2012 Plan Design-Rochester Over 65 BENEFITS Monthly Retiree Rates Annual Deductible Annual Out-of-pocket limit Lifetime maximum United Healthcare Indemnity Group # 195643 Single over 65: $220 Single, $250; family, $750 Single $2,000, family $4,000; prescriptions per person, $2,500 None Not Applicable Out-of-Network Option None Medicare Blue Choice Group # 7630-653-4 Single over 65: None $3,400 $128.84 None Travel benefit available, 80% up to $5,000 annually $650/year for gym membership, fitness classes at any facility and qualified weight management programs MVP Preferred Gold HMO Group # A001361065 Single over 65: None $4,000 $122.60 None Travel benefit available, 70% up to $5,000 annually Free fitness center membership benefits at a participating fitness center, including use of equipment and other amenities Fitness HOSPITAL / Inpatient Care Hospital care (semi-private room), 80% coverage of Reasonable and surgery, x-rays and lab Customary (R&C); after deductible 100% coverage after $250 copayment; $250 per admission; $750 max per max 2 per year year Skilled Nursing Facility 80% coverage of R & C; after deductible (up to 120 days per benefit period) 100% days 1-20; 50% days 21-100 $0 copay days 1-20; $105 copay days 21-100 80% of R & C, after deductible $50 copay, waived if admitted; $50 copay Urgent Care $50 copay, waived if admitted; $30 copay, Urgent Care Center EMERGENCY CARE Emergency Room Emergency transportation OUTPATIENT CARE Office visit 80% of R & C, after deductible $50 per trip copay $50 per trip copay 80% of R & C,, after deductible $15 copay $ p y Outpatient Surgery Immunizations and injections 80% of R & C, after deductible 80% of R & C, after deductible $15 copay 100% Flu, Pneumonia and Hepatitus Vaccines Preventive care 80% of R & C, after deductible Periodic routine physicials 100%; $0 copay for mammograms, prostate screenings and bone mass measurement Gynecological care 80% of R & C, after deductible $0 copay for pap smears and pelvin exams $ copay, $15 p y, PCP;; $ $30 copay, p y, Specialist $0 copay $0 for pneumonia, flu and Hepatitis B; Office visit copay for allergy injections and testing $0 copay, routine physicals at PCP; $0 copay mammograms, prostate screenings and bone mass measurement (office copay may apply) $15 copay, PCP; $30 copay, Specialist X-ray, lab and diagnostic testing 80% of R & C, after deductible $15 copay, x-ray; 100% coverage, lab $30 copay for radiology and x-rays; $0 copay lab tests Home Health 80% of R & C, after deductible 100% coverage $0 copay OTHER BENEFITS Mental health MANAGED BY UNITED HEALTHCARE Outpatient 80% of R & C, after deductible Inpatient 80% of R & C, after deductible Substance abuse 40% coinsurance $30 copay 100% coverage after $250 copayment; $250 per stay; $750 max per year maximum 2 per year MANAGED BY UNITED HEALTHCARE Outpatient 80% of R & C, after deductible Inpatient 80% of R & C, after deductible Outpatient Short-term speech, physical, occupational and respiratory therapy Dental Care 80% of R & C, after deductible 50% coinsurance $30 copay 100% coverage after $250 copayment; $250 per stay; $750 max per year maximum 2 per year $15 copay $30 copay per visit Inpatient oral surgery, accidental Medicare covered dental services, $15 $300 allowance/year for preventative injury - 80% of R&C after deductible copay services Medical Supplies Prescriptions 80% coverage Up to 90-day Supply: Member pays 40% at participating pharmacy up to $3,900. Then member pays 100% until total drug cost reaches $4,550. Catastrophic coverage (Greater of 5% or $2.50/$6.30 copayment) begins once Mail Order 90-day Supply: $17.50, $4,700 OOP is met 20% - $62.50, $187.50 and 50%, $125, $250 copays. Administered through ExpressScripts (http://www.expresscripts.com) 80% coverage 30-day Supply: $8 copay generic; $35 copay preferred brand name; $90 copay non-preferred brand name, 33% for specialty drugs. $ 0 copay for generics Mail order 90 day supply: 2 x's the cost of a 30-day supply for preferred and nonpreferred brand name drugs. 33% copay for specialty drugs and $ 0 copay for generics. When the total cost of covered prescriptions reaches $2930 you will ill pay 86% ffor Ti Tier 1 drugs, 50% for Medicare-contracted brands,100% for non-Medicare contracted brands and $0 copay for Tier 5 drugs Catastrophic coverage (Greater of 5% or $2.60/$6.50 copayment) begins once $4,700 OOP is met Hearing Aids Vision None None $300 allowance every 3 years $15 copay routine eye exam once per calendar year; $60 eyewear allowance per calendar year None $30 copay eye exam; $100 annual eyewear allowance plus an eyewear discount at participating providers Chiropractic 80% coverage of R&C, after deductible, $1,500 annual limit www.myuhc.com $15 copay for manual manipulation to correct subluxation www.excellusbcbs.com $30 copay Website address 80% of R & C, after deductible 30-day Supply: Generic - $7 copay Formulary - 20% (Min-$25; Max $75) Non-Formulary - (50% Min - $50; Max $100) www.mvphealthcare.com *The above contains a brief overview of the various benefit programs and does not describe any plan, its provisions or limitations in any detail. Please refer to the benefit plan booklet for more information.