical equipment/prosthetics
50% after ded
50% after ded
Mental health, serious mental illness & substance abuse - outpatient
$50 no ded
50% after ded
Mental health, serious mental illness & substance abuse - inpatient
10% after ded
50% after ded
Ambulatory surgical facility
10% after ded
50% after ded
Hospital-based
10% after ded
50% after ded
Freestanding
$0 no ded
50% after ded
Hospital-based
$0 no ded
50% after ded
Rx deductible (individual/family)
$0
$0
Retail generic
$7
Member pays 70% of retail
Retail brand
$50
Member pays 70% of retail
Retail non-formulary brand
$75
Member pays 70% of retail
Pediatric routine eye exam25, 26
$0 no ded
Not covered
Pediatric glasses25, 27
$0 no ded
Not covered
$0 no ded
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
Pediatric dental deductible (per individual)30
$0
Not covered
Pediatric exams and cleanings30, 31
$0
Not covered
Copay varies
Not covered
Out-of-pocket maximum, individual/family includes:
12
Preventive services8
Physician services
Physical/occupational therapy (30 visits per year)
9
10
Hospital/other medical services
10
Outpatient surgery
Outpatient lab/pathology
Prescription drugs16, 17, 18, 19, 20
Additional benefits
Vision24
Adult routine eye exam
26
Adult eyewear (glasses or contacts)
28
Dental29
Pediatric basic, major and orthodontia services
30, 32, 33
22
HMO Gold Premier3
HMO Gold2
Keystone HMO Gold Proactive2
You pay in-network6
You pay in-network6
You pay in-network6
Tier 1 - Preferred
You pay in-network6
Tier 2 - Enhanced
You pay in-network6
Tier 3 - Standard
$0
$1,000/$2,000
$0
$0
$0
0%
10%
0%; unless otherwise noted
20%; unless otherwise noted
30%; unless otherwise noted
$6,600/$13,200
coinsurance and copays
$6,600/$13,200
coinsurance, copays, and ded
$6,600/$13,200
coinsurance and copays
$6,600/$13,200
coinsurance and copays
$6,600/$13,200
coinsurance and copays
$0
$0 no ded
$0
$0
$0
$0
$0 no ded
$0
$0
$0
$750
$750 no ded
$750
$750
$750
$30
$25 no ded
$15
$30
$45
$60
$50 no ded
$40
$60
$80
$87
10% after ded
$100
$100
$100
$60
$50 no ded
$50
$50
$50
$60
$50 no ded
$60
$60
$60
$500 per day11
10% after ded
$350 per day11
$700 per day11
$1,100 per day11
$0
10% after ded
0%
20%
30%
$300
10% after ded
$400
$400
$400
$60
$40 no ded
$60
$60
$60
$250
$80 no ded
$120
$120
$120
$125
$100 no ded
50%
50%
50%
50%
50% after ded
50%
50%
50%
$60
$50 no ded
$40
$40
$500 per day
10% after ded
$350 per day
$350 per day
$350 per day11
$300
10% after ded
$150
$550
$1,000
$500
10% after ded
$150
$550
$1,000
$0
$0 no ded
$0
$0
$0
$0
$0 no ded
$0
$0
$0
$0
$0
$021
$021
$021
$7
$7
$15
$15
$1521, 23
$50
$50
50% up to $200 max per prescription21, 22
50% up to $200 max per prescription21, 22
50% up to $200 max per prescription21, 22
$75
$75
50% up to $300 max per prescription21, 22
50% up to $300 max per prescription21, 22
50% up to $300 max per prescription21, 22
$0
$0 no ded
$0
$0
$0
$0
$0 no ded
$0
$0
$0
$0
$0 no ded
$0
$0
$0
Allowance up to $150 for
frames or $100 for contact
lenses at Visionworks stores
Allowance up to $150 for
frames or $100 for contact
lenses at Visionworks stores
Allowance up to $150 for
frames or $100 for contact
lenses at Visionworks stores
Allowance up to $150 for
frames or $100 for contact
lenses at Visionworks stores
Allowance up to $150 for
frames or $100 for contact
lenses at Visionworks stores
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Copay varies
Copay varies
Copay varies
Copay varies
Copay varies
11
11
21, 23
$40
11
21, 23
All footnotes listed on page 35
ded = Deductible
23
Gold health plans (cont.)
PPO GOLD HSA 254
PPO Gold HSA4
Employer Contribution $500 individual/$1,000 family
Benefits per contract year1
You pay
in-network
You pay
out-of-network7
You pay
in-network
You pay
0ut-of -network7
Deductible, individual/family
$1,500/$3,000
$10,000/$20,000
$2,000/$4,000
$10,000/$20,000
Coinsurance
0%
50%
0%
50%
Out-of-pocket maximum, individual/family includes:
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
Preventive care for adults and children
$0 no ded
50% no ded
$0 no ded
50% no ded
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0 no ded
N/A
$0 no ded
N/A
Preventive colonoscopy for colorectal cancer screening - All other providers
$750 no ded
50% no ded
$750 no ded
50% no ded
Primary care office visit/retail clinic
$0 after ded
50% after ded
$0 after ded
50% after ded
Specialist office visit
$0 after ded
50% after ded
$0 after ded
50% after ded
Urgent care
$0 after ded
50% after ded
$0 after ded
50% after ded
Spinal manipulations (20 visits per year)
$0 after ded
50% after ded
$0 after ded
50% after ded
Physical/occupational therapy (30 visits per year)9
$0 after ded
50% after ded
$0 after ded
50% after ded
Inpatient hospital services (includes maternity)
$0 after ded
50% after ded
$0 after ded
50% after ded
Inpatient professional services (includes maternity)
$0 after ded
50% after ded
$0 after ded
50% after ded
Emergency room (not waived if admitted)
$0 after ded
$0 after in-network ded
$0 after ded
$0 after in-network ded
Routine radiology/diagnostic
$0 after ded
50% after ded
$0 after ded
50% after ded
MRI/MRA, CT/CTA scan, PET scan
$0 after ded
50% after ded
$0 after ded
50% after ded
Biotech/specialty injectables
$0 after ded
50% after ded
$0 after ded
50% after ded
Durable medical equipment/prosthetics
$0 after ded
50% after ded
$0 after ded
50% after ded
Mental health, serious mental illness & substance abuse - outpatient
$0 after ded
50% after ded
$0 after ded
50% after ded
Mental health, serious mental illness & substance abuse - inpatient
$0 after ded
50% after ded
$0 after ded
50% after ded
Ambulatory surgical facility
$0 after ded
50% after ded
$0 after ded
50% after ded
Hospital-based
$0 after ded
50% after ded
$0 after ded
50% after ded
Freestanding
$0 after ded
50% after ded
$0 after ded
50% after ded
Hospital-based
$0 after ded
50% after ded
$0 after ded
50% after ded
Rx deductible (individual/family)
Integrated
Integrated
Integrated
Integrated
Retail generic
$7 after ded
50% after ded
$7 after ded
50% after ded
Retail brand
$40 after ded
50% after ded
$40 after ded
50% after ded
Retail non-formulary brand
$60 after ded
50% after ded
$60 after ded
50% after ded
Pediatric routine eye exam25, 26
$0 after ded
Not covered
$0 after ded
Not covered
Pediatric glasses25, 27
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
Allowance up to $150 for frames
or $100 for contact lenses at
Visionworks stores after ded
Not covered
Allowance up to $150 for frames
or $100 for contact lenses at
Visionworks stores after ded
Not covered
Integrated
Not covered
Integrated
Not covered
$0 no ded
Not covered
$0 no ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
Preventive services8
Physician services
9
Hospital/other medical services
Outpatient surgery
Outpatient lab/pathology
Prescription drugs16, 17, 18, 19, 20
Additional benefits
Vision24
Adult routine eye exam
26
Adult eyewear (glasses or contacts)
28
Dental29
Pediatric dental deductible (per individual)30
Pediatric exams and cleanings30, 31
Pediatric basic, major and orthodontia services
30, 32, 33
24
PPO Gold HRA 252
PPO Gold HSA 504
PPO Gold HRA 502
Employer Contribution $500 individual/$1,000 family
Employer Contribution $1,000 individual/$2,000 family
Employer Contribution $1,000 individual/$2,000 family
You pay
in-network
You pay
out-of-network7
You pay
in-network
You pay
out-of-network7
You pay
in-network
You pay
out-of-network7
$2,000/$4,000
$10,000/$20,000
$2,000/$4,000
$10,000/$20,000
$2,000/$4,000
$10,000/$20,000
30%
50%
0%
50%
30%
50%
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
$0 no ded
50% no ded
$0 no ded
50% no ded
$0 no ded
50% no ded
$0 no ded
N/A
$0 no ded
N/A
$0 no ded
N/A
$750 no ded
50% no ded
$750 no ded
50% no ded
$750 no ded
50% no ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
30% after in-network ded
$0 after ded
$0 after in-network ded
30% after ded
30% after in-network ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
30% after ded
50% after ded
$0 after ded
50% after ded
30% after ded
50% after ded
Integrated
Integrated
Integrated
Integrated
Integrated
Integrated
$7 after ded
50% after ded
$7 after ded
50% after ded
$7 after ded
50% after ded
$40 after ded
50% after ded
$40 after ded
50% after ded
$40 after ded
50% after ded
$60 after ded
50% after ded
$60 after ded
50% after ded
$60 after ded
50% after ded
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
Not covered
Allowance up to $150 for frames
or $100 for contact lenses at
Visionworks stores after ded
Not covered
Allowance up to $150 for frames
or $100 for contact lenses at
Visionworks stores after ded
Not covered
Integrated
Not covered
Integrated
Not covered
Integrated
Not covered
$0 no ded
Not covered
$0 no ded
Not covered
$0 no ded
Not covered
30% after ded
Not covered
$0 after ded
Not covered
30% after ded
Not covered
Allowance up to $150 for frames or
$100 for contact lenses at Visionworks
stores after ded
All footnotes listed on page 35
ded = Deductible
25
Silver health plans
PPO Silver2
Benefits per contract year1
You pay in-network
You pay out-of-network7
Deductible, individual/family
$2,500/$5,000
$7,500/$15,000
Coinsurance
20%
50%
Out-of-pocket maximum, individual/family includes:
$6,000/$12,000
coinsurance, copays, and ded
$25,000/$50,000
coinsurance and ded
Preventive care for adults and children
$0 no ded
50% no ded
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0 no ded
N/A
Preventive colonoscopy for colorectal cancer screening - All other providers
$750 no ded
50% no ded
Primary care office visit/retail clinic
$30 no ded
50% after ded
Specialist office visit
$60 no ded
50% after ded
Urgent care
20% after ded
50% after ded
Spinal manipulations (20 visits per year)
$60 no ded
50% after ded
Physical/occupational therapy (30 visits per year)9
$60 no ded
50% after ded
Inpatient hospital services (includes maternity)
20% after ded
50% after ded
Inpatient professional services (includes maternity)
20% after ded
50% after ded
Emergency room (not waived if admitted)
20% after ded
20% after in-network ded
Routine radiology/diagnostic
20% after ded
50% after ded
MRI/MRA, CT/CTA scan, PET scan
20% after ded
50% after ded
Biotech/specialty injectables
$100 no ded
50% after ded
Durable medical equipment/prosthetics
50% after ded
50% after ded
Mental health, serious mental illness & substance abuse - outpatient
$60 no ded
50% after ded
Mental health, serious mental illness & substance abuse - inpatient
20% after ded
50% after ded
Ambulatory surgical facility
20% after ded
50% after ded
Hospital-based
20% after ded
50% after ded
$0 no ded
50% after ded
50% after ded
50% after ded
Rx deductible (individual/family)
$0
$0
Retail generic
$7
Preventive services8
Physician services
9
Hospital/other medical services
Outpatient surgery
Outpatient lab/pathology
Freestanding
Hospital-based
Prescription drugs
16, 17, 18, 19, 20, 21
Member pays 70% of retail
Retail brand
50% up to $125 max per prescription
22
Member pays 70% of retail22
Retail non-formulary brand
50% up to $250 max per prescription22
Member pays 70% of retail22
Pediatric routine eye exam25, 26
$0 no ded
Not covered
Pediatric glasses
$0 no ded
Not covered
$0 no ded
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
Pediatric dental deductible (per individual)30
$50
Not covered
Pediatric exams and cleanings30, 31
$0 no ded
Not covered
50% after ded
Not covered
Additional benefits
Vision24
25, 27
Adult routine eye exam
26
Adult eyewear (glasses or contacts)
28
Dental29
Pediatric basic, major and orthodontia services
30, 32, 33
26
DPOS Silver Premier2
DPOS Silver2
You pay in-network
You pay out-of-network5
You pay in-network
You pay out-of-network5
$2,000/$4,000
$7,500/$15,000
$2,500/$5,000
$7,500/$15,000
30%
50%
40%
50%
$6,600/$13,200
coinsurance, copays, and ded
$25,000/$50,000
coinsurance and ded
$6,600/$13,200
coinsurance, copays, and ded
$25,000/$50,000
coinsurance and ded
$0 no ded
50% no ded
$0 no ded
50% no ded
$0 no ded
N/A
$0 no ded
N/A
$750 no ded
50% no ded
$750 no ded
50% no ded
$25 no ded
50% after ded
$30 no ded
50% after ded
$50 no ded
50% after ded
$60 no ded
50% after ded
30% after ded
50% after ded
40% after ded
50% after ded
10
$50 no ded
50% after ded
10
$60 no ded
50% after ded
$50 no ded10
50% after ded
$60 no ded10
50% after ded
30% after ded
50% after ded
40% after ded
50% after ded
30% after ded
50% after ded
40% after ded
50% after ded
30% after ded
30% after in-network ded
40% after ded
40% after in-network ded
$50 no ded10
50% after ded
$60 no ded10
50% after ded
$100 no ded
50% after ded
$120 no ded
50% after ded
$100 no ded
50% after ded
$100 no ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
$50 no ded
50% after ded
$60 no ded
50% after ded
30% after ded
50% after ded
40% after ded
50% after ded
30% after ded
50% after ded
40% after ded
50% after ded
30% after ded
50% after ded
40% after ded
50% after ded
$0 no ded
50% after ded
$0 no ded
50% after ded
$0 no ded
50% after ded
$0 no ded
50% after ded
$0
$0
$0
$0
$7
Member pays 70% of retail
$7
Member pays 70% of retail
50% up to $125 max per prescription
Member pays 70% of retail
50% up to $250 max per prescription22
Member pays 70% of retail22
50% up to $250 max per prescription22
Member pays 70% of retail22
$0 no ded
Not covered
$0 no ded
Not covered
$0 no ded
Not covered
$0 no ded
Not covered
$0 no ded
Not covered
$0 no ded
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
$0
Not covered
$0
Not covered
$0
Not covered
$0
Not covered
Copay varies
Not covered
Copay varies
Not covered
22
22
50% up to $125 max per prescription
22
Member pays 70% of retail22
All footnotes listed on page 35
ded = Deductible
27
Silver health plans (cont.)
HMO Silver Premier2
HMO Silver 2
Benefits per contract year1
You pay in-network6
You pay in-network6
Deductible, individual/family15
$2,000/$4,000
$2,500/$5,000
Coinsurance
30%
40%
$6,600/$13,200
coinsurance, copays, and ded
$6,600/$13,200
coinsurance, copays, and ded
Preventive care for adults and children
$0 no ded
$0 no ded
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0 no ded
$0 no ded
Preventive colonoscopy for colorectal cancer screening - All other providers
$750 no ded
$750 no ded
Primary care office visit/retail clinic13
$25 no ded
$30 no ded
Specialist office visit
$50 no ded
$60 no ded
30% after ded
40% after ded
Spinal manipulations (20 visits per year)
$50 no ded
$60 no ded
Physical/occupational therapy (30 visits per year)9
$50 no ded
$60 no ded
Inpatient hospital services (includes maternity)
30% after ded
40% after ded
Inpatient professional services (includes maternity)
30% after ded
40% after ded
Emergency room (not waived if admitted)14
30% after ded
40% after ded
Routine radiology/diagnostic
$50 no ded
$60 no ded
MRI/MRA, CT/CTA scan, PET scan
$100 no ded
$120 no ded
Biotech/specialty injectables
$100 no ded
$100 no ded
Durable medical equipment/prosthetics
50% after ded
50% after ded
Mental health, serious mental illness & substance abuse - outpatient
$50 no ded
$60 no ded
Mental health, serious mental illness & substance abuse - inpatient
30% after ded
40% after ded
Ambulatory surgical facility
30% after ded
40% after ded
Hospital-based
30% after ded
40% after ded
Freestanding
$0 no ded
$0 no ded
Hospital-based
$0 no ded
$0 no ded
Rx deductible (individual/family)
$0
$0
Retail generic
$7
Out-of-pocket maximum, individual/family includes:
12
Preventive services8
Physician services
Urgent care
9
Hospital/other medical services
Outpatient surgery
Outpatient lab/pathology
Prescription drugs16, 17, 18, 19, 20, 21
$7
Retail brand
50% up to $125 max per prescription
22
50% up to $125 max per prescription22
Retail non-formulary brand
50% up to $250 max per prescription22
50% up to $250 max per prescription22
Pediatric routine eye exam25, 26
$0 no ded
$0 no ded
Pediatric glasses
$0 no ded
$0 no ded
Adult routine eye exam26
$0 no ded
$0 no ded
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Pediatric dental deductible (per individual)30
$0
$0
Pediatric exams and cleanings
$0
$0
Pediatric basic, major and orthodontia services30, 32, 33
Copay varies
Copay varies
Additional benefits
Vision24
25, 27
Adult eyewear (glasses or contacts)
28
Dental29
30, 31
28
Keystone HMO Silver Proactive2
You pay in-network6
Tier 1 - Preferred
You pay in-network6
Tier 2 - Enhanced
You pay in-network6
Tier 3 - Standard
$0
$4,500/$9,000
$4,500/$9,000
0%; unless otherwise noted
5%; unless otherwise noted
10%; unless otherwise noted
$6,600/$13,200
coinsurance and copays
$6,600/$13,200
coinsurance, copays, and ded
$6,600/$13,200
coinsurance, copays, and ded
$0
$0 no ded
$0 no ded
$0
$0 no ded
$0 no ded
$750
$750 no ded
$750 no ded
$25
$40 no ded
$50 no ded
$50
$70 no ded
$100 no ded
$100
$100 no ded
$100 no ded
$50
$50 no ded
$50 no ded
$60
$60 no ded
$60 no ded
$500 per day11
Subject to ded and $900 per day11
Subject to ded and $1,300 per day11
0%
5% after ded
10% after ded
$550
$550 no ded
$550 no ded
$60
$60 no ded
$60 no ded
$250
$250 no ded
$250 no ded
50%
50% no ded
50% no ded
50%
50% no ded
50% no ded
$50
$50 no ded
$50 no ded
$500 per day
$500 per day no ded
$500 per day11 no ded
$250
Subject to ded and $750 copay
Subject to ded and $1,250 copay
$250
Subject to ded and $750 copay
Subject to ded and $1,250 copay
$0
$0 no ded
$0 no ded
$0
$0 no ded
$0 no ded
$022
$022
$022
11
11
$1522,23
50% up to $400 max per prescription
$1522,23
50% up to $400 max per prescription
$1522,22
22
50% up to $400 max per prescription22
50% up to $500 max per prescription22
50% up to $500 max per prescription22
50% up to $500 max per prescription22
$0
$0 no ded
$0 no ded
$0
$0 no ded
$0 no ded
$0
$0 no ded
$0 no ded
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
$0
$0
$0
$0
$0
$0
Copay varies
Copay varies
Copay varies
22
All footnotes listed on page 35
ded = Deductible
29
Silver health plans (cont.)
Benefits per contract year1
PPO Silver HSA4
You pay in-network
You pay out-of-network7
Deductible, individual/family
$2,200/$4,400
$10,000/$20,000
Coinsurance
10%
50%
Out-of-pocket maximum, individual/family includes:
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
Preventive care for adults and children
$0 no ded
50% no ded
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0 no ded
N/A
Preventive colonoscopy for colorectal cancer screening - All other providers
$750 no ded
50% no ded
Primary care office visit/retail clinic
10% after ded
50% after ded
Specialist office visit
10% after ded
50% after ded
Urgent care
10% after ded
50% after ded
10% after ded
50% after ded
10% after ded
50% after ded
Inpatient hospital services (includes maternity)
10% after ded
50% after ded
Inpatient professional services (includes maternity)
10% after ded
50% after ded
Emergency room (not waived if admitted)
10% after ded
10% after in-network ded
Routine radiology/diagnostic
10% after ded
50% after ded
MRI/MRA, CT/CTA scan, PET scan
10% after ded
50% after ded
Biotech/specialty injectables
10% after ded
50% after ded
Durable medical equipment/prosthetics
10% after ded
50% after ded
Mental health, serious mental illness & substance abuse - outpatient
10% after ded
50% after ded
Mental health, serious mental illness & substance abuse - inpatient
10% after ded
50% after ded
Ambulatory surgical facility
10% after ded
50% after ded
Hospital-based
10% after ded
50% after ded
Freestanding
10% after ded
50% after ded
Hospital-based
10% after ded
50% after ded
Rx deductible (individual/family)
Integrated
Integrated
Retail generic
$7 after ded
50% after ded
Retail brand
$40 after ded22
50% after ded22
Retail non-formulary brand
$60 after ded
50% after ded22
Preventive services8
Physician services
Spinal manipulations (20 visits per year)
9
Physical/occupational therapy (30 visits per year)
9
Hospital/other medical services
Outpatient surgery
Outpatient lab/pathology
Prescription drugs16, 17, 18, 19, 20, 21
22
Additional benefits
Vision24
Pediatric routine eye exam25, 26
$0 after ded
Not covered
Pediatric glasses25, 27
$0 after ded
Not covered
Adult routine eye exam
$0 after ded
Not covered
Adult eyewear (glasses or contacts)28
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores after ded
Not covered
Pediatric dental deductible (per individual)30
Integrated
Not covered
Pediatric exams and cleanings
$0 no ded
Not covered
Pediatric basic, major and orthodontia services30, 32, 33
10% after ded
Not covered
26
Dental29
30, 31
30
PPO Silver HSA 254
PPO Silver HRA 252
Employer Contribution - $550 individual/$1,100 family
Employer Contribution - $550 individual/$1,100 family
You pay in-network
You pay out-of-network7
You pay in-network
You pay out-of-network7
$2,200/$4,400
$10,000/$20,000
$2,200/$4,400
$10,000/$20,000
50%
50%
50%
50%
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
$0 no ded
50% no ded
$0 no ded
50% no ded
$0 no ded
N/A
$0 no ded
N/A
$750 no ded
50% no ded
$750 no ded
50% no ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after in-network ded
50% after ded
50% after in-network ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
Integrated
Integrated
Integrated
Integrated
$7 after ded
50% after ded
$7 after ded
50% after ded
$40 after ded22
50% after ded22
$40 after ded22
50% after ded22
$60 after ded
50% after ded
$60 after ded
50% after ded22
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
$0 after ded
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores after ded
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores after ded
Not covered
Integrated
Not covered
Integrated
Not covered
$0 no ded
Not covered
$0 no ded
Not covered
50% after ded
Not covered
50% after ded
Not covered
22
22
22
All footnotes listed on page 35
ded = Deductible
31
Bronze health plans
DPOS Bronze2
Benefits per contract year1
You pay in-network
You pay out-of-network5
Deductible, individual/family
$6,000/$12,000
$10,000/$20,000
Coinsurance
0%
50%
Out-of-pocket maximum, individual/family includes:
$6,600/$13,200
coinsurance, copays, and ded
$40,000/$80,000
coinsurance and ded
Preventive care for adults and children
$0 no ded
50% no ded
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0 no ded
N/A
Preventive colonoscopy for colorectal cancer screening - All other providers
$750 no ded
50% no ded
Primary care office visit/retail clinic
$40 no ded
50% after ded
Specialist office visit
$80 no ded
50% after ded
Urgent care
$0 after ded
50% after ded
Spinal manipulations (20 visits per year)9
$80 no ded10
50% after ded
10
$80 no ded
50% after ded
Inpatient hospital services (includes maternity)
$0 after ded
50% after ded
Inpatient professional services (includes maternity)
$0 after ded
50% after ded
Emergency room (not waived if admitted)
$0 after ded
$0 after in-network ded
Routine radiology/diagnostic
10
$60 no ded
50% after ded
MRI/MRA, CT/CTA scan, PET scan
$250 no ded
50% after ded
Biotech/specialty injectables
$100 no ded
50% after ded
Durable medical equipment/prosthetics
50% after ded
50% after ded
Mental health, serious mental illness & substance abuse - outpatient
$80 no ded
50% after ded
Mental health, serious mental illness & substance abuse - inpatient
$0 after ded
50% after ded
Ambulatory surgical facility
$0 after ded
50% after ded
Hospital-based
$0 after ded
50% after ded
Freestanding
$0 no ded
50% after ded
Hospital-based
$0 no ded
50% after ded
Rx deductible (individual/family)
Integrated
Integrated
Retail generic
$7 no ded
Member pays 70% of retail no ded
Retail brand
$50 after ded22
Member pays 70% of retail after ded22
Retail non-formulary brand
$75 after ded
Member pays 70% of reatil after ded22
Pediatric routine eye exam25, 26
$0 no ded
Not covered
Pediatric glasses25, 27
$0 no ded
Not covered
$0 no ded
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
Pediatric dental deductible (per individual)30
$0
Not covered
Pediatric exams and cleanings30, 31
$0
Not covered
Copay varies
Not covered
Preventive services8
Physician services
Physical/occupational therapy (30 visits per year)
9
Hospital/other medical services
Outpatient surgery
Outpatient lab/pathology
Prescription drugs16, 17, 18, 19, 20, 21
22
Additional benefits
Vision24
Adult routine eye exam
26
Adult eyewear (glasses or contacts)
28
Dental29
Pediatric basic, major and orthodontia services
30, 32, 33
32
HMO Bronze2
HMO Bronze Basic2
PPO Bronze HSA4
You pay in-network6
You pay in-network6
You pay in-network
You pay out-of-network7
$6,000/$12,000
$6,300/$12,600
$5,500/$11,000
$10,000/$20,000
0%
0%
0%
50%
$6,600/$13,200
coinsurance, copays, and ded
$6,600/$13,200
coinsurance, copays, and ded
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
$0 no ded
$0 no ded
$0 no ded
50% no ded
$0 no ded
$0 no ded
$0 no ded
N/A
$750 no ded
$750 no ded
$750 no ded
50% no ded
$40 no ded
$50 no ded
$0 after ded
50% after ded
$80 no ded
$0 after ded
$0 after ded
50% after ded
$0 after ded
$0 after ded
$0 after ded
50% after ded
$80 no ded
$0 after ded
$0 after ded
50% after ded
$80 no ded
$50 no ded
$0 after ded
50% after ded
$0 after ded
$0 after ded
$0 after ded
50% after ded
$0 after ded
$0 after ded
$0 after ded
50% after ded
$0 after ded
$0 after ded
$0 after ded
$0 after in-network ded
$60 no ded
$60 no ded
$0 after ded
50% after ded
$250 no ded
$250 no ded
$0 after ded
50% after ded
$100 no ded
$100 no ded
$0 after ded
50% after ded
50% after ded
50% after ded
$0 after ded
50% after ded
$80 no ded
$0 after ded
$0 after ded
50% after ded
$0 after ded
$0 after ded
$0 after ded
50% after ded
$0 after ded
$0 after ded
$0 after ded
50% after ded
$0 after ded
$0 after ded
$0 after ded
50% after ded
$0 no ded
$0 no ded
$0 after ded
50% after ded
$0 no ded
$0 no ded
$0 after ded
50% after ded
Integrated
Integrated
Integrated
Integrated
$7 no ded
$7 after ded
$7 after ded
50% after ded
$50 after ded22
$30 after ded22
$40 after ded22
50% after ded22
$75 after ded
$50 after ded
$60 after ded
50% after ded22
$0 no ded
$0 no ded
$0 after ded
Not covered
$0 no ded
$0 no ded
$0 after ded
Not covered
$0 no ded
Not covered
$0 after ded
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores
Not covered
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores after ded
Not covered
$0
$0
Integrated
Not covered
$0
$0
$0 no ded
Not covered
Copay varies
Copay varies
50% after ded
Not covered
22
22
22
All footnotes listed on page 35
ded = Deductible
33
Bronze health plans (cont.)
PPO Bronze Premier HSA4
Benefits per contract year1
You pay in-network
You pay out-of-network7
Deductible, individual/family
$4,000/$8,000
$10,000/$20,000
Coinsurance
50%
50%
Out-of-pocket maximum, individual/family includes:
$6,450/$12,900
coinsurance, copays, and ded
$20,000/$40,000
coinsurance and ded
Preventive care for adults and children
$0 no ded
50% no ded
Preventive colonoscopy for colorectal cancer screening - Preventive Plus providers
$0 no ded
N/A
Preventive colonoscopy for colorectal cancer screening - All other providers
$750 no ded
50% no ded
Primary care office visit/retail clinic
50% after ded
50% after ded
Specialist office visit
50% after ded
50% after ded
Urgent care
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
50% after ded
Inpatient hospital services (includes maternity)
50% after ded
50% after ded
Inpatient professional services (includes maternity)
50% after ded
50% after ded
Emergency room (not waived if admitted)
50% after ded
50% after in-network ded
Routine radiology/diagnostic
50% after ded
50% after ded
MRI/MRA, CT/CTA scan, PET scan
50% after ded
50% after ded
Biotech/specialty injectables
50% after ded
50% after ded
Durable medical equipment/prosthetics
50% after ded
50% after ded
Mental health, serious mental illness & substance abuse - outpatient
50% after ded
50% after ded
Mental health, serious mental illness & substance abuse - inpatient
50% after ded
50% after ded
Ambulatory surgical facility
50% after ded
50% after ded
Hospital-based
50% after ded
50% after ded
Freestanding
50% after ded
50% after ded
Hospital-based
50% after ded
50% after ded
Rx deductible (individual/family)
Integrated
Integrated
Retail generic
$7 after ded
50% after ded
Retail brand
$40 after ded22
50% after ded22
Retail non-formulary brand
$60 after ded
50% after ded22
Pediatric routine eye exam25, 26
$0 after ded
Not covered
Pediatric glasses25, 27
$0 after ded
Not covered
Adult routine eye exam
$0 after ded
Not covered
Adult eyewear (glasses or contacts)28
Allowance up to $150 for frames or $100
for contact lenses at Visionworks stores after ded
Not covered
Pediatric dental deductible (per individual)30
Integrated
Not covered
Pediatric exams and cleanings
$0 no ded
Not covered
Pediatric basic, major and orthodontia services30, 32, 33
50% after ded
Not covered
Preventive services8
Physician services
Spinal manipulations (20 visits per year)
9
Physical/occupational therapy (30 visits per year)
9
Hospital/other medical services
Outpatient surgery
Outpatient lab/pathology
Prescription drugs16, 17, 18, 19, 20, 21
22
Additional benefits
Vision24
26
Dental29
30, 31
34
All footnotes listed on page 35
ded = Deductible
Important plan details
Medical
1. Certain plan benefits may be enhanced to comply with health care reform law/regulations. Eligible dependent children are covered to age 26.
2. Family deductible and out-of-pocket maximum apply when an individual and one or more dependents are enrolled. Once an individual meets the individual deductible amount,
claims for that individual will apply. Once the family deductible is met, claims for all individuals will pay. Single deductible and out-of pocket maximum apply only when an
individual is enrolled without dependents.
3. Family out-of-pocket maximum applies when an individual and one or more dependents are enrolled. Once an individual meets the individual out-of-pocket maximum, benefits
for that individual are covered in full. Once the family out-of-pocket maximum is met, benefits for all family members are covered in full. Single out-of pocket maximum applies
only when an individual is enrolled without dependents.
4. Family deductible and out-of-pocket maximum apply when an individual and one or more dependents are enrolled. The full family deductible must be met by family members
before claims are eligible to pay. Once the family out-of pocket maximum is met, benefits for all family members are covered in full. If an individual is enrolled without
dependents, the single deductible and out-of-pocket maximum apply.
5. To receive maximum benefits, services must be provided by a Keystone Health Plan East participating provider. This is a highlight of benefits available. The benefits and exclusion
for in-network and out-of-network care are not the same. All benefits are provided in accordance with the HMO group contract and out-of-network benefit booklet/certificate.
6. There are no out-of-network services available except for emergency services.
7. Non-Participating Preferred Providers may bill you for differences between the Plan allowance, which is the amount paid by IBC, and the actual charge of the provider. This amount
may be significant. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual
charge of the provider. For covered services that are not recognized or reimbursed by Medicare, payment is based on the lesser of the IBC applicable proprietary fee schedule or the
actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC’s fee schedule, the payment is based on 50 percent of the actual charge of
the provider. It is important to note that all percentages for out-of-network services are percentage of the Plan allowance, not the actual charge of the provider.
8. Age and frequency schedules may apply. For routine colonoscopy for colorectal cancer screening, your cost share may vary depending on where you receive service.
9. For PPO plans, visit limits are combined in-and out-of-network.
10. Referral required from primary care physician.
11. Amount shown reflects the copayment per day. There is a maximum of five copayments per admission.
12. For Keystone HMO Proactive plans, the out-of-pocket maximum for Tiers 1, 2, and 3 are combined.
13. For Keystone HMO Proactive plans, all in-network retail clinics are assigned to Tier 1, with the exception of Walgreens Healthcare Clinic, which is assigned Tier 3.
14. For Keystone HMO Proactive plans, if admitted to an in-network hospital from the emergency room, the out-of-pocket costs for inpatient hospital will apply based on the tier of
the in-network hospital. If admitted to an out-of-network hospital following an emergency room admission, the Tier 3 in-network level of benefits will apply. Non-Participating
Providers for Emergency Services will be covered at the Tier 3 level of benefits.
15. For Keystone HMO Silver Proactive plan, deductible is combined for Tiers 2 and 3.
Prescription Drugs
16. Prescription drug benefits are administered by FutureScripts, a Catamaran company, an independent company providing pharmacy benefit management services.
17. No cost-sharing is required at participating retail and mail order pharmacies for certain designated preventive drugs, prescription and over-the-counter (with a doctor’s prescription).
18. Out-of-Network benefits apply to prescriptions filled at non-participating pharmacies and the member must pay the full retail price for their prescription then file a paper claim
for reimbursement. The member should refer to their benefit booklet to determine the out-of-network coverage for their plan.
19. Mail Order coverage is available for all Prescription Drug Plans. The FutureScripts Mail Order service is a convenient and cost-effective way to order up to a 90-day supply
of maintenance or long-term medication for delivery to a home, office, or location of choice.
20. All covered self-administered specialty medications except insulin will be provided through the convenient FutureScripts Specialty Pharmacy Program for the appropriate
retail cost sharing. Benefits are available for up to a 30-day supply. If the doctor wants the member to start the drug immediately, an initial 30-day supply may be obtained
at a participating retail pharmacy. However, all subsequent fills must be purchased through the Specialty Pharmacy Program.
21. Select plans utilize the FutureScripts Preferred Pharmacy Network – a subset of the national retail pharmacy network. It includes over 50,000 pharmacies, including most
major chains and local pharmacies except Walgreens and Rite Aid.
22. When a prescription drug is not available in a generic form, benefits will be provided for the brand drug and the member will be responsible for the cost sharing for a brand drug.
When a prescription drug is available in a generic form, benefits will be provided for that drug at the generic drug level only. If the member chooses to purchase a brand drug,
the member will be responsible for paying the dispensing pharmacy the difference between the negotiated discount price for the generic drug and the brand drug plus the
appropriate cost sharing for a brand drug.
23. Certain designated generic drugs available at participating retail and mail order pharmacies for a reduced member cost sharing
($4 Retail/$8 Mail Order), after any applicable deductible.
Additional Benefits
24. IBC Vision Care is administered by Davis Vision, an independent company.
25. Pediatric vision benefits expire at the end of the month in which the child turns 19.
26. One eye exam per calendar year period.
27. Pediatric spectacle lenses covered at no extra cost include: single vision, lined bifocal, lined trifocal, or lenticular lenses. For frames to be covered in full, choose from
Davis Vision’s Pediatric Frame Selection (available at most independent participating providers and at Visionworks retail centers, a national optical chain).
28. For all other Davis Vision providers, there is a $100 allowance for frames or contact lenses, after any applicable deductible to high deductible health plans.
29. Independence Blue Cross dental plans are administered by United Concordia, an independent company.
30. Pediatric dental benefits are covered until the end of the contract year in which the child turns 19.
31. One exam and one cleaning every six months per contract year.
32. Only medically necessary orthodontia is covered. There is a 12-month waiting period for all orthodontia.
33. You can find descriptions of covered Pediatric Dental services and specific member cost share by visiting ibx.com/sgdental.
The Member has the right to receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, genetic information,
color, religion, gender, sexual orientation, national origin, or source of payment.
35
Underwriting information
Maximum Product offerings1
• Small
groups (2-50) are allowed up to three packaged plans which include
medical, prescription drug, vision (adult and pediatric) and pediatric
dental benefits.
• If
a group is offering a PPO plan for out of area enrollment, the PPO
benefit level must be equivalent to the benefit plans offered to the in-area
employees. Group offerings may not exceed three plans, including a plan
for out-of-area PPO coverage.
Participation requirements2
• Groups
of 2-50 must have 70 percent participation, which includes all
product lines. IBC and affiliates must be sole carrier.
• IBC
will count waivers in the eligibility calculations.
• Credit
is given for those eligible subscribers who opt out because they
have coverage through a spouse, as an eligible dependent to 26, or are
enrolled in Medicare or Medicaid. Only these types of opt-outs, or waivers,
are excluded from the calculation to determine if a group meets the
participation requirement.
• Retiree-only
groups will not be accepted. For groups covering retirees,
100 percent participation will be required for retired employees.
The group must consist of a minimum of 70 percent active employees.
Employer contribution requirement2
• For
contributory plan offerings, you must contribute a minimum of
25 percent of the calculated gross monthly premium.
Off-anniversary benefit change
• Upgrades
and downgrades will only be allowed on anniversary.
High deductible health plan funding limitation
• Per
the ACA regulations, employers should not fund more or less than
the federally mandated standards for funding employee deductibles.
• The high deductible plan design selected will specify the funding requirement;
please refer to each plan design for specific funding requirements.
Submission guidelines
• All
offerings are subject to final underwriting review and acceptance.
Additional guidelines and policies may apply. This document is for
informational purposes only and is not intended to be all inclusive.
1. P
lease visit ibx.com/bc for maximum product offerings and underwriting guidelines specific to Blue Solutions Choice.
2. As permitted by the state and federal laws and regulations.
36
What’s not covered?
The information in this brochure represents only a partial listing of benefits
and exclusions of the plans. Benefits and exclusions may be further defined
by medical policy. The managed care plan may not cover all of your health
care expenses. Read your contract/member handbook/benefit booklet
carefully to determine which health care services are covered. If you need
more information please call 1-800-275-2583.
• Services
not medically necessary
• Services
or supplies that are experimental or investigative, except routine
costs associated with qualifying clinical trials
• Hearing
aids, hearing examinations/tests for the prescription/fitting of
hearing aids, and cochlear electromagnetic hearing devices
• Assisted fertilization techniques, such as in vitro fertilization, GIFT, and ZIFT
• Reversal
of voluntary sterilization
• Expenses
related to organ donation for nonemployee recipients
• Music
therapy, equestrian therapy, and hippotherapy
• Treatment
of sexual dysfunction not related to organic disease except for
sexual dysfunction relating to an injury
• Routine
foot care, unless medically necessary or associated with the
treatment of diabetes
• Foot
orthotics, except for orthotics and podiatric appliances required for
the prevention of complications associated with diabetes
• Cranial
prosthesis, including wigs intended to replace hair loss
• Alternative
therapies/complementary medicine such as acupuncture
• Routine
physical exams for nonpreventive purposes, such as insurance or
employment applications, college, or premarital examinations
• Immunizations
for travel or employment
• Services
or supplies payable under workers’ compensation, motor vehicle
insurance, or other legislation of similar purpose
• Cosmetic
services/supplies
• Bariatric
or obesity surgery
• Outpatient
private duty nursing
Benefits that require preapproval
Additional approval from IBC may be required before your employees may
receive certain tests, procedures, and medications. When your employees need
services that require preapproval, their primary care physician or provider
contacts the Care Management and Coordination (CMC) team and submits
information to support the request for services. The CMC team, made up
of physicians and nurses, evaluates the proposed plan of care for payment
of benefits. The CMC team will notify your employee’s physician/provider
if the services are approved for coverage. If the CMC team does not have
sufficient information or the information evaluated does not support coverage,
your employee and his or her physician/provider are notified in writing of
the decision. Employees or a provider acting on their behalf may appeal the
decision. At any time during the evaluation process or the appeal, the provider
or your employee may submit additional information to support the request.
For a list of services that require
preapproval, visit
www.ibx.com/preapproval.
37
Blue Solutions
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company,
and with Highmark Blue Shield. Independent Licensees of the Blue Cross and Blue Shield Association
17357 2014-1537 7/14