Verisk Analytics Comprehensive Indemnity Plan
This is a summary of benefits for your Comprehensive Indemnity plan with Horizon Blue Cross Blue Shield. Pharmacy plan deductibles, out-of-pocket maximums, copays and annual maximums do not integrate with the employer medical program.
Lifetime Maximum and Coinsurance Levels
| Benefit Highlights | Comprehensive |
|---|---|
| Lifetime Maximum | Unlimited |
| Coinsurance Levels | 80% |
Calendar Year Deductible
| Retirees retired after 1/1/2003: | |
| Individual | $350 per person |
| Family Maximum | $700 per family |
| Retirees retired prior to 1/1/1988: | |
| Individual | $100 per person |
| Family Maximum | $200 per family |
| Retirees retired 1/1/1988 to 1/1/1991: | |
| Individual | $200 per person |
| Family Maximum | $400 per family |
| Retirees retired 1/1/1991 to 1/1/2000: | |
| Individual | $200 per person |
| Family Maximum | $400 per family |
| Retirees retired 1/1/2000 to 1/1/2003: | |
| Individual | $250 per person |
| Family Maximum | $500 per family |
| Family Maximum Deductible Calculation | Individual Deductible |
Out-of-Pocket Maximum Accumulators
| Includes Plan Deductible | Yes |
| Includes Copays (deductibles) | Yes |
| Does Not Apply To:
Benefits are paid at 100% once an individual’s out-of-pocket has been reached. |
Non-compliance penalties |
Out-of-Pocket (OOP) Maximum
| Retirees retired after 1/1/2003: | |
| Individual | $2,500 per person |
| Family Maximum | $5,000 per family |
| Retirees retired prior to 1/1/1988: | |
| Individual | $1,000 per person |
| Family Maximum | $2,000 per family |
| Retirees retired 1/1/1988 to 1/1/1991: | |
| Individual | $1,000 per person |
| Family Maximum | $2,000 per family |
| Retirees retired 1/1/1991 to 1/1/2000: | |
| Individual | $1,000 per person |
| Family Maximum | $2,000 per family |
| Retirees retired 1/1/2000 to 1/1/2003: | |
| Individual | $1,250 per person |
| Family Maximum | $2,500 per family |
| Family Maximum OOP Calculation | Individual OOP |
Automated Annual Reinstatement
| Automated Annual Reinstatement | Not applicable |
Physician’s Services
| Primary Care Physician’s Office visit
Note: OB/GYN is considered a Specialist |
80% after deductible; 80% after deductible if only x-ray and/or lab services performed and billed |
| Specialty Care Physician’s Office visit Consultant and Referral Physician’s Services |
80% after deductible; 80% after deductible if only x-ray and/or lab services performed and billed |
| Surgery Performed In the Physician’s Office | 80% after deductible |
| Second Opinion Consultations (services will be provided on a voluntary basis) |
80% after deductible |
| Allergy Treatment/Injections | 100% |
| Allergy Serum (dispensed by the physician in the office) |
100% |
Preventive Care
| Routine Preventive Care for children through age 18 (including immunization) |
100% |
| Immunizations | 100% |
| Routine Preventive Care for adults from age 18 (including immunization) |
100% |
Inpatient Hospital
| Inpatient Hospital - Facility Services | 80% after deductible |
| Inpatient Hospital - Facility Services | 80% after deductible |
| Semi Private Room and Board | Limited to semi-private room negotiated rate |
| Private Room | Limited to semi-private room negotiated rate |
| Special Care Units (ICU/CCU) | Limited to ICU/CCU daily room rate |
Outpatient Facility Services
| Operating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room | 80% after deductible |
Inpatient Hospital Physician’s Visits/Consultations
| Inpatient Hospital Physician’s Visits/Consultations | 80% after deductible |
Inpatient Hospital Professional Services
| Surgeon, Radiologist, Pathologist, Anesthesiologist | 80% after deductible |
Outpatient Professional Services
| Surgeon, Radiologist, Pathologist, Anesthesiologist | 80% after deductible |
Emergency and Urgent Care Services
| Physician’s Office | 80% after deductible; 80% after deductible if only x-ray and/or lab services performed and billed |
| Hospital Emergency Room | 80% after deductible |
| Outpatient Professional services (radiology, pathology and ER physician) | 880% after deductible (if the ER facility benefit is subject to coinsurance and plan deductible) |
| Urgent Care Facility or Outpatient Facility | 80% after deductible |
| Ambulance | 80% after deductible |
Inpatient Services at Other Health Care Facilities
| Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub-Acute Facilities 120 days Skilled Nursing Facility maximum per calendar year |
80% after deductible |
Laboratory and Radiology Services (includes preadmission testing)
| Physician’s Office | 80% after deductible |
| Outpatient Hospital Facility | 80% after deductible |
| Emergency Room/Urgent Care Facility (billed by the facility as part of the ER/UC visit) | 80% after deductible (if the ER/UC facility is covered subject to plan coinsurance and deductible) |
| Independent X-ray and/or Lab Facility | 80% after deductible |
| Independent X-ray and/or Lab Facility in conjunction with an ER visit | 80% after deductible (if the ER facility is covered subject to plan coinsurance and deductible) |
Advanced Radiological Imaging (i.e. MRI’s, MRAs, CAT Scans, PET Scans, etc.)
| Inpatient Facility | 80% after deductible |
| Outpatient Facility | 80% after deductible |
| Emergency Room (billed by the facility as part of the ER visit) | 80% after deductible |
| Physician’s Office | 80% after deductible |
Note: Scans are subject to the applicable place of service coinsurance and plan deductible.
Outpatient Short-Term Rehabilitative Therapy, Cardiac Rehabilitation and Chiropractic Services
| Unlimited days combined maximum per calendar year Includes:
|
80% after deductible; 80% after deductible if only x-ray and/or lab services performed and billed. |
Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the Outpatient Short Term Rehab Therapy maximum. If multiple outpatient services are provided on the same day, they constitute one day.
Home Health Care
| Home Health Care
60 days maximum per calendar year (includes outpatient private duty nursing when approved as medically necessary) |
80% after deductible |
Hospice
| Inpatient Services | 80% after deductible |
| Outpatient Services | 80% after deductible |
Bereavement Counseling
| Services provided as part of Hospice Care | |
| Inpatient | 80% after deductible |
| Outpatient | 80% after deductible |
| Services provided by Mental Health Professional | Covered under Mental Health benefit |
Maternity Care Services
| Initial Visit to Confirm Pregnancy
Note: OB/GYN provider is considered a Specialist |
80% after deductible; 80% after deductible if only x-ray and/or lab services performed and billed. |
| All Subsequent Prenatal Visits, Postnatal Visits, and Delivery (i.e. global maternity fee) | 80% after deductible |
| Office Visits in addition to the global maternity fee when performed by an OB or Specialist | 80% after deductible; 80% after deductible if only x-ray and/or lab services performed and billed |
| Delivery – Facility (Inpatient Hospital, Birthing Center) | 80% after deductible |
Abortion
Includes elective and non-elective procedures
| Inpatient Facility | 80% after deductible |
| Outpatient Surgical Facility | 80% after deductible |
| Physician’s Office | 80% after deductible |
| Outpatient Professional Services | 80% after deductible |
| Inpatient Professional Services | 80% after deductible |
Family Planning Services
| Office Visits, Tests and Counseling | 100% |
| Surgical Sterilization Procedure for Vasectomy/Tubal Ligations (exclude reversals) | 100% |
| Inpatient Facility | 100% |
| Outpatient Facility | 100% |
| Inpatient Physician’s Services | 100% |
| Outpatient Physician’s Services | 100% |
| Physician’s Office | 100% |
Infertility Treatment
Coverage will be provided for the following services:
Services not covered include: In-vitro, GIFT, ZIFT, etc. Office Visit (Lab and Radiology Test, Counseling) |
80% after deductible; 80% after deductible if only x-ray and/or lab services performed and billed. |
| Inpatient Facility | 80% after deductible |
| Outpatient Facility | 80% after deductible |
| Physician’s Office | 80% after deductible |
Organ Transplant
Includes all medically appropriate, non-experimental transplants
| Inpatient Facility | 80% after deductible |
| Physician’s Office | 80% after deductible |
| Travel Services Maximum | $10,000 |
Durable Medical Equipment
| $50,000 maximum per calendar year | 80% after deductible |
External Prosthetic Appliances
| $1,000 maximum per calendar year | 80% after deductible |
Dental Care
Limited to charges made for a continuous course of dental treatment of an injury to sound, natural teeth
| Doctor’s Office | 80% after deductible |
| Inpatient Facility | 80% after deductible |
| Outpatient Surgical Facility | 80% after deductible |
| Physician’s Services | 80% after deductible; 80% after deductible if only x-ray and/or lab services performed and billed. |
TMJ - Surgical and Non-surgical
| Surgical and Non-surgical | 80% after deductible |
Routine Foot Disorders
Not covered, except for services associated with foot care for diabetes and peripheral vascular disease, when medically necessary.
Prescription Drugs Pharmacy Retail Drug Program 30-day supply
| Generic Push, Incentive Prescription Drug List Includes prescription vitamins; self-administered injectables; oral contraceptives and contraceptive devices |
$7 Generic drugs $25 Preferred brand-name drugs $50 Non-preferred brand-name drugs |
Mail Order Drug Program 90-day supply
| Generic Push, Incentive Prescription Drug List Includes prescription vitamins; self-administered injectables; oral contraceptives and contraceptive devices |
$14 Generic drugs $50 Preferred brand-name drugs $100 Non-preferred brand-name drugs |
Mental Health
| Inpatient | 80% after deductible |
| Outpatient | 80% after deductible |
Substance Abuse (Alcohol & Drug)
| Inpatient | 80% after deductible |
| Outpatient | 80% after deductible |
MH/SA Utilization Review & Case Management
Inpatient Management Only (FFS):
- CBH provides utilization review and case management for Inpatient Services.
Pre-Admission Certification – Continued Stay Review
Personal Health Solutions
*Horizon’s PAC/CSR is not necessary for Medicare Primary individuals
| Inpatient Pre-Admission Certification – Continued Stay Review (required for all inpatient admissions) | Mandatory: Employee is responsible for contacting Horizon Healthcare. Penalties for non-compliance:
|
This chart summarizes the benefit plan you requested; it has not been adjusted to reflect state benefit mandates. A complete description of the terms of the coverage, exclusions and limitations, including legislated benefits (if applicable); will be provided in your Certificate or Summary Plan Description.
Medical Benefit Exclusions (by way of example but not limited to):
Your plan provides coverage for medically necessary services. Your plan does not provide coverage for the following except as required by law:
- Care for health conditions that are required by state or local law to be treated in a public facility.
- Care required by state or federal law to be supplied by a public school system or school district.
- Care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably available.
- Treatment of an illness or injury which is due to war, declared or undeclared.
- Charges for which you are not obligated to pay or for which you are not billed or would not have been billed except that you were covered under this Agreement.
- Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.
- Any services and supplies for or in connection with experimental, investigational or unproven services. Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance abuse or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by the Healthplan Medical Director to be: Not demonstrated, through existing peer-reviewed, evidence-based scientific literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed; or Not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed for the proposed use; or The subject of review or approval by an Institutional Review Board for the proposed use, except as provided in the “Clinical Trials” section of “Section IV. Covered Services and Supplies;” or The subject of an ongoing phase I, II or III clinical trial, except as provided in the “Clinical Trials” section of “Section IV. Covered Services and Supplies.”
- Cosmetic Surgery and Therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance.
- The following services are excluded from coverage regardless of clinical indications: Macromastia or Gynecomastia Surgeries; Surgical treatment of varicose veins; Abdominoplasty; Panniculectomy; Rhinoplasty; Blepharoplasty; Redundant skin surgery; Removal of skin tags; Acupressure; Craniosacral/cranial therapy; Dance therapy, movement therapy; Applied kinesiology; Rolfing; Prolotherapy; and Extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.
- Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental x-rays, examinations, repairs, orthodontics, periodontics, casts, splints and services for dental malocclusion, for any condition. However, charges made for services or supplies provided for or in connection with an accidental injury to sound natural teeth are covered provided a continuous course of dental treatment is started within 6 months of the accident. Sound natural teeth are defined as natural teeth that are free of active clinical decay, have at least 50% bony support and are functional in the arch.
- Medical and surgical services to alter appearances or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a physician or under medical supervision. Non-surgical and cosmetic procedures related to bariatric surgery are not covered.
- Unless otherwise covered as a basic benefit, reports, evaluations, physical examinations, or hospitalization not required for health reasons, including but not limited to employment, insurance or government licenses, and court ordered, forensic, or custodial evaluations.
- Court ordered treatment or hospitalization, unless such treatment is otherwise covered.
- The following infertility services are excluded: Infertility drugs, In vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage.
- Reversal of male and female voluntary sterilization procedures.
- Any services, supplies, medications or drugs for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmia, and premature ejaculation.
- Medical and hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise eligible under the Agreement.
- Non-medical counseling or ancillary services, including, but not limited to Custodial Services, education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return-to-work services, work hardening programs, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning disabilities or developmental delays.
- Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including, but not limited to routine, long-term or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
- Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the “Inpatient Hospital Services," “Outpatient Facility Services,” “Home Health Services” or “Breast Reconstruction and Breast Prostheses” sections of “Section IV. Covered Services and Supplies.”
- Private hospital rooms and/or private duty nursing except as provided in the Home Health Services section of “Section IV. Covered Services and Supplies”.
- Personal or comfort items such as personal care kits provided on admission to a hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of illness or injury.
- Artificial aids, including but not limited to arch supports, elastic stockings, garter belts, corsets and dentures.
- Hearing aids, including, but not limited to semi-implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs). A hearing aid is any device that amplifies sound.
- Aids or devices that assist with non-verbal communications, including, but not limited to communication boards, pre-recorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
- Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or postcataract surgery).
- Eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.
- Treatment by acupuncture.
- All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, non-prescription drugs, and investigational and experimental drugs, except as provided in “Section IV. Covered Services and Supplies.”
- Routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary.
- Membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs.
- Genetic screening or pre-implantation genetic screening. General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
- Dental implants for any condition.
- Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the Healthplan Medical Director’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
- Blood administration for the purpose of general improvement in physical condition.
- Cosmetics, dietary supplements and health and beauty aids.
- Nutritional supplements and infant formula are not covered unless a sole source of nutrition under BCBS medical policy.
- Services for or in connection with an injury or illness arising out of, or in the course of, any employment for wage or profit.
- Telephone, e-mail & Internet consultations and telemedicine.
- Massage Therapy
