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Benefit Changes for the New Plan Year 2011/2012
Plan Year Maximum:
Removal of the Plan Year benefit maximum of $500,000, there is now no limit.
Lifetime Maximum:
Removal of the Lifetime benefit maximum of $1,000,000, there is now no limit.
Office Visit Co-Pay:
The Plan has created an Office Visit Co-Pay. In-Network Office Visits with a BlueChoice primary-care physician
will be subject to a $25 Office Visit Co-Pay. In-Network Office Visits with a specialist physician will be subject to a
$50 Office Visit Co-Pay. An Office Visit Co-pay only applies to the Office Visit charge; it does not count towards
additional services received during the Office Visit. An Office Visit Co-Pay does not count towards the Plan
Year Deductible or Co-Insurance Out-of-Pocket Limits.
Diabetic Brand-Name Rx Co-Pay:
Added a $10 co-payment for Brand-Name Diabetic prescriptions. Generic Diabetic prescriptions will still be
covered with a $0 co-payment. The $50 Brand-Name Deductible (see below) does not apply to Brand-Name
diabetic prescriptions.
3-Step Therapy for Statins:
Added a 3-Step Therapy for the Statin drug class (primarily used to treat high cholesterol), would require
member to first fail on a generic Statin before allowing coverage for Lipitor, if member then fails on Lipitor only
then would coverage for Crestor be covered. Any member already taking Lipitor or Crestor will not have to
meet these new criteria.
Plan Year Brand-Name Rx Deductible:
The Plan has created a Plan Year Brand Name Rx Deductible. This deductible is $50 per plan year per member
and is only applied to any amount of the cost of a brand name Rx prescription in excess of the Brand Name
Co-Pay of $45. It may take one or more brand name prescriptions over one or more months to meet the Plan
Year Brand Name Rx Deductible of $50.
Plan Year Deductibles:
The Plan has added a Plan Year Out-of-Network deductible. The deductible phase of the Plan’s health
coverage occurs with the first dollar of allowable medical claims. In-Network medical claims are subject to a
$500 deductible per individual (this is limited to $1,500 for a family of 3 or more). Out-of-Network medical claims
are subject to a $1,000 deductible (this is limited to $3,000 for a family of 3 or more). Any Plan Year deductible
amounts paid will count towards both the In-Network and Out-of-Network Plan Year deductibles.
Co-Insurance & Co-Insurance Out-of-Pocket Limits:
The Plan has increased the Co-Insurance Out-of-Pocket Limits. The Co-Insurance phase of the Plan’s health
coverage occurs after a member has fulfilled their Plan Year Deductible. During the Co-Insurance phase, the
member pays a percentage of each medical claim up to the Co-Insurance Out-of-Pocket Limit (Rx Claims are
not subject to Co-Insurance). The Plan has 3 Co-Insurance Limits:
 When using In-Network BlueChoice providers a member will pay 30% of medical claims incurred after
the fulfillment of their Plan Year Deductible up to an Out-of-Pocket Limit of $3,000 per plan year (this is
limited to $9,000 per plan year for families of 3 or more).
 When using In-Network BlueTraditional providers a member will pay 40% of medical claims incurred
after the fulfil ment of their Plan Year Deductible up to an Out-of-Pocket Limit of $4,000 per plan year
(this is limited to $12,000 per plan year for families of 3 or more).
 When using Out-of-Network providers a member wil pay 40% of the allowable charges of medical
claims incurred after the fulfillment of their Plan Year Deductible up to an Out-of-Pocket Limit of $4,000
per plan year (this is limited to $12,000 per plan year for families of 3 or more). Additionally when using
an Out-of-Network provider a member will be responsible for amounts billed above the Plan’s allowable
charge. It therefore financially benefits a member to use In-Network providers whenever possible.
Once a member has met their Plan Year Deductible and Co-Insurance Out-of-Pocket Limit the Plan pays 100% of allowable with no upper limit. Dependent Eligibility:
The maximum age for dependent eligibility is now up to age 26. A dependent is now deemed eligible whether
or not they live with member and/or are married, even if the member no longer claims them as a dependent
on their personal tax return. If a dependent has access to their own health benefit plan (where they are
considered as the member/subscriber) then they are not eligible to join the Plan.
Pre-Existing Conditions Limitation:
There is no-longer a pre-existing conditions limitation period for covered individuals up to age 19.
Occupational Therapy, Speech Therapy & Physical Therapy:
Created a plan year visit maximum of 60 visits. Whereby, the 60 visit maximum is the combined coverage
maximum for all 3 types of services, and is still subject to plan year deductible and co-insurance.
Chiropractic Medical Services:
The plan year maximum of $500 is removed and replaced with a 10 visit maximum per plan year, and is still
subject to plan year deductible and co-insurance. This does not affect the Plan’s benefit provision for
Chiropractic Manipulative Services which continue to have a $500 play year maximum and be subject to the
Plan Year Deductible and Co-Insurance (although the Co-Insurance for Manipulative Services is not applied to
the Co-Insurance Out-of-Pocket Limit)
Durable Medical Equipment:
The plan year maximum of $5,000 is removed, but is stil subject to plan year deductible and co-insurance.
Out-of-Network Emergency Room Claims:
Out-of-Network Emergency Room claims for emergency services wil be paid as an In-Network claim. Out-of-
Network Emergency Room services of a non-emergency nature will be paid as an Out-of-Network claim. Both
scenarios are still subject to plan year deductible and co-insurance.
Hospice Coverage:
The plan lifetime maximum of $5,000 is removed, but is stil subject to plan year deductible and co-insurance.
Private Duty Nursing:
The plan year maximum of $20,000 is removed, and replaced with an 85 visit plan year maximum, but is still
subject to plan year deductible and co-insurance.
Skilled Nursing Facility:
The covered day’s maximum is reduced from 100 days to 30 days per plan year, but is still subject to plan year
deductible and co-insurance.
Mental Health Care:
Pre-certification for outpatient care now required. Now covering claims for Mental Health Care from Licensed
Professional Counselors (LPC’s), still subject to plan year deductible and co-insurance.
Preventive Care:
The following are just some of the Preventive Care benefits which are now covered in ful (100%) including the
cost of the office-visit:
Colorectal Cancer Screening (Colonoscopy) For a current and complete list of covered Preventive Care benefits offered through the Plan, please refer to those services which have a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force (USPSTF), which you can find on the web here  www.ahrq.gov.

Source: http://www.opehw1.com/documents/Benefit%20Changes%20for%202011-2012%20PY.pdf

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