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Summary of Benefits and Coverage Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020-12/31/2020 HealthPartners:Peak $3000 Plus Silver - Peak Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-877-838-4949 or visit us at www.healthpartners.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-877-838-4949 to request a copy. Important Questions Answers Why This Matters: In-network: $3,000 Generally, you must pay all of the costs from providers up to the deductible amount before this What is the overall Individual/$6,000 Family plan begins to pay. If you have other family members on the plan, each family member must meet deductible? Out-of-network: $20,000 their own individual deductible until the total amount of deductible expenses paid by all family Individual/$40,000 Family members meets the overall family deductible. Yes. Coinsurance marked with * This plan covers some items and services even if you haven’t yet met the deductible amount. But Are there services under What You Will Pay and a copayment or coinsurance may apply. For example, this plan covers certain preventive services covered before you meet copays and benefits with no without cost-sharing and before you meet your deductible. See a list of covered preventive your deductible? charge are not subject to services at https://www.healthcare.gov/coverage/preventive-care-benefits/. deductible Are there other deductibles for specific No. You don’t have to meet deductibles for specific services. services? In-network medical/pharmacy: The out-of-pocket limit is the most you could pay in a year for covered services. If you have other What is the out-of-pocket $7,900 Individual/$15,800 Family family members in this plan, they have to meet their own out-of-pocket limits until the overall limit for this plan? There is no out-of-network out-of- family out-of-pocket limit has been met. pocket limit. Premium, balance-billed charges What is not included in (unless balanced billing is Even though you pay these expenses, they don’t count toward the out-of-pocket limit. the out-of-pocket limit? prohibited), and health care this plan doesn't cover. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. Yes. See You will pay the most if you use an out-of-network provider, and you might receive a bill from a Will you pay less if you healthpartners.com/peaknetwork provider for the difference between the provider’s charge and what your plan pays (balance use a network provider? or call 1-877-838-4949 for a list of billing). Be aware your network provider might use an out-of-network provider for some services in-network providers. (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the in-network specialist you choose without a referral. see a specialist? 1 of 6 PSBC-IE139-200101-01 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most) Primary Office Visit: $30 copay for the first three visits and 20% Primary Office Visit: 50% Each family member's first three combined coinsurance thereafter Primary care visit to treat an coinsurance office or urgent care visits are a copay. Other Convenience Care: $15 injury or illness Convenience Care: 50% services like lab, x-rays, MRI/CT scans are copay for the first three coinsurance covered at deductible/coinsurance. visits and 20% If you visit a health coinsurance thereafter care provider’s office virtuwell: No charge or clinic Each family member's first three combined $30 copay for the first office or urgent care visits are a copay. Other Specialist visit three visits and 20% 50% coinsurance services like lab, x-rays, MRI/CT scans are coinsurance thereafter covered at deductible/coinsurance. You may have to pay for services that aren’t Preventive care/screening/ preventive. Ask your provider if the services No charge 50% coinsurance immunization you need are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood 20% coinsurance 50% coinsurance None If you have a test work) Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance None Formulary Low Cost: $5 copay at retail, $15 If you need drugs to copay at mail Formulary: 50% treat your illness or Formulary High Cost: coinsurance at retail, mail Generic drugs condition $25 copay at retail, $75 not covered 30 day supply retail / 90 day supply mail order. copay at mail Non-formulary: Not covered Non-formulary drugs are not covered unless More information about Non-formulary: Not an exception is granted. prescription drug covered coverage is available at 50% coinsurance at retail, Formulary brand drugs 20% coinsurance healthpartners.com/gen mail not covered ericsadvantagerx Non-formulary brand drugs Not covered Not covered Specialty drugs are limited to drugs on the Specialty drugs 50% coinsurance Not covered specialty drug list and must be obtained from a 2 of 6 Common What You Will Pay Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most) designated vendor. Facility fee (e.g., ambulatory If you have outpatient 20% coinsurance 50% coinsurance None surgery center) surgery Physician/surgeon fees 20% coinsurance 50% coinsurance None $250 copay before $250 copay before First visit $250 copay, then deductible for the first deductible for the first one Emergency room care deductible/coinsurance. Out-of-network one visit(s) and 20% visit(s) and 20% services apply to the in-network deductible. coinsurance thereafter coinsurance thereafter If you need immediate Emergency medical Out-of-network services apply to the in- 20% coinsurance 20% coinsurance medical attention transportation network deductible. Each family member's first three combined $30 copay for the first office or urgent care visits are a copay. Other Urgent care three visits and 20% 50% coinsurance services like lab, x-rays, MRI/CT scans are coinsurance thereafter covered at deductible/coinsurance. If you have a hospital Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance None stay Physician/surgeon fees 20% coinsurance 50% coinsurance None Each family member's first three combined If you need mental $30 copay for the first office or urgent care visits are a copay. Other health, behavioral Outpatient services three visits and 20% 50% coinsurance services like lab, x-rays, MRI/CT scans are health, or substance coinsurance thereafter covered at deductible/coinsurance. use disorder services Inpatient services 20% coinsurance 50% coinsurance None Depending on the type of services, a Office visits No charge 50% coinsurance copayment, coinsurance, or deductible may apply. If you are pregnant Childbirth/delivery professional 20% coinsurance 50% coinsurance None services Childbirth/delivery facility 20% coinsurance 50% coinsurance None services Home health care 20% coinsurance 50% coinsurance 120 visit limit If you need help Rehabilitation services 20% coinsurance 50% coinsurance None recovering or have Habilitation services 20% coinsurance 50% coinsurance None other special health Skilled nursing care 20% coinsurance 50% coinsurance 120 day maximum needs Durable medical equipment 20% coinsurance 50% coinsurance None Hospice services 20% coinsurance 50% coinsurance Respite care is limited to 5 days per episode 3 of 6 Common What You Will Pay Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most) and respite care and continuous care combined are limited to 30 days. Children’s eye exam No charge 50% coinsurance None If your child needs Limited to one pair of eyeglasses (lenses and Children’s glasses 20% coinsurance Not covered dental or eye care frames) or one pair of contact lenses per year. Children’s dental check-up 20% coinsurance 50% coinsurance None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Infertility treatment Private-duty nursing Bariatric surgery Long-term care Routine eye care (Adult) Cosmetic surgery with the exception of port wine Non-emergency care when traveling outside the Routine foot care stain removal and reconstructive surgery U.S. Weight loss programs Dental care (Adult) Non-formulary drugs without a formulary Hearing aids(Adult) exception Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Your plan at 1-800-883-2177, or the MN Dept of Health at 651-201-5100 / 1-800-657-3916, or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
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