POAH 2017 APR Final_opt 2

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POAH COMMUNITIES
BCBSKC Medical Renewal Benefits Comparison
May 1, 2017
MEDICAL Blue Cross Blue Shield Blue Cross Blue Shield
Carrier Website
Plan Type & Network PPO Base Plan Preferred Care Blue PPO Buy Up Plan Preferred Care Blue
In Network Out of Network In Network Out of Network
Annual Deductible (calendar year) (1)
Individual
Family
Coinsurance
Member Pays 20% 40% 10% 30%
Maximum Out-of-pocket (calendar year) (2)
Individual $3,600 $7,200 $2,000 $4,000
Family $7,200 $14,400 $4,000 $8,000
Lifetime Maximum
Per Individual
Preventive Care*
Adult and Child Routine Physicals Covered at 100% Ded. Then 40% Covered at 100% Ded. Then 30%
Routine Mammogram Covered at 100% Ded. Then 40% Covered at 100% Ded. Then 30%
Routine Colonoscopy Covered at 100% Ded. Then 40% Covered at 100% Ded. Then 30%
Routine Lab and X-ray Covered at 100% Ded. Then 40% Covered at 100% Ded. Then 30%
Routine Vision Exam Covered at 100% Ded. Then 40% Covered at 100% Ded. Then 30%
Physician Services
Office Visits $30 PCMH/$35 Copay Ded. Then 40% $25 PCMH/$30 Copay Ded. Then 30%
Diagnostic (Non-routine) Tests and Labs Ded. Then 20% Ded. Then 40% Ded. Then 10% Ded. Then 30%
Urgent Care $35 Copay Ded. Then 40% $30 Copay Ded. Then 30%
Hospital Services
Inpatient Care Ded. Then 20% Ded. Then 40% Ded. Then 10% Ded. Then 30%
Outpatient Surgery Ded. Then 20% Ded. Then 40% Ded. Then 10% Ded. Then 30%
Outpatient Nonsurgical Care Ded. Then 20% Ded. Then 40% Ded. Then 10% Ded. Then 30%
Emergency room $150 Copay $150 Copay
Additional Services
Ambulance Ded. Then 20% Ded. Then 20% Ded. Then 10% Ded. Then 10%
Chiropractic Ded. Then 20% Ded. Then 40% Ded. Then 10% Ded. Then 30%
Durable Medical Equipment ($5,000 Cal Year Max) Ded. Then 20% Ded. Then 40% Ded. Then 10% Ded. Then 30%
Occupational & Physical Therapy
(Combined 40 visits per calendar year)
Ded. Then 20% Ded. Then 40% Ded. Then 10% Ded. Then 30%
Speech & Hearing Therapy
(Combined 20 visits per calendar year ) Ded. Then 20% Ded. Then 40% Ded. Then 10% Ded. Then 30%
Dependent Age Limit
Prescription Drugs
Deductible
Level 1 $15 $15
Level 2 $35 $35
Level 3 $55 $55
Level 4 N/A
Mail Order (90 Day Supply) 3x Copay Not Covered 3x Copay Not Covered
$1,250 $625
$2,500 $1,250
Unlimited Unlimited
To age 26 To age 26
Copay then 50% Copay then 50%
N/A
Note: This is only a summary. Please refer to the booklet/certificate for specific details. If a conflict arises, the booklet/certificate will govern in all cases.
(1) Family deductible is embedded. An individual covered in a family will not pay more than the individual deductible.
(2) PPO out-of-pocket amount includes coinsurance, deductible and all copays.
*Copay covers office visit charge and lab and x-ray (excluding MRI, CT, ultra sound and allergy testing that is performed and billed in a network physician's office other services are subject to deductible and coinsurance)
** Inpatient Services at non-participating hospitals inside the service area are limited to $200 max per day, 30 days per year. Outpatient services also at non-participating facilities are limited to $200 per calendar year.
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