Page 12 - 2015 Advia CU Benefits & Notices
P. 12
Advia CU - MI 2015
Advia CU BCBSM PPO HRA 1500 Plan In Network Out-of-Network
Benefit Summary
Deductible and Coinsurance Maximums
Deductible $1,500 Single / $3,000 Family $3,000 Single / $6,000 Family
Coinsurance (Percentage copays) 90% most services 70% most services
Total Annual Out-of-Pocket Maximum* $2,500 Single / $5,000 Family $5,000 Single / $10,000 Family
* Includes all deductible, co-insurance and fixed dollar copays
Prescription Drugs
Generic (Tier I) - $7 copay; Preferred Brand (Tier II) - $35 copay; Brand Non-
Pharmacy (30 day supply) Formulary (Tier III) - $70 copay.
Out-of-Network Pharmacy is reimbursed 75% of the approved amount less copay.
Pharmacy or Mail Order (90 day supply) $14 Generic; $70 Preferred Brand; $140 Brand Non-Formulary
Preventive Services
Health Maintenance Exam 100% (one per calendar year) Not Covered
Annual Gynecological Exam & PAP 100% (one per calendar year) Not Covered
Prostate Specific Antigen (PSA) Screening 100% (one per calendar year) Not Covered
Mammography Screening 100% (one per calendar year) Not Covered
Expanded Women’s Preventive Care 100% (one per calendar year) Not Covered
Well-Baby and Child Care 100% (one per calendar year) Not Covered
Immunizations – pediatric & adult 100% (one per calendar year) Not Covered
Colonoscopy – screening or diagnostic 100% (one per calendar year) Not Covered
Physician Office Visits
Office visits, including Specialist visits $20 copay 70% after deductible
Emergency Medical Care
Hospital Emergency Room $75 copay per visits (waived if admitted or for an accidental injury)
Facility Based Urgent Care Center $20 copay 70% after deductible
Ambulance Services (air/ground) 90% after deductible
Diagnostic Services
Diagnostic Tests, Lab & X-Ray 90% after deductible 70% after deductible
Maternity Services
Pre and Post-natal Care 100% covered 70% after deductible
Delivery & Nursery Care 90% after deductible 70% after deductible
Hospital Care
Semi-Private Room, Inpatient physician 90% after deductible 70% after deductible
care, Hospital services and supplies
Inpatient Medical Care & Chemotherapy 90% after deductible 70% after deductible
Alternatives to Hospital Care
Skilled Nursing Care 90% after deductible 70% after deductible
Hospice Care
Surgical Services
Surgery – includes related surgical services and 90% after deductible 70% after deductible
medically necessary in or out-patient facility
charges
Voluntary Sterilization 90% after deductible 70% after deductible
Human Organ Transplants
Specified Organ Transplants 100% covered 70% after deductible
Bone Marrow & Other Transplants 90% after deductible 70% after deductible
Mental Health & Substance Abuse Treatment
In Patient Mental & Substance Abuse Treatment 90% after deductible 70% after deductible
Out Patient Mental & Substance Abuse Treatment 90% after deductible 70% after deductible
Other Services
Chiropractic Care (24 visits / year) $20 copay 70% after deductible
Outpatient Diabetes MT, DME, P&O appliances 90% after deductible 70% after deductible
O/P Occ/SP/Physical Therapy (60) 90% after deductible 70% after deductible
Allergy Testing & Therapy 100% covered 70% after deductible
Salus Group© Copyright 2014 Page | 12
Advia CU BCBSM PPO HRA 1500 Plan In Network Out-of-Network
Benefit Summary
Deductible and Coinsurance Maximums
Deductible $1,500 Single / $3,000 Family $3,000 Single / $6,000 Family
Coinsurance (Percentage copays) 90% most services 70% most services
Total Annual Out-of-Pocket Maximum* $2,500 Single / $5,000 Family $5,000 Single / $10,000 Family
* Includes all deductible, co-insurance and fixed dollar copays
Prescription Drugs
Generic (Tier I) - $7 copay; Preferred Brand (Tier II) - $35 copay; Brand Non-
Pharmacy (30 day supply) Formulary (Tier III) - $70 copay.
Out-of-Network Pharmacy is reimbursed 75% of the approved amount less copay.
Pharmacy or Mail Order (90 day supply) $14 Generic; $70 Preferred Brand; $140 Brand Non-Formulary
Preventive Services
Health Maintenance Exam 100% (one per calendar year) Not Covered
Annual Gynecological Exam & PAP 100% (one per calendar year) Not Covered
Prostate Specific Antigen (PSA) Screening 100% (one per calendar year) Not Covered
Mammography Screening 100% (one per calendar year) Not Covered
Expanded Women’s Preventive Care 100% (one per calendar year) Not Covered
Well-Baby and Child Care 100% (one per calendar year) Not Covered
Immunizations – pediatric & adult 100% (one per calendar year) Not Covered
Colonoscopy – screening or diagnostic 100% (one per calendar year) Not Covered
Physician Office Visits
Office visits, including Specialist visits $20 copay 70% after deductible
Emergency Medical Care
Hospital Emergency Room $75 copay per visits (waived if admitted or for an accidental injury)
Facility Based Urgent Care Center $20 copay 70% after deductible
Ambulance Services (air/ground) 90% after deductible
Diagnostic Services
Diagnostic Tests, Lab & X-Ray 90% after deductible 70% after deductible
Maternity Services
Pre and Post-natal Care 100% covered 70% after deductible
Delivery & Nursery Care 90% after deductible 70% after deductible
Hospital Care
Semi-Private Room, Inpatient physician 90% after deductible 70% after deductible
care, Hospital services and supplies
Inpatient Medical Care & Chemotherapy 90% after deductible 70% after deductible
Alternatives to Hospital Care
Skilled Nursing Care 90% after deductible 70% after deductible
Hospice Care
Surgical Services
Surgery – includes related surgical services and 90% after deductible 70% after deductible
medically necessary in or out-patient facility
charges
Voluntary Sterilization 90% after deductible 70% after deductible
Human Organ Transplants
Specified Organ Transplants 100% covered 70% after deductible
Bone Marrow & Other Transplants 90% after deductible 70% after deductible
Mental Health & Substance Abuse Treatment
In Patient Mental & Substance Abuse Treatment 90% after deductible 70% after deductible
Out Patient Mental & Substance Abuse Treatment 90% after deductible 70% after deductible
Other Services
Chiropractic Care (24 visits / year) $20 copay 70% after deductible
Outpatient Diabetes MT, DME, P&O appliances 90% after deductible 70% after deductible
O/P Occ/SP/Physical Therapy (60) 90% after deductible 70% after deductible
Allergy Testing & Therapy 100% covered 70% after deductible
Salus Group© Copyright 2014 Page | 12
