Coverage Period: 01/01/2014 - 12/31/2014
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
In-Network
Provider
$0 copay
$0 copay
$0 copay
$0 copay
Out-of-Network
Provider
20% coinsurance
20% coinsurance
20% coinsurance
Same as In-Network
Bone Mass Measurement Exam
Breast Screening/Mammography
Cardia Rehab/Intensive Cardiac Rehab
Cardiovascular Disease Testing
Cardiovascular Disease Therapy
$0 copay
$0 copay
$0 copay
$15 copay
$0 copay
$0 copay
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
Cervical Cancer Screening
$0 copay
20% coinsurance
Chemotherapy Drugs
Chemotherapy Services
Chiropractic Services
Colorectal Screenings
Complex Radiology
Depression Screening
Diabetes Screening
Diabetes Supplies and Self-monitoring
Training
$0 copay
$0 copay
$10 copay
$0 copay
$0 copay
$0 copay
$0 copay
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
$0 copay
20% coinsurance
Dialysis
$0 copay
Services You May Need
Abdominal Screening
Allergy Immunotherapy
Allergy Testing
Ambulance
Annual Wellness Visit/Routine Physical
Examination
QM87- Drexel
Coverage for: Group | Plan Type: PPO
Limitations & Exceptions
none
none
none
Non-emergent requires prior authorization.
You are covered up to 1 exam every year.
none
none
none
none
none
You pay $0 for each additional Pap Smear and Pelvic
Exam up to 1 Pap Smear(s) and Pelvic Exam(s) every
two years.
Prior authorization is required for certain Part B
injectable drugs when administered in a physician's
office or outpatient setting.
none
none
none
none
none
none
none
If dialysis is performed at the PCP or Specialist office
Same as In-Network setting, only the dialysis copayment will apply.
Coverage Period: 01/01/2014 - 12/31/2014
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Durable
Medical
Equipme
Services
You
May Need
In-Network
Provider
Disease Management
Durable Medical Equipment
EKG Screening
$0 copay
$0 copay
Emergency Care
$40 copay
Fitness Center
Glaucoma Screening
Hearing Services-Hearing Aids
Hearing Services-Medicare Covered
Hearing Exam
Hearing Services-Non-Medicare Covered
Home Health Care
Hospice
Human Immunodeficiency Virus (HIV)
Screening
Immunizations (influenza vaccine,
Hepatitis B vaccine, Pneumonia vaccine
$0 copay
Non-covered
Services
QM87- Drexel
Out-of-Network
Provider
Limitations & Exceptions
Refer to your Evidence of Coverage for Benefit
Information.
none
Covered annually with routine physical exam.
N/A
20% coinsurance
20% coinsurance
Services performed
in the U.S. will be
covered same as (innetwork)
Copay waived if admitted
Receive a basic fitness membership to a participating
facility.
N/A
20% coinsurance
none
N/A
Covered up to $500 for hearing aids every three years
$15 copay
20% coinsurance
Non-covered Service N/A
$0 copay
20% coinsurance
Same as In-Network
none
none
none
Covered in full at a Medicare Certified Hospice.
$0 copay
20% coinsurance
none
$0 copay
$0 [visits 1-90]
20% coinsurance
none
20% coinsurance
You are covered for unlimited days each benefit period
190 Day Lifetime Maximum includes Mental Health
and Substance Abuse Treatment received in a
Medicare Approved Mental Health Facility.
Inpatient Hospital Care
Inpatient Mental Health/Substance Abuse
Facility Days
Coverage for: Group | Plan Type: PPO
$0 [visits 1-90]
20% coinsurance
Coverage Period: 01/01/2014 - 12/31/2014
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Durable
Medical
Equipme
Services
You
May Need
Medical Nutrition Therapy
Medicare Part B Drugs
Obesity Screening/Therapy
Outpatient Diagnostic Procedures/Lab
Outpatient Mental-Psychiatric Services
Outpatient Occupational Therapy
Outpatient Physical Therapy
Outpatient Speech Language
Outpatient Substance Abuse
Outpatient Surgery-Ambulatory Surgical
Center
Outpatient Surgery-Outpatient Hospital
Partial Hospitalization Includes Intensive
Outpatient Programs
In-Network
Provider
Out-of-Network
Provider
Limitations & Exceptions
$0 copay
$0 copay
$0 copay
$0 copay
$15 copay
$15 copay
$15 copay
$15 copay
$15 copay
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
Up to 6 nutrition counseling sessions yearly with an
in-network doctor or registered dietician.
none
none
none
none
none
none
none
none
$0 copay
$0 copay
20% coinsurance
20% coinsurance
none
none
$15 copay
$15 copay
$10 copay
$0 copay
$0 copay
$15 copay
$0 copay
$0 copay
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
none
none
none
none
none
none
none
none
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
none
none
Covers up to six sessions
No prior hospitalization required.
none
Podiatry Services
Primary Care Office Visit
Prostate Cancer Screenings
Prosthetics
Pulmonary Rehab
Radiation Therapy
Routine Radiology
Screening Sexually Transmitted Infections
Counseling
$0 copay
Screening/Counseling Alcohol Misuse
$0 copay
Services Kidney Disease Education
$0 copay
Skilled Nursing Facility
$0 [visits 1-100]
Smoking Cessation
$0 copay
QM87- Drexel
Coverage for: Group | Plan Type: PPO
Coverage Period: 01/01/2014 - 12/31/2014
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
In-Network
Provider
Durable
Medical
Equipmen
Services
You
May Need
Smoking Cessation Program
Specialist Office Visit
Urgent Care
Vision Care-Medicare Covered
Vision Care-Non-Medicare Covered
Vision Care-Medicare Covered Eye Wear
Weight Management
Out-of-Network
Provider
Coverage for: Group | Plan Type: PPO
Limitations & Exceptions
Up to $200 will be covered as long as there is proof of
N/A
enrollment.
$15 copay
20% coinsurance
none
Services performed in
the U.S. will be
covered same as (in$15 copay
See below for additional details.
network)
$15 copay
20% coinsurance
none
Non-covered services N/A
none
You are covered for one pair of eyeglasses or contact
lenses after each cataract surgery.
Access to plan -approved weight manangement
programs.
N/A
IN Network Maximum Out-of-Pocket (MOOP)
Combined IN/Out of Network Pocket Maximum
Out of Network Deductable
$6,700
$10,000
$250.00
* If there is a separate and distinct office visit evaluation and service, a copay will apply.
* The copayment amount depends on the provider type.
* Worldwide Coverage available. Amounts you pay for Emergency and Urgently needed care services
received outside the U.S. do not count toward your maximum out-of-pocket amount (MOOP)
* Normal plan rules apply. Please refer to your Evidence of Coverage for more information.
* You are covered for each Medicare covered urgently needed care visit. If seeking services from
a PCP or Specialist normal cost-share will apply. Outside the U.S. you pay $65.00.
QM87- Drexel