BCBS VHP BCBS MVP In-Network Services

In-Network Services
New BCBS VHP
Open Access Plan
FY11 BCBS
VT Freedom Plan
FY11 MVP
Health Plan
Calendar Year Deductible
Preferred Benefits 1, 2, 3 ,4, 5
You Pay $0 Individual
$0 Family
Preferred Providers 4, 5
You Pay $100 Individual
$300 Family
Copay 15 2, 4
You Pay $0 Individual
$0 Family
$0 Individual
$0 Family
$1,000 Individual
$3,000 Family
$0 Individual
$0 Family
Calendar Year Out-of-Pocket Limit
Lifetime Maximum
Outpatient Care
Office Visits with Primary Care Physician
Gynecological Preventive Office Visits
Unlimited
You Pay:
You Pay Deductible and:
You Pay:
$10 copay—excludes
diagnostic services such as lab
and x-ray (see below)
10% of allowed
$15 copay
$10 copay for two routine
annual visits with a network
provider; $20 copay each
additional visit
10% of allowed
$15 copay
Preventative Screening Mammogram
No Member Cost
$15 copay
Preventative Colorectal Screening
No Member Cost
$15 copay
Well Baby and Child Office Visits—includes routine
immunizations
No Member Cost
10% of allowed
$15 copay
Maternity Office Visits
One preferred $20 copay
covers all maternity office visits
10% of allowed
No Member Cost
Specialist Office Visits
$20 copay
10% of allowed
$15 copay
No Member Cost
10% of allowed
$15 copay
Nutritional Counseling—up to three visits; visits for the
treatment of diabetes do not count toward the threevisit limit
$20 copay
10% of allowed
$15 copay
Chiropractic—prior approval required after 12 visits
$20 copay
10% of allowed
$15 copay—requires PCP
prescription
Diagnostic Services—includes laboratory and x-rays
No Member Cost
10% of allowed
$15 copay
Emergency Care—covered when your condition meets
criteria for necessary emergency care
$50 copay
10% of allowed
$50 copay
Outpatient Surgery—prior approval may be required
$100 copay
10% of allowed
20% or $100 copay
Physical, Occupational and Speech Therapy
$20 copay
10% of allowed
$15 copay
Inpatient Care
You Pay:
You Pay Deductible and:
You Pay:
Inpatient, General Hospital—requires precertification
$250 copay
10% of allowed
$240 copay
Inpatient Care, Mental Health or Substance Abuse —
requires prior approval; combined inpatient and
outpatient deductible, annual benefit limit and lifetime
benefit limit for standard providers
$250 copay
10% of allowed
$240 copay
You Pay:
You Pay Deductible and:
You Pay:
Inpatient Skilled Nursing
$250 copay
10% of allowed
$240 copay
Inpatient Rehabilitation—requires prior approval
$250 copay
10% of allowed
$240 copay
Home Health and Hospice Care Services
No Member Cost
10% of allowed
$240 copay
Cardiac Rehabilitation—up to 36 sessions per acute
cardiac event; requires prior approval
No Member Cost
10% of allowed
$240 copay
Private Duty Nursing—up to $2,000 per member per
calendar year, requires prior approval
$20 copay
10% of allowed
Not Applicable
Other Services
You Pay:
You Pay Deductible and:
You Pay:
Ambulance—includes emergency + routine transport;
prior approval required for non-emergency transport
$50 copay
10% of allowed
No Member Cost
Medical Equipment and Supplies—prior approval may
be required
$100 individual / $300 family
deductible, then 20% of allowed
to $15,000 out-of-pocket max
10% of allowed
No Deductible - 20% copay
$20 copay—one exam a year
Not a covered benefit
$15 copay—one exam every 2 yrs.
Outpatient Mental Health and Substance Abuse
Service and Office Visits (call Magellan Health)
Home Care and Rehabilitation Services
Vision Exam
Prescription Drugs—diabetic medications are covered
like any other medication
$100 individual / $300 family deductible for retail pharmacy program
services; $1,300 individual / $2,600 two-person / $3,800 family outof-pocket maximum applies to retail and mail order pharmacy
program services; mail order deductibles waived
$100 individual
Retail Pharmacy—up to a 30-day supply; prior
approval may be required
Copays: $5 generic; $20 preferred brand; $40 non-preferred brand
Mail Order Pharmacy—up to a 90-day supply
Copays: $10 generic; $40 preferred brand; $80 non-preferred brand
Out-of-Network Services
Calendar Year Deductible
New BCBS VHP
Open Access Plan
FY11 BCBS
VT Freedom Plan
FY11 MVP
Health Plan
Standard Providers 4, 5
You Pay $500 Individual
$1,000 Family
Non-Preferred Providers 4, 5
You Pay $200 Individual
$400 Family
No Coverage
$2,500 Individual
$5,000 Family
No Coverage
Unlimited
No Coverage
You Pay Deductible and:
You Pay:
Office Visits with Primary Care Physician
30% of allowed
No Coverage
Gynecological Preventive Office Visits
30% of allowed
No Coverage
Preventative Screening Mammogram
No Member Cost
No Coverage
Preventative Colorectal Screening
30% of allowed
No Coverage
Well Baby and Child Office Visits—includes routine
immunizations
30% of allowed
No Coverage
Maternity Office Visits
30% of allowed
No Coverage
Specialist Office Visits
30% of allowed
No Coverage
Outpatient Mental Health and Substance Abuse
Service and Office Visits
30% of allowed
No Coverage
Nutritional Counseling—up to three visits; visits for the
treatment of diabetes do not count toward the threevisit limit
100% of charges
No Coverage
Chiropractic—prior approval required after 12 visits
100% of charges
No Coverage
Diagnostic Services—includes laboratory and x-rays
30% of allowed
No Coverage
Calendar Year Out-of-Pocket Limit
Lifetime Maximum
Outpatient Care
Emergency Care—covered when your condition meets
criteria for necessary emergency care
$50 copay
30% of allowed
No Coverage
Outpatient Surgery—prior approval may be required
30% of allowed
No Coverage
Physical, Occupational and Speech Therapy
30% of allowed
No Coverage
You Pay Deductible and:
You Pay:
30% of allowed
No Coverage
Inpatient Care
Inpatient, General Hospital—requires precertification
Inpatient Care, Mental Health or Substance Abuse —
requires prior approval; combined inpatient and
outpatient deductible, annual benefit limit and lifetime
benefit limit for standard providers
Home Care and Rehabilitation Services
30% of allowed
100% of charges
No Coverage
You Pay Deductible and:
You Pay:
30% of allowed
No Coverage
100% of charges
No Coverage
30% of allowed
No Coverage
Cardiac Rehabilitation—up to 36 sessions per acute
cardiac event; requires prior approval
100% of charges
No Coverage
Private Duty Nursing—up to $2,000 per member per
calendar year, requires prior approval
30% of allowed
No Coverage
You Pay Deductible and:
You Pay:
Inpatient Skilled Nursing
Inpatient Rehabilitation—requires prior approval
Home Health and Hospice Care Services
Other Services
Ambulance—includes emergency and routine
transport; prior approval required for non-emergency
transport
$50 copay
10% of allowed
Medical Equipment and Supplies
No Coverage
Vision Exam
No Coverage
Prescription Drugs—diabetic medications are covered
like any other medication
No Coverage
Retail Pharmacy—up to a 30-day supply; prior
approval may be required
No Coverage
Mail Order Pharmacy—up to a 90-day supply
No Coverage
No Coverage
Notes on the Charts
1
In-Network includes the State of Vermont and western New Hampshire Dartmouth Network. Network
Participating includes physicians, hospitals and/or providers that are participating in Blue Cross and Blue Shield
nationwide (PPO).
2
Plan does not require referral for in-network providers.
3
Inpatient Care is limited to three co-payments per family per year.
4
Deductible will accumulate January 1 through December 31 with no carry-over to the following year.
5
Federal Mental Health Parity
This information is in summary form, therefore many details are not included. For a detailed description of benefits, you
must read the appropriate Subscriber Certificate. In the event of a conflict between this summary and the Subscriber
Certificate, the Subscriber Certificate will prevail.
The out-of-pocket maximum does not apply to Mental Health and Substance Abuse treatment.
In-patient hospitalization and hospital-based surgery must receive Pre-admission Review or Admission Review for all
hospital admissions. If you do not call for Managed Benefits review, you may get $1,000 less in-patient benefits. This
penalty is charged for each occurrence, and it applies, in addition, to Plan deductibles, including the standard benefits
[out-of-network] deductibles in the Vermont Health Partnership Plan.
VHP Open Access Procedures that Require Prior Approval
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Orthotics/prosthetics
Polysomnography (sleep studies)
Chondrocyte transplants
Home infusion therapy
Private duty nursing
Transplants
TENS units/neuromuscular stimulators
UPPP/somnoplasty
Services by an out-of-network provider
Durable Medical Equipment (over $1,000)
Chiropractic care after 12 visits in a calendar year
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Dental surgery (oral surgery, trauma, orthognathic
surgery)
Plastic or cosmetic surgery (e.g., abdominoplasty,
lipectomy, blepharoplasty, breast reconstruction,
otoplasty, panniculectomy, rhinoplasty or
septorhinoplasty)
Radiology special procedures (MRI, MRA, MRS,
PET scans)
Continuous Passive Motion (CPM) equipment
Rehabilitation (cardiac/pulmonary/inpatient
rehabilitation facility)
Coverage Examples
Again, the new VHP Open Access provides the same coverage as the current VHP plan except that it is enhanced with
access to a worldwide network. In the examples below we compare coverage under the new VHP Open Access plan with
the current VFP and MVP plans.
Employee One has single coverage. She visits her Primary Care Physician (PCP) twice a year, takes a generic blood
pressure medication and had an Emergency Room visit for a sports injury.
New VHP Open Access: $10 copay per PCP visit; $50 copay per ER visit; deductible and copay for prescription.**
Old VFP Plan: Deductible plus 10% of the allowed for each PCP visit; deductible and 10% of the allowed for each ER
visit; same deductible and copay as VHP Open Access for the prescription.
Old MVP Plan: $15 per PCP visit; $50 copay for each ER visit; same deductible and copay as VHP Open Access for
the prescription.
Employee Two has family coverage. She has chronic back pain and sees her chiropractor monthly. Following diagnostic
lab work and x-rays, her spouse had outpatient surgery. Her young daughter had three visits to the PCP and filled three
prescriptions for antibiotics.
New VHP Open Access: 12 chiropractic visits annually with $20 copays; no cost for lab and x-rays; outpatient
surgery $100 copay; $10 copay for PCP visits; deductible and copay for prescriptions.**
Old VFP Plan: 12 chiropractic visits annually at 10% of allowed; 10% of allowed for lab and x-rays; outpatient surgery
20% or $100 copay; deductible plus 10% of allowed for each PCP visit; same deductible and copay for prescriptions.
Old MVP Plan: chiropractic visit $15 with PCP prescription; $15 copay for lab and x-rays; outpatient surgery 20% or
$100 copay; $15 copay for PCP visits same deductible and copay for prescriptions.
Employee Three has family coverage and his child needs surgery. After discussing options with the PCP, he and his
spouse have decided to take the child to Boston for the surgery.
New VHP Open Access: Select physicians and/or hospitals that belong to the national BCBS PPO network and pay
the same as if you were being treated by FAHC; $250 copay for inpatient hospital care (with prior approval).
Old VFP Plan: Select physicians and/or hospitals that belong to the national BCBS PPO network and pay the same
as if you were being treated by FAHC; pay deductible and 10% of allowed for inpatient hospital care (prior approval).
Old MVP Plan: Subject to the permission process for out-of-network services; $240 for inpatient hospital care.
Employee Four has family coverage and her child needs dental surgery.
New VHP Open Access: With prior approval, certain dental surgery procedures are covered as out-patient surgery.**
Old VFP Plan: This procedure would be covered at a lesser percentage through Delta Dental.
Old MVP Plan: This procedure would be covered at a lesser percentage through Delta Dental.
** This represents no change from the current Vermont Healthcare Partnership plan coverage.