Page 53 - 2022 Large Group benefits

Important plan details
Medical
1
Family deductible deductible deductible and and out-of-pocket maximum apply when an an an an individual individual individual individual individual and and one or or or or more dependents are enrolled Once Once an an an an individual individual individual individual individual meets meets the the the the individual individual individual individual individual individual individual individual deductible deductible deductible amount claims claims for for for that that individual individual individual individual individual individual individual individual will will pay pay Once Once Once Once the the the the family family deductible deductible deductible is met claims claims for for for all individuals will will pay pay Once Once Once an an individual individual individual individual individual individual meets meets the the the the individual individual individual individual individual individual out-of-pocket out-of-pocket maximum maximum maximum benefits benefits for for for for that that individual individual individual individual individual individual are are covered
covered
in in in in in in in in full full Once Once Once the the the the family family family out-of- out-of- out-of- pocket pocket pocket maximum maximum maximum is is met benefits benefits for for all family family members are are covered
covered
in in in in in in full full Individual deductible and out-of-pocket out-of-pocket maximum maximum maximum apply when an an individual is is enrolled without dependents 2 Family deductible deductible and and out-of-pocket maximum apply when an an an an individual individual and and one one or or or or more dependents dependents are are enrolled enrolled The full family family family deductible deductible must be be be be met met by one one or or or or or several family family family family members before claims are are eligible to pay however no family family family family member member will contribute more than the the the the individual individual individual out-of-pocket out-of-pocket out-of-pocket maximum maximum maximum amount Once an an individual individual individual in in in in in in the the the the family family family family family has met met the the the the individual individual individual out-of-pocket out-of-pocket out-of-pocket maximum maximum maximum benefits for for that member member are are covered
covered
in in in in in in in in full full Benefits for for all family family family members are are covered
covered
in in in in in in in in full full once the the the the family family family out-of-pocket out-of-pocket out-of-pocket out-of-pocket maximum maximum maximum maximum is is met If an an an an individual individual is enrolled without dependents individual individual deductible deductible and and out-of-pocket out-of-pocket maximum maximum apply 3 In-network out-of-pocket out-of-pocket maximum includes copayments coinsurance and and and deductible deductible 4 Age and frequency schedules may apply 6 For For PPO plans plans visit limits are are combined in- and and and out-of-network 7 7 For For DPOS and and and POS POS plans plans a a a a a a a a a a a a a a a a referral is is required from primary care physician 8 70 day day Inpatient hospital day day limit combined for all self-referred and and and out-of-network inpatient medical maternity mental mental health serious mental illness substance abuse and detoxification services 9 Amount shown reflects the copayment copayment per per day day There is is is a a a a a a a a a a a a a a a a a maximum of of ten ten copayments per per admission Copayment waived if if readmitted within ten days of discharge for any condition 10 Amount shown reflects the copayment copayment per per day day day There is is is is a a a a a a a a a a a a a a a maximum of of of five copayments per per admission Copayment waived if readmitted within ten days of of discharge for any condition 11 Out-of-network emergency room benefits benefits are covered
at at the in-network cost-sharing level 18 To receive maximum benefits benefits benefits benefits benefits services must be be be be be be provided provided by a a a a a a a a a a a a a a a a a a a a participating provider This is is a a a a a a a a a a a a a a a a a a a a highlight of of of available benefits benefits benefits benefits benefits The benefits benefits benefits benefits benefits and and and exclusions
for in-network and and and out-of-network out-of-network care are are are not the the same All benefits benefits benefits benefits benefits are are are provided provided in in in accordance with the the group contract and and and out-of-network out-of-network benefits booklet/certificate 19 For PPO plans non-participating preferred preferred providers may may bill you for for differences between the the the the Plan allowance which is is the the the the amount amount paid by Independence and the the the the the the the actual actual charge charge of of of of the the the the the the the provider provider provider This amount amount may may be be significant Claims payments for for non-preferred professional providers (physicians) are are are are based based on on on on on the the the the the the the the lesser lesser of of of of of of the the the the the the the the Medicare Medicare Professional Allowable Payment or or or or the the the the the the the the actual actual charge charge of of of of of of the the the the the the the the provider provider provider For For covered
covered
services services that are are are are are not not recognized recognized or or or or or or reimbursed reimbursed by by Medicare Medicare Medicare payment is based based on on on on the the the the the the the the lesser lesser of of of of of of the the the the the the the the Independence applicable proprietary fee fee schedule schedule or or or or or or or the the the the the the the actual actual charge charge of of of of the the the the the the the provider provider provider For For covered
covered
services services not not not recognized recognized or or or or or or or reimbursed reimbursed by by Medicare Medicare or or or or or or or Independence’s fee fee schedule schedule the the the the the the the the payment is is based on 50 percent percent percent of of of of of of the the the the the the the the actual actual actual charge charge charge of of of of of of the the the the the the the the provider provider provider It is is important to note that all all percentages for out-of-network services services are percentage percentage of of of of of of the the the the the the the Plan allowance not the the the the the the the actual actual charge charge of of of of of of the the the the the the the provider provider provider 20 For all all plans additional copayments may apply when you you receive other services services at your providers’ office 21 Out-of-network out-of-pocket maximum includes coinsurance only 22 For routine colonoscopy for colorectal cancer screening your cost-share will vary depending on on on where you you receive service service 23 Virtual Care from a a a a a a a a a a a a a a a a a a a a a a a designated virtual virtual virtual provider provider includes telemedicine teledermatology and and and telebehavioral health services services offered through
our virtual virtual virtual virtual care care provider provider MDLive In addition Penn Medicine On Demand provides provides virtual virtual virtual virtual urgent care care services services services and and and Magellan provides provides virtual virtual telebehavioral health services Vision
5 Independence vision benefits are administered by Davis Vision
an an independent company One eye exam every two two years in-network only Prescription Drug 12 Prescription drug drug benefits are administered by FutureScripts FutureScripts an an an an an independent company providing pharmacy benefit benefit management services 13 Mail-order Mail-order coverage is is is available for for all prescription drug drug plans The FutureScripts FutureScripts Mail-order Mail-order service service is is is a a a a a a a a a a a a a a a a a a a a a a a a a a convenient and cost-effective way to to to order order order up up to to a a a a a a a a a a a a a a a a a a a a a 90-day supply of of of maintenance or or or or or or or or or long-term medication for for for delivery to to a a a a a a a a a a a a a a a a a a a a a home office or or or or or or or or or location of of of choice 14 Benefits provided for for Covered Drugs and and medicines appearing on on on the Drug Drug Formulary 15 Certain designated generic drugs are available at at at participating retail retail and and mail-order pharmacies for for reduced member cost-sharing ($3 retail/$6
mail order) after any applicable deductible 16 Out-of-network benefits benefits apply to to to prescriptions filled at at non-participating pharmacies and the the the the the the member member must pay the the the the the the full retail price for for their their prescription prescription then file a a a a a a a a a a a a a a paper claim for for for reimbursement The member member should refer to to to their their their benefits benefits booklet to to to determine the the the the the the the out-of-network coverage for their plan 17 A30-daysupplyofself-administeredspecialtydrugsisavailableexclusivelythroughtheOptumSpecialtyPharmacy Thereisnoout-of-networkcoverage † $250 per per person brand drugs only The member has the right to receive health care services without discrimination based on on on on on on race ethnicity age
mental or or or or or or physical disability genetic information color religion gender sexual orientation national origin or or or or or source of payment 2022 Large Group Plans | Independence Blue Cross 52