[SECTION XXVIII]
NORTH SHORE-LIJ CARECONNECT INSURANCE COMPANY, INC.
VALUE PLATINUM ACCESS SCHEDULE OF BENEFITS
COST-SHARING
Deductible
•
Individual
•
Family
Out-of-Pocket Limit
• Individual
• Family
Participating Provider
Member Responsibility for CostSharing
Non-Participating Provider
Member Responsibility for CostSharing
$0
$0
Non-Participating Provider services are
not Covered except as required for
emergency care.
$3,000
$6,000
[Deductibles, Coinsurance
and Copayments that make
up Your Out-of-Pocket Limit
accumulate on a calendar
year ending on December 31
of each year]
OFFICE VISITS
Primary Care Office Visits (or
Home Visits)
Specialist Office Visits (or
Home Visits)
Participating Provider Member
Responsibility for Cost-Sharing
$20 Copayment
Non-Participating Provider Member
Responsibility for Cost-Sharing
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Limits
$30 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
See Benefit For
Description
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 1
PREVENTIVE CARE
•
Well Child Visits and
Immunizations*
Participating Provider Member
Responsibility for Cost-Sharing
Covered in full
Non-Participating Provider Member
Responsibility for Cost-Sharing
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Adult Annual Physical
Examinations*
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Adult Immunizations*
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Routine Gynecological
Services/Well Woman
Exams*
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Mammography
Screenings*
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
[Sterilization
Procedures for
Women*
Covered in full
[Vasectomy
$20 Copayment (PCP)/$30 Copayment
(Specialist)
•
•
•
Bone Density Testing*
•
Screening for Prostate
Cancer
Limits
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost]
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost]
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 2
•
All other preventive
services required by
USPSTF and HRSA.
•
*When preventive
services are not
provided in
accordance with the
comprehensive
guidelines supported
by USPSTF and
HRSA.
EMERGENCY CARE
Pre-Hospital Emergency
Medical Services (Ambulance
Services)
Non-Emergency Ambulance
Services
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Use Cost Sharing for appropriate service
Not Covered and You Pay the Full Cost
(Primary Care Office Visit; Specialist Office
Visit; Diagnostic Radiology Services;
Laboratory Procedures & Diagnostic
Testing)
Participating Provider Member
Responsibility for Cost-Sharing
$100 Copayment
Non-Participating Provider Member
Responsibility for Cost-Sharing
$100 Copayment
Limits
$100 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
$250 Copayment
$250 Copayment.
See Benefit For
Description
$75 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
See Benefit For
Description
Preauthorization Required
Emergency Department
Copayment waived if Hospital
admission
Urgent Care Center
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 3
PROFESSIONAL SERVICES
AND OUTPATIENT CARE
Acupuncture
Participating Provider Member
Responsibility for Cost-Sharing
$30 Copayment
Non-Participating Provider Member
Responsibility for Cost-Sharing
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Limits
See Benefit For
Description
Preauthorization Required
Advanced Imaging Services
• Performed in a
Freestanding
Radiology Facility or
Office Setting
• Performed as
Outpatient Hospital
Services
$100 Copayment
$100 Copayment
Preauthorization Required
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Allergy Testing & Treatment
•
•
Performed in a PCP
Office
Performed in a
Specialist Office
Ambulatory Surgical Center
Facility Fee
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
$30 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
10% Coinsurance
See Benefit For
Description
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefits For
Description
Preauthorization Required
Anesthesia Services (all
settings)
10% Coinsurance
Preauthorization Required
Autologous Blood Banking
10% Coinsurance
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 4
Cardiac & Pulmonary
Rehabilitation
• Performed in a
Specialist Office
See Benefits For
Description
$30 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Performed as
Outpatient Hospital
Services
$30 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Performed as
Inpatient Hospital
Services
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Preauthorization Required
Chemotherapy
• Performed in a PCP
Office
•
Performed in a
Specialist Office
•
Performed as
Outpatient Hospital
Services
Chiropractic Services
Clinical Trials
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
$30 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Preauthorization Required
$30 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Preauthorization Required
Use Cost Sharing for Appropriate Service
Non-Participating Provider Services Are
(Primary Care Office Visit; Specialist Office Not Covered and You Pay the Full Cost
Visit; Surgery; Laboratory & Diagnostic
Procedures)
Preauthorization Required
See Benefit For
Description
See Benefit For
Description
See Benefit For
Description
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 5
Diagnostic Testing
• Performed in a PCP
Office
$40 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Performed in a
Specialist Office
$40 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Performed as
Outpatient Hospital
Services
$40 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Preauthorization Required
Dialysis
• Performed in a PCP
Office
•
•
Performed in a
Freestanding Center
or Specialist Office
Setting
$20 Copayment
$30 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Dialysis
Performed by
Non-Participating
Providers is
limited to 10
visits per
calendar year
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Performed as
Outpatient Hospital
Services
10% Coinsurance
Preauthorization Required
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 6
Habilitation Services
(Physical Therapy,
Occupational Therapy or
Speech Therapy)
$30 Copayment
Home Health Care
$30 Copayment
Infertility Services
Infusion Therapy
• Performed in a PCP
Office
•
•
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
60 visits per
condition, per
lifetime
combined
therapies
40 Visits per
Plan Year
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Preauthorization Required
Preauthorization Required
Use Cost Sharing for Appropriate Service
(Office Visit; Diagnostic Radiology
Services; Surgery; Laboratory &
Diagnostic Procedures)
Preauthorization Required
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Performed in
Specialist Office
$30 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Performed as
Outpatient Hospital
Services
10% Coinsurance
$30 Copayment
•
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Home Infusion
Therapy
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Home infusion
counts towards
home health
care visit limits
Preauthorization Required
Inpatient Medical Visits
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Laboratory Procedures
• Performed in a PCP
Office
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
See Benefit For
Description
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 7
•
•
Performed in a
Freestanding
Laboratory Facility or
Specialist Office
Performed as
Outpatient Hospital
Services
Maternity & Newborn Care
• Prenatal Care
•
Inpatient Hospital
Services and Birthing
Center
•
Physician and Midwife
Services for Delivery
•
Breast Pump
•
Postnatal Care
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Covered in full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Preauthorization Required
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
One (1) Home
Care Visit is
Covered at no
Cost-Sharing if
mother is
discharged from
Hospital early
Covered in Full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Covered in Full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Covered for
duration of
breast feeding
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Covered in full
Preauthorization Required
Outpatient Hospital Surgery
Facility Charge
10% Coinsurance
Preauthorization Required
Preadmission Testing
10% Coinsurance
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 8
Diagnostic Radiology
Services
• Performed in a PCP
Office
•
•
Performed in a
Freestanding
Radiology Facility or
Specialist Office
Performed as
Outpatient Hospital
Services
Therapeutic Radiology
Services
• Performed in a
Freestanding
Radiology Facility or
Specialist Office
•
Performed as
Outpatient Hospital
Services
Rehabilitation Services
(Physical Therapy,
Occupational Therapy or
Speech Therapy)
See Benefit For
Description
$40 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
$40 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
$40 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
$40 Copayment
$40 Copayment
Preauthorization Required
$30 Copayment
Preauthorization Required
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
60 visits per
condition, per
lifetime
combined
therapies.
Speech and
physical therapy
are only Covered
following a
Hospital stay or
surgery.
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 9
Second Opinions on the
Diagnosis of Cancer, Surgery
& Other
$30 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Second opinions on diagnosis of cancer
are Covered at Participating CostSharing for Non-Participating Specialist
Surgical Services (Including
Oral Surgery; Reconstructive
Breast Surgery; Other
Reconstructive & Corrective
Surgery; Transplants; &
Interruption of Pregnancy)
• Inpatient Hospital
Surgery
See Benefit For
Description
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Outpatient Hospital
Surgery
•
Surgery Performed at
an Ambulatory
Surgical Center
10% Coinsurance
Office Surgery
10% Coinsurance
•
Preauthorization Required
All transplants
must be
performed at
designated
Facilities
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Telemedicine Program
Covered In Full
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
ADDITIONAL SERVICES,
EQUIPMENT & DEVICES
Participating Provider Member
Responsibility for Cost-Sharing
Non-Participating Provider Member
Responsibility for Cost-Sharing
Limits
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 10
ABA Treatment for Autism
Spectrum Disorder
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Preauthorization Required
Assistive Communication
Devices for Autism Spectrum
Disorder
Diabetic Equipment, Supplies
& Self-Management
Education
• Diabetic Equipment,
Supplies and Insulin
(30-Day Supply)
•
Diabetic Education
$20 Copayment
Preauthorization Required
See Benefit For
Description
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Preauthorization Required
Durable Medical Equipment &
Braces
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Single Purchase
Once Every
three (3) Years
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
One (1) Per Ear
Per Time
Covered
Preauthorization Required for Items
Above $500
External Hearing Aids
10% Coinsurance
Preauthorization Required
Cochlear Implants
10% Coinsurance
Preauthorization Required
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 11
Hospice Care
• Inpatient
•
Outpatient
10% Coinsurance
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Preauthorization Required
210 Days per
Plan Year
Five (5) Visits for
Family
Bereavement
Counseling
Medical Supplies
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Prosthetic Devices
• External
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
10% Coinsurance
Preauthorization Required
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
INPATIENT SERVICES &
FACILITIES
Inpatient Hospital for a
Continuous Confinement
(Including an Inpatient Stay
for Mastectomy Care, Cardiac
& Pulmonary Rehabilitation, &
End of Life Care)
Participating Provider Member
Responsibility for Cost-Sharing
10% Coinsurance
Non-Participating Provider Member
Responsibility for Cost-Sharing
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost.
Limits
Observation Stay
10% Coinsurance
Skilled Nursing Facility
(Includes Cardiac &
Pulmonary Rehabilitation)
10% Coinsurance
Preauthorization Required
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
200 Days Per
Plan Year
•
Internal
One (1)
prosthetic
device, per limb,
per lifetime
Unlimited
See Benefit For
Description
See Benefit For
Description
Preauthorization Required. However,
Preauthorization is Not Required for
Emergency Admissions.
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 12
Inpatient Rehabilitation
Services (Physical, Speech &
Occupational therapy)
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
60 Consecutive
Days Per
Condition, Per
Lifetime
Participating Provider Member
Responsibility for Cost-Sharing
Non-Participating Provider Member
Responsibility for Cost-Sharing
Limits
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
See Benefit For
Description
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Unlimited
Participating Provider Member
Responsibility for Cost-Sharing
Non-Participating Provider Member
Responsibility for Cost-Sharing
Limits
Retail Pharmacy
30 Day Supply
Tier 1
$0 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Tier 2
$50 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
MENTAL HEALTH &
SUBSTANCE USE
DISORDER SERVICES
Inpatient Mental Health Care
(for a continuous confinement
when in a Hospital)
Outpatient Mental Health
Care (Including Partial
Hospitalization & Intensive
Outpatient Program Services)
Inpatient Substance Use
Services (for a continuous
confinement when in a
Hospital)
Outpatient Substance Use
Services
PRESCRIPTION DRUGS
10% Coinsurance
Preauthorization Required
Preauthorization Required. However,
Preauthorization is Not Required for
Emergency Admissions.
Covered in Full
10% Coinsurance
Preauthorization Required. However,
Preauthorization is Not Required for
Emergency Admissions.
Covered in Full
See Benefit For
Description
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 13
Tier 3
50% Coinsurance up to max $500
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Up to a 90 Day Supply For
Maintenance Drugs
Tier 1
$0 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Tier 2
$150 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Tier 3
50% Coinsurance up to max $1,500
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Mail Order Pharmacy
Up to a 90 Day Supply
Tier 1
$0 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Tier 2
$125 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Tier 3
50% Coinsurance up to max $1,250
Enteral Formulas
$0 Copayment
Preauthorization Required
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
WELLNESS BENEFITS
Participating Provider Member
Responsibility for Cost-Sharing
Up to $200 per six (6) month period; up to
an additional $100 per six (6) month
period for Spouse
Non-Participating Provider Member
Responsibility for Cost-Sharing
Up to $200 per six (6) month period; up
to an additional $100 per six (6) month
period for Spouse
Gym Reimbursement
See Benefit For
Description
See Benefit For
Description
See Benefit For
Description
Up to $200 per
six (6) month
period; up to an
additional $100
per six (6) month
period for
Spouse
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 14
PEDIATRIC DENTAL
&VISION CARE
Pediatric Dental Care
Participating Provider Member
Responsibility for Cost-Sharing
Non-Participating Provider Member
Responsibility for Cost-Sharing
•
Preventive Dental
Care
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Routine Dental Care
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Major Dental
(Endodontics,
Prosthodontics &
Periodontics
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Orthodontics
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
Limits
One (1) Dental
Exam &
Cleaning Per six
(6)-Month Period
Orthodontics & Major Dental Require
Preauthorization.
Pediatric Vision Care
•
Exams
$20 Copayment
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Lenses & Frames
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
•
Contact Lenses
10% Coinsurance
Non-Participating Provider Services Are
Not Covered and You Pay the Full Cost
One (1) Exam
Per 12-Month
Period; One (1)
Prescribed
Lenses &
Frames in a 12Month Period
NSLIJGO/NSLIJ NS VP Acc
NSLIJCC 2016 SOB NS VP acc 15