HomeMy WebLinkAboutPR 23352: BLUE CROSS MEDICARE ADVANTAGE RENEWAL EFFECTIVE 1/1/2024 E, g
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INTEROFFICE MEMORANDUM
Human Resources Department
Date: September 19, 2023
To: Ronald Burton, City Manager
Trameka Williams, Director of Human Resources
From: Elizabeth Diaz, Assistant Director of Human Resource
RE: Blue Cross Medicare Advantage Renewal Effective 1/01/2024
P. R. No. 23352 - A Resolution Authorizing The City Manager To Execute Contracts
Between Its Third-Party Administrator(Blue Cross and Blue Shield of Texas, Inc.)For
The City of Port Arthur Blue Cross Medicare Advantage PPO and Prescription Drug
Plan for its Existing Medicare Eligible Retirees and/or Their Medicare Eligible
Dependent(s)
Nature of the request:
The City of Port Arthur provides access to their Medicare eligible retirees and/or their Medicare
eligible dependent(s) to the Blue Cross Medicare Advantage PPO and Prescription Drug Plan for
major medical health insurance coverage, including prescription drug coverage. Medicare eligible
retirees and their Medicare eligible dependent(s)transitioned to the Blue Cross Medicare Advantage
PPO and Prescription Drug Plan effective on 11/1/2016.
Staff Analysis, Considerations:
The City of Port Arthur has a Preferred Provider Organization (PPO) insurance format which
provides participants freedom of choice in the selection of health care providers. This format has
been deemed most beneficial for plan participants and most compatible with our organizational
culture.
The upcoming 1/1/2024 renewal has presented a 3% increase over last year's renewal. As per the
attached, all aspects of the plan are renewing as current other than the mandated change by CMS.
There are approximately 87 Medicare eligible retirees and/or Medicare dependents on the plan.
P.R.No. 23352
09.14.2022--evd
Staff views the health insurance benefit as an earned as well as deserved benefit for its city retirees
and will continue to strive to provide the best health plan available at the best price to all of its plan
participants. The only change is the standard in Phase 2: Initial Coverage Limit on the prescription
drug plan,it's noted in red on the exhibit. All other benefits stay the same.
No change in the current benefit levels as follows:
• $0 Annual Deductible
• Maximum Out-of-Pocket$1,500
• Level Copays
• SilverSneakers Program(i.e., YMCA,Curves,World Gym,etc.)
• Hearing Aid Benefits
• Incentives totaling$100/per year for Wellness Benefits
It is recommended that the City continue to share the premium cost with the Medicare eligible
retiree. Medicare eligible retirees are required to pay 50% of the proposed monthly premium cost
and/or their Medicare eligible dependent(s) are required to pay 100%of their premium cost. The City
currently has approximately 57 Medicare eligible retiree participants for whom the City has a shared
premium cost.
Recommendation: It is recommended that the City Council adopt P. R. No. 23352 authorizing
the renewal of the Blue Cross Medicare Advantage PPO and Prescription Drug Plan for its
Medicare eligible retirees and/or their Medicare eligible dependent(s) and authorizing the City
Manager to execute all documents necessary for its 1/01/2024-12/31/2024 plan year.
Bucket Considerations: Approval of P.R.No. 23352 will have a budgetary impact of$80,000
which is available in the FY 2023-2024 Health Insurance Fund(614-11-025-5127-00-00-00).
"Remember we are here to serve the Citizens of Port Arthur
P.R. No. 23352
09/18/2023—evd
RESOLUTION NO.
A RESOLUTION AUTHORIZING THE CITY MANAGER
TO EXECUTE CONTRACTS BETWEEN ITS THIRD PARTY ADMINISTRATOR
(BLUE CROSS AND BLUE SHIELD OF TEXAS, INC.) FOR THE CITY OF PORT
ARTHUR'S BLUE CROSS MEDICARE ADVANTAGE PPO AND PRESCRIPTION
DRUG PLAN FOR ITS MEDICARE ELIGIBLE RETIREES AND/OR MEDICARE
ELIGIBLE DEPENDENT(S),AND AUTHORIZING THE CITY MANAGER TO
EXECUTE ALL DOCUMENTS
FUND NO: 614-11-025-5127-00-00-00 (HEALTH INSURANCE FUND)
WHEREAS, the City Council of the City of Port Arthur deems it necessary and
appropriate to provide major medical health care benefits along with a prescription drug
benefit to its Medicare eligible retirees and/or Medicare eligible dependent(s) effective
01/01/2024; and,
WHEREAS, inasmuch as the upcoming year's renewal reflects a 3% increase over
last year's renewal, the City recommends acceptance of the BC/BS Medicare Advantage
PPO Prescription and Drug Plan renewal as presented with minor positive changes in its
current benefits levels, as fully delineated in Exhibit"A"; and,
WHEREAS, Blue Cross and Blue Shield of Texas will take the necessary actions
to comply with the Centers for Medicare and Medicaid Services' (CMS) requirements to
continue the provisions enacted annually,and do hereby affirm to continue to make changes
to its existing health plan policies or products required to comply with the law; and,
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY PORT ARTHUR, TEXAS:
Section 1. That, the City Council of the City of Port Arthur hereby accepts the
contract proposal from Blue Cross and Blue Shield of Texas, Inc.,to renew the Blue Cross
Medicare Advantage PPO and Prescription Drug Plan for its Medicare eligible retirees and/
P.R.No. 23352
09/18/2023 evd
Page 2 of 3
or their Medicare eligible dependent(s) for the 01/01/2024 plan year which includes a
renewal rate of 3% over last year's renewal.
Section 2. That, the City will be billed 50% of the proposed premium cost of
$218.60/month for all impacted Medicare eligible retirees (approximately 57 Medicare
retiree participants). The City's monthly premium cost which equates to $109.30/per
member/month, for all impacted Medicare eligible retirees for the 01/01/2024 —
12/31/2024 plan year as is fully delineated in Exhibit"B".
Section 3. That, the City Manager is hereby further authorized to execute the
necessary contracts and other documents on behalf of the City of Port Arthur subject to the
approval of the City Attorney, and to make payment of necessary premium and
administrative charges to bind coverage subject to the terms and conditions of the contract
for Third Party Administrator(Blue Cross and Blue Shield of Texas,Inc.)and the Contracts
for Insurance attached hereto as required to effectuate said services.
Section 4. That,a copy of the caption of this Resolution be spread upon the minutes
of the City Council.
READ, ADOPTED, AND APPROVED this day of
AD, 2023, at a Regular Meeting of the City Council of the City of Port Arthur, by the
following vote: AYES: Mayor
Councilmembers:
NOES:
Thurman Bartie, Mayor
Ft
P.R.No. 23352
09/18/2023 evd
Page 3 of 3
ATTEST:
Sherri Bellard, City Secretary
APPROVED AS TO FORM:
Valecia Tizeno, City Attorney
APPROVED FOR ADMINISTRATION:
Trameka Williams, Director of Human Resources
Ron Burton, City Manager
APPROVED AS TO AVAILABILI FUNDS:
Kandy Daniel, terim Director of Finance
EXHIBIT "A"
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1 0 Blue Cross Group Options
0 tions
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Blue Cross Group Medicare Advantage
Account Information
Account Name _ City of Port Arthur
1 Account State TX
Plan T e MAPD Traditional PPO
CMS Contract-PBP H1666 801
Benefit Effective Date 1/1/2024
Plan Name Traditional PPO
Premium —
Benefit Design In-Network Out-of-Network
Annual Medical Deductible' $0 $250
Annual Combined Medical Deductibl ' n/a
Annual Out of-Pocket Maximum e $1,500
Annual Combined Out-of-Pocket Maximum $2,250 $2,250
Referral R-.uirement None
Inpatient Hos•ital
Inpatient Hospital-Acute $100/day(days 1-6) — 40%
$0/day(days 7+)
Inpatient Mental Health Care $100/day(days 1-6)
Limited to 190 lifetime days $0/day(days 7+) 40%
Skilled Nursing Facility
Benefit Period 1-20 days ,
No prior hosh,_, $0 copay 40%
Benefit Period 21-100 days2 $100/per day 40%
1 Lu tiled to 100 day - . :ae Bereft Period'
Home Health/Hospice
Home Health $0 copay 40%
Hospice(Medicare-covered)3 Covered by Original Medicare at a Medicare certified hospice
Emergent&Urgent Care
Emergency Care(Worldwide)
e.same cc $50 copay $50 copay
Urgently Needed Services(Worldwide)
Cost share weir ad,t sorartso w r ,13 i 3 days for the same condition $40 copay $40 copay
1 Virtual Urgent Care-Visit through rtMDLrve $25 copay(through MDLive only) Not Applicable
Ambulance Services(Ground) 20% 20%
Ambulance Services(Air) 20% 20%
Health Care Professional Services
Primary Care Physician Services $30 copay 40%
Physician Specialist Services
$50 copay 40%
I Other Health Care Professional Services $30 copay/PCP °
$50 copay/SPC 40/o
Medicare-Covered Specialist Visits
Chiropractic Services(Medicare-covered)
1 Coverage is,mated to manual maopuiatton of thy sp,re to gar,ac:ter $10 copay 40%
suhht,atron
Podiatry Services(Medicare-covered)
treatment for diabetes-related no re $5 copay 40%
- -u merit for foot injuries or diseases.
J Acupuncture(Medicare-covered)
2 visits in 90 days No more than 20 $0 copay $0 copay
e0 annually.
Dental Services(Medicare-covered)
c.ui e,a,,,T.:-.ra: pa e c.,r moorgency or compl,cated dental 20% 40%
I pro e J re
'Eye Exam(Medicare-covered)
crFc condition. $0 copay 40%
Eyewear(Medicare-covered)
.:o.erage for correcnoe'eases t hare cataract surgery to implant an $0 copay 40%
,ntraor:t'ar'ens-ore pair of eyeglasses with standard frames or one set of
Hearing Exam(Medicare-covered)
Co,erege tor d agoo rc heating and halance era-talons to determine d you 25% 40%
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j 0 Blue Cross Group Medicare Options
1 Blue Cross Group Medicare Advantage
Outpatient Rehabilitation Services
Cardiac Rehabilitation Services
1 Maximum of 2 one-hour sessions per day up to 36 sessions in 36 weeks
Limit to 36 per year $20 copay 40%
Medicare-covered Intensive Cardiac Rehab up to 72 sessions per years
Pulmonary Rehabilitation Services $20 copay 40%
Limit to 36 sessions per year
Supervised Exercise Therapy for PAD $20 copay 40%
Up to 36 sessions in 12 weeks
Occupational Therapy Services $20 copay --_ 40%
Physical Therapy and Speech Language Pathology Services $20 copay 40%
I Outpatient Mental Health Services
Mental Health Specialty Services- Individual Visit $20 copay 40%
Mental Health Specialty Services-Group Visit $20 copay 40%
Virtual Mental Health Specialty Services-Visit through MDLive $20 copay(through MDLive only) Not Apglicable . .
Psychiatric Services- .rvidual Visit $20 copay 40%
Psychiatric Services-Group Visit $20 copay 40%
Virtual Psychiatric Services-Visit through Motive $20 copay(through MDLive only) Not Applicable
Partial Hospitalization $30 co.a 40%
Outpatient Substance Abuse ServicesI —
Outpatient Substance Abuse: Individual Visit $40 copay 40%
Outpatient Substance Abuse:Group Visit $40 copay 40%
Opioid Services $0 co•a $0 co•a
Outpatient Diagnostic/Therapeutic Radiation Services
Lab Services $20 copay 40%
Diagnostic Procedures $10 copay 40%
Therapeutic Radiology $60 copay 40%
1 Diagnostic Radiology Services/X-Ray $30 copay 40%
Advanced Imaging(MRI,MRA,CT Scan,PET) $50 co.a 40%
Other Outpatient Services
Outpatient Observation $0 copay $0 copay
Outpatient Hospital Services $100 copay _ 40%
I Ambulatory Surgical Center(ASC)Services $100 copay _ 40%
OP Blood Services-Coverage begins with the first pint of blood $0 copay $0 copay
End-Stage Renal Disease/Dialysis Services _ 10% 40%
Kidney Disease Education Services $0 Co•- $0 Copay
DME,Prosthetics,Diabetic Supplies — —
Durable Medical Equipment(DME) 10% 40%
Prosthetics/Orthotics _ 10% 40%
Medical Supplies 10% 40%
I Diabetes Supplies and Services-Preferred Testing Supplies' _J _ 0% 40%
Diabetes Supplies and Services-Non Preferred Testing Supplies 20% 40%
Diabetes Supplies and Services-All other supplies 20% 40%
1 Therapeutic Shoes and Inserts
Limit to 1 pair of diabetic shoes per year.Limit to 2 pans of inserts per year for 20% 40%
custom fitted shoes.Limit to 3 pairs of inserts per year for off the shelf shoes
Medicare Preventive Services
I Medicare-covered Preventive Services $0 Co.- $0 Co.a
Medicare Part B Rx Drugs
Medicare Part B Rx Drugs:Chemotherapy/Radiation 20% 40%
-- ----------
Medicare Part B Rx Drugs:Other 20% 40%
1 Home Infusion Therapy Administration $0 copay $0 copay
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Medicare d Blue Cross GroupOptions-
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Blue Cross Group Medicare Advantage
Supplemental Benefits
Routine Dental—_
Preventive&Diagnostic
I
x exams - ay each year Not covered Not covered
- --- —
Basic Restorative Not covered Not covered
-surgical extractions.dental pain relief
Major Restorative
— Example.Surgical tooth extractions.root canals includes crowns and Not covered Not covered --_-_—
denhne
Dental Deductible/Waiting Periods n/a
Dental Annual Calendar Maximum
Con! n-network a : ..sk allowance on supplemental n/a
1 Routine Vision 1 srve dental ser vices Hach rear
--- -- --------
Routine Eye Exam Not Covered Not Covered
- =:--h year
I Eyewear Allowance J Not Covered Not Covered—
EyewearAllowance Benefit Period n/a
Routine Hearing _
Routine Hearing Exam $10 copay 40%
1 roes_.: :.Haring exam each year
Hearing Aids Allowance $1,000 Allowance
Benefit Per Ear or Both Ears Both Ears
I Hearing Aid Allowance Benefit Period 36 months
Other Supplemental Benefits
Annual Physical Exam $0 copay $0 Copay
Routine Podiatry Services Not Covered Not Covered
J Routine Chiropractic Services Not Covered _ Not Covered
Routine Acupuncture Not Covered Not Covered
Private Duty Nursing Not Covered Not Covered
Over-the-Counter Rx Allowance Not Covered Not Applicable v1t'
(Provided by Conve, :d:onsJ ,, .i
Post-Discharge Meal Benefit Not Covered Not Applicable s i
(Provided by Moms'. .A
Non-Emergency Transportation Services Not Covered Not Applicable I
(Provided by Modivca,e Solutions LLC)
I Wellness/Clinical Pro.rams
Fitness Program
Included Not Applicable
_':;sake:
Member Rewards Program Up to$100 per year Not Applicable 111
(Pi ovrded by Healthmine) I
NurseLine Included Not Applicable
BIue365® Included Not Applicable
Intensive Case Management Included Not Applicable
I Complex Care Management Programse Included Not Applicable
Transplants Management Program Included Not Applicable
Preferred Diabetic Supply Program Included Not Applicable
Tru Hearing Aid Discount Program Included I Not Applicable _1
In-home assessments(Signify Health) Included Not Applicable
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Blue Cross Group Medicare Advantage
Footnotes
' Deductible:
Only applicable to coinsurance,not copay.Deductible counts toward out of pocket maximum.Deductible does not apply to Medicare Preventive
1 Service,Ambulance Services,ER,and Urgent Care Services. _
2 Skilled Nursing Facility-The member cost sharing applies to covered benefits incurred during a member's inpatient stay.A benefit period begins
the day you go into a hospital or skilled nursing facility.The benefit period ends when you haven't received any inpatient hospital care(or skilled
care in a SNF)for 60 days in a row.If you go into a hospital or a skilled nursing facility after one benefit period has ended,a new benefit period
begins. There is no limit to the number of benefit periods.
7 Hospice-When you enroll in a Medicare-certified hospice program,your hospice services and your Part A and Part B services related to your
4 Diabetes:
This footnote cell left blank due to non-applicability
3 Continuous Glucose Monitoring(CGM)products obtained through the pharmacy will be subject to prior authorization.
s Complex Care Management Programs include:Alcohol and substance abuse disorders,Anxiety and panic disorders,Asthma/chronic obstructive
pulmonary disease,Cancer,Congestive heart failure,Coronary artery disease,Depression,Diabetes,Hypertension,Schizophrenia,other
psychotic disorders and ESRD(End Stage Renal Disease)
HMO plan in New Mexico,HMO and HMO-POS plans in Illinois,and PPO plans in Illinois,Montana,and New Mexico are provided by Health
Care Service Corporation,a Mutual Legal Reserve Company(HCSC).HMO plan in Illinois provided by Illinois Blue Cross Blue Shield Insurance
Company(ILBCBSIC).HMO Special Needs Plan and PPO Special Needs Plan in New Mexico provided by HCSC.HMO,PPO,and Dual Care
HMO Special Needs plans in Texas provided by HCSC Insurance Services Company(HISC).HMO and PPO plans in Texas provided by GHS
Insurance Company(GHSIC).All HMO and PPO employer/union group plans provided by HCSC.HMO plan in Oklahoma provided by GHS
Health Maintenance Organization,Inc.d/b/a BlueLincs HMO(BlueLincs).PPO plan in Oklahoma provided by GHS Insurance Company(GHSIC).
HCSC,ILBCBSIC,HISC,GHSIC,and BlueLincs are Independent Licensees of the Blue Cross and Blue Shield Association.ILBCBSIC,GHSIC
and BlueLincs are Medicare Advantage organizations with a Medicare contract.HCSC is a Medicare Advantage organization with a Medicare
contract and a contract with the New Mexico Medicaid program.HISC is a Medicare Advantage organization with a Medicare contract and a
contract with the Texas Medicaid program.Enrollment in these plans depends on contract renewal.
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' x t1 Blue Cross Group Medicare Options
Blue Cross Group Medtcare Advantage •
Account Name City of Port Arthur Phase 1:Deductible
Account State TX
Plan Name Traditional PPO $0
Benefit Effective Date 1/1/2024
Fo.CMS Contract H1666 Phase 2:Initial Coverage Limit(ICL)
PBP 801 1Semi Custom The followi t shares will a $5,030
fmantel Drug Premium'
Na n9 c°s ppy up to the ICL amount:
Premium' Retail Pharmacy Mall Order Pharmacy
30-day supply 60-day supply 90-day supply 30-day supply 60-day supply 90-day supply
Preferred Standard Preferred Standard Preferred Standard Preferred Standard Preferred Standard Preferred Standard
71 Tier 1:Preferred Generic SO $5 $0 $10 $0 $15 S0 $5 $0 $10 $0 $15
Tier 2:Generic $6 $11 $12 $22 $18 $33 $6 $11 $12 $22 $18 $33
Tier 3:Preferred Brand $39 S44 $78 $88 $117 $132 $39 $44 $78 $88 $117 $132
Tier 4:Non-Preferred Drug $85 $95 $170 $190 $255 $285 $85 $95 $170 $190 S255 $285
Tier 5:Specialty 33%. 33%. 33%. 33%. 33%. 33%. 33%. 33%. 33% 33%. 33%. 33%.
I
Coverage Gap Tiers 1 though 4 The following cost shares will apply for the Coverage Gap until member reaches the eta
Defined Standard Tiers 5 TrOOP amount of. (Reference Out-of-Pocket Maximum)
1 Members will pay 25%.of the cos • • -
on Generic Drugs and 25%.of the 30-day supply 60-day supply 90-day supply 30-day supply 60-day supply 90-day supply
cost on Brand Neme Drugs for all
defined standard tiers. Preferred Standard Preferred Standard Preferred Standard Preferred Standard Preferred Standard Preferred Standard
Tier 1:Preferred Generic SO $5 $0 $10 s0 $15 $0 $5 $0 $10 $0 $15
Tier 2:Generic $6 $11 $12 $22 $18 $33 $6 $11 $12 $22 $18 $33
Tier 3:Preferred Brand $39 $44 $78 $88 $117 $132 $39 $44 $78 $88 S117 $132
i Tier 4:Non-Preferred Drug. $85 $95 $170 $190 $255 $285 $85 $95 $170 $190 $255 $285
Tier 5:Specially 25%. 25%. 25% 25%. 25%. 25%. 25% 25%. 25%. 25%. 25%. 25%.
Phase 4:Catastrophic
The following cost shares will apply for the Catastrophic Phase after you meet this
TrOOP threshold: Na
Member share of the cost fora covered drug wll be either coinsurance or (Reference Out-of-Pocket Maximum)
copeyment the greater of the amounts listed below:
MI Percentage of the total cost,or
Na Ccpayment for generic(including brand drugs treated as generic).or
eta Copeyment for all other drugs
Maximum Out-of-Pocket
When member reaches the maximum out-of-pocket $1,500
limit,cost shares will no longer apply.
Notes
'Rates are per member per month for persons who have Medicare as primary coverage.
•Areas in red indicate amounts required by the federal government to all 2024 Medicare Part D program and are not subject to negotiation.
i •Al cost-sharing presumes elgible prescriptions filed at a network pharmacy or our mail-order vendor.
•The formulary is reviewed and approved annually by the Centers for Medicare 8 Medicaid Services(CMS),but is subject to change as maintenance updates are made
throughout the year.
•Prescription drug plans provided by HCSC Insurance Services Company(HISC),an Independent Licensee of the Blue Cross and Blue Shield Association.A Medicare-
approved Part D sponsor.Enrolment in HISC's plans depends on contract renewal.
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1 :.; V Blue Cross Group Medicare Options
1 Blue Cross Group Medicare Advantage
Account Information
Account Name City of Port Arthur
Account State TX
Plan T e MAPD Traditional PPO
CMS Contract-PBP H1666 l 801
Benefit Effective Date 1/1/2023
Plan Name Traditional PPO
--
Premium
ri
1 Benefit Design In-Network Out-of-Network
Annual Medical Deductible' $0 $250
Annual Combined Medical Deductible' n/a
I Annual Out-of-Pocket Maximum $1,500 $2,250
Annual Combined Out-of-Pocket Maximum $2,250
Referral R-.uirement None
Inpatient Hos.itai
Inpatient Hospital-Acute $100/day(days 1-6) — 40%.
$0/day(days 7+)
Inpatient Mental Health Care $100/day(days 1-6) 40%.
Limited to 190lifetime days $0/day(days 7+)
, iSkilled Nursing Facility
Benefit Period 1-20 days $0 copay gook.
No prior hospitalization required _
Benefit Period 21-100 days2
$100/per day 40%.
Limited to 100 days per Medicare Benefit Period'
Home Health I Hospice
Home Health $0 copay 40%.
f
Hospice(Medicare-covered)3 Covered by Original Medicare at a Medicare certified hospice
I Emergent&Urgent Care
Emergency Care(Worldwide)
Cost sham waived if admitted within 3 days for the same condition $50 copay $50 copay
Urgently Needed Services(Worldwide) • !
Cost share waived if admitted within 3 days for the same condition. $40 copay $40 copay
Virtual Urgent Care-visit through MDLive $25 copay(through MDLive only) Not Applicable
Ambulance Services(Ground) 20%. 20%.
Ambulance Services(Air) 20%. 20%.
Health Care Professional Services
Primary Care Physician Services $30 copay 40%.
Physician Specialist Services $50 copay 40%.
Other Health Care Professional Services $30 copay/PCP 40%.
$50 copay/SPC
Medicare-Covered Specialist Visits
Chiropractic Services(Medicare-covered)
j Coverage is limited to manual manipulation of the spate to correct for $10 copay 40%.
subluxation.
Podiatry Services(Medicare-covered)
Coverage is limited to foot exams or treatment for diabetes-related nerve $5 copay 40%.
damage or medically necessary treatment for foot injuries or diseases.
-------- ----_.---`-----
Acupuncture(Medicare-covered)
Cc, r,;12 visits in 90 days No more than 20 $0 copay $0 copay
aaw .ad annually
Dental Services(Medicare-covered)
i r,,. patient hospital care for emergency or complicated dental 20%. 40%.
Eye Exam(Medicare covered) $0 copay 40/0 o
.
arras limited to specific condition.
'Eyewear(Medicare-covered)
i Coverage for conectrve lenses if you have cataract surgery to implant an $0 copay 40%.
intraocular lens-one pair of eyeglasses with standard frames or one set of
contact lenses
Hearing Exam(Medicare-covered)
Coverage lot diagnostic hearing and balance evaluations to determine if you 25%. 40%.
ineed medical treatment.
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1 0 V Blue Cross Group Medicare Options'
- Blue Cross Group Medicare Advantage
iOutpatient Rehabilitation Services
Cardiac Rehabilitation Services
Maximum of 2 one-hour sessions per day up to 36 sessions in 36 weeks. $20 Copay 40%.
Limit to 36 per year
I Medical e, we Cardiac Rehab up to 72 sessions per years
Pulmonary Rehabilitation Services $20 copay 40%.
Limit to.,t, -per year
Supervised Exercise Therapy for PAD
4 DI $20 copay 40%.
Occupational Therapy Services $20 copay 40%.
Physical Therapy and Speech Language Pathology Services $20 co.. 40%.
Outpatient Mental Health Services
1 Mental Health Specialty Services- Individual Visit $20 copay 40%
Mental Health Specialty Services-Group Visit $20 copay 40%
Virtual Mental Health Specialty Services- ;it through MDLive $20 copay(through MDLive only) Not Applicable
Psychiatric Services-r,:,; .. $20 copay 40%.
Psychiatric Services-Group Visit $20 copay I _40%
Virtual Psychiatric Services-Visit through MDLive $20 copay(through MDLive only) Not Applicable
Partial Hospitalization $30 co•a 40%.
Outpatient Substance Abuse Services
Outpatient Substance Abuse: Individual Visit $40 copay 40%.
Outpatient Substance Abuse:Group Visit $40 copay ^_ 40%.
Opioid Services $0 co.a $0 co.a
Outpatient Diagnostic/Therapeutic Radiation Services
Lab Services $20 copay 40%.
Diagnostic Procedures $10 copay 40%.
Therapeutic Radiology _ - o
Pe 9Y _ $60 copay 40/o
Diagnostic Radiology Services/X-Ray $30 copay 40%.
Advanced Imaging(MRI,MRA,CT Scan,PET) $50 co.a 40%.
Other Outpatient Services
Outpatient Observation
_ $0 copay -------- $0 copay
I Outpatient Hospital Services $100 copay 40%.
Ambulatory Surgical Center(ASC)Services $100 copay 40%.
OP Blood Services- hist pint of blood $0 copay 1 $0 copay
End-Stage Renal Disease/Dialysis Services 10%. 40%.
'Kidney Disease Education Services $0 Copay $0 Copay
DME,Prosthetics,Diabetic Supplies
I Durable Medical Equipment(DME) 10% 40%.
Prosthetics/Orthotics 10%. 40%.
Medical Supplies 10%. I 40%.
Diabetes Supplies and Services-Preferred Testing Supplies' 0%, 40%.
20%. 40%.
•Diabetes Supplies and Services-Non Preferred Testing Supplies
I rDiabetes Supplies and Services-VI other supplies 20%. 40%.
Therapeutic Shoes and Inserts
ii Limit 10 2 pans of inserts per rear for 20%. 40%.
{ Medicare Preventive Services
J) Medicare-covered Preventive Services $0 Co.a $0 Co.a
Medicare Part B Rx Drugs
Medicare Part B Rx Drugs:Chemotherapy/Radiation '' 20%. 40%.
1 Medicare Part B Rx Drugs:Other - 20%. 40%.
$0 �
Home Infusion Therapy Administration $0 copay copay
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1 Blue Cross Group Medicare Advantage
1 Su••lemental Benefits
Routine Dental
Preventive&Diagnostic
— ^ Not covered Not covered
icy each year
Basic Restorative
Example.cavil., con-surgical extractions.dental pain relief Not covered Not Covered
Major Restorative
1 Example.Surgical tooth extractions root canals includes crowns and Not covered Not covered
dentures
Dental Deductible/Waiting Periods n/a
Dental Annual Calendar Maximum
Combined in-network and out-of-network allowance on supplemental n/a
comprehensive dental services each year
Routine Wslon°- — — ----_—--— -_-.---
Routine Eye Exam Not Covered Not Covered
1 routine eye exam each year
I — Eyewear Allowance Not Covered Not Covered
Eyewear Allowance Benefit Period n/a
Routine Hearing —
Routine Hearing Exam $10 copay 40%.
I routine hearing exam each year
Hearing Aids Allowance $1,000 Allowance
Cowls '.vork e. • • '-network allowance
Benefit per Ear or Combined Combined
Hearing Aid Allowance Benefit Period 36 months
1 Other Supplemental Benefits
Annual Physical Exam $0 copay $0 Co a
Routine Podiatry Services —_ _ Not Covered Not Covered
Routine Chiropractic Services Not Covered Not Covered
.]
Routine Acupuncture Not Covered Not Covered
Private Duty Nursing _ Not Covered _ Not Covered
Over-the-Counter Rx Allowance
I
(Provided by C ;lions) Not Covered Not Applicable
Post-Discharge Meal Benefit Not Covered Not Applicable HI
(Provider' -- .
Non-Emergency Transportation Services Not Covered Not Applicable
(Provided by',l, ...are Solutions LL C i
Wellness/Clinical Programs
i Fitness Program Included Not Applicable
Member Rewards Program Up to$100 per year Not Applicable
f ,-
�NurseLine Included Not Applicable
BIue365Ox
;n
Included Not Applicable
Intensive Case Management Included Not Applicable
J
Complex Care Management Programs6 Included Not Applicable
Transplants Management Program Included Not Applicable
i Preferred Diabetic Supply Program Included iNot Applicable
Tru Hearing Aid Discount Program Included Not Applicable
t In-home assessments(Signify Health) Included I- Not Applicable
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Blue Cross Group Medicare Advantage
Footnotes
1 Deductible:
Only applicable to coinsurance,not copay.Deductible counts toward out of pocket maximum.Deductible does not apply to Medicare Preventive
Service,Ambulance Services,ER,and Urgent Care Services.
2 Skilled Nursing Facility-The member cost sharing applies to covered benefits incurred during a member's inpatient stay.A benefit period begins
the day you go into a hospital or skilled nursing facility.The benefit period ends when you haven't received any inpatient hospital care(or skilled
care in a SNF)for 60 days in a row.If you go into a hospital or a skilled nursing facility after one benefit period has ended,a new benefit period
yy begins. There is no limit to the number of benefit periods.
@ 3 Hospice-When you enroll in a Medicare-certified hospice program,your hospice services and your Part A and Part B services related to your
f4 Diabetes:
This footnote cell left blank due to non-applicability
5 Continuous Glucose Monitoring(CGM)products obtained through the pharmacy will be subject to prior authorization.
5 Complex Care Management Programs include:Alcohol and substance abuse disorders,Anxiety and panic disorders,Asthma/chronic obstructive
pulmonary disease,Cancer,Congestive heart failure,Coronary artery disease,Depression,Diabetes,Hypertension,Schizophrenia,other
psychotic disorders and ESRD(End Stage Renal Disease)
7 Amounts in are determined by CMS.
HMO plan in New Mexico,HMO and HMO-POS plans in Illinois,and PPO plans in Illinois,Montana,and New Mexico are provided by Health
Care Service Corporation,a Mutual Legal Reserve Company(HCSC).HMO plan in Illinois provided by Illinois Blue Cross Blue Shield Insurance
Company(ILBCBSIC).HMO Special Needs Plan and PPO Special Needs Plan in New Mexico provided by HCSC.HMO,PPO,and Dual Care
HMO Special Needs plans in Texas provided by HCSC Insurance Services Company(HISC).HMO and PPO plans in Texas provided by GHS
Insurance Company(GHSIC).All HMO and PPO employer/union group plans provided by HCSC.HMO plan in Oklahoma provided by GHS
Health Maintenance Organization,Inc.d/b/a BlueLincs HMO(BlueLincs).PPO plan in Oklahoma provided by GHS Insurance Company(GHSIC).
HCSC,ILBCBSIC,HISC,GHSIC,and BlueLincs are Independent Licensees of the Blue Cross and Blue Shield Association.ILBCBSIC,GHSIC
and BlueLincs are Medicare Advantage organizations with a Medicare contract.HCSC is a Medicare Advantage organization with a Medicare
contract and a contract with the New Mexico Medicaid program.HISC is a Medicare Advantage organization with a Medicare contract and a
contract with the Texas Medicaid program.Enrollment in these plans depends on contract renewal.
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1DI(J Blue Cross Group Medicare Options
Blue Cross Group Medicare Advantage
Account Name City of Port Arthur
Account State TX Phase 1:Deductible
Plan Name Traditional PPO S0
Benefit Effective Date 1/12023
CMS Contract H1666
PBP 801 Phase 2:Initial Coverage Limit(ICL)
Formulary Semi Custom1 The following Supplemental Drug ryang cost shares will apply up to the ICL amount. 54 nt'-
Premium' Retail Pharmacy Mail Order Pharmacy
30-day supply 60-day supply 90-day supply 30.day supply 60-day supply 90-day supply
Preferred Standard i Preferred Standard Preferred i Standard Preferred i Standard Preferred Standard Preferred Standard
l Tier 1:Preferred Generic $0 $5 $0 $10 $0 $15 $0 $5 $0 $10 $0 $15
ITier 2:Generic $6 $11 $12 $22 $18 E33 $6 $11 $12 E22 $18 $33
1 Tier 3:Preferred Brand $39 $44 $78 $88 $117 $132 $39 $44 $78 $88 $117 $132
•
Tier 4:Non-Preferred Drug $85 $95 $170 $190 $255 $285 $85 $95 $170 $190 $255 $285
Tier 5:Specialty 33% 33%. 33% 33%. 33%. 33%. 33%. 33%. 33% 33%. 33% 33%.
1
Coverage Gap Tiers 1 through 4 The following cost shares will apply for the Coverage Gap until member reaches the Na
Defined Standard Tiers 5 TrOOP amount of. (Reference Out-of-Pocket Maximum)
I Members will pay 25%.of the cost • .,-
on Generic Drugs and 25%of the i
30.day supply 60-day supply 90.day supply 30-day supply 60-day supply 90.day supply
cost on Brand Name Drugs for all '
defined standard tiers. Preferred Standard Preferred Standard Preferred Standard Preferred Standard Preferred Standard Preferred Standard
Tier 1:Preferred Generic $0 $5 $0 $10 $0 $15 $0 $5 $0 $10 $0 $15
TIer2:Generic $6 $11 $12 $22 $18 $33 $6 $11 $12 $22 $18 $33
Tier 3:Preferred Brand $39 $44 $78 $88 $117 $132 $39 $44 $78 $88 $117 $132
Tier 4:Non-Preferred Drug $85 $95 $170 $190 $255 $285 $85 $95 $170 $190 - $255 $285
Tier 5:Specialty 25%. 25%. 25% 25%. 25% 25%. 25%. 25%. 25% 25%. 25%. 25%.
1 Phase 4:Catastrophic
The following cost shares will apply for the Catastrophic Phase after you meet this
TrOOP threshold: Na
Member share of the cost for a covered drug will be either coinsurance or copayment (Reference Out-of-Pocket Maximum)
the greater of the amounts listed below'.
I Ns Percentage of the total cost or
Ne Copeyrnenl for generic(including brand drugs treated as generic),or
Na Percentage
for all other drugs
Maximum Out-of-Pocket
•1 When member reaches the maximum out-of-pocket limit,cost shares will no longer $
apply. 1,500
Notes
'Rates are per member per month for persons who have Medicare as primary coverage.
i •Areas in red indicate amounts required by the federal govemment to at 2023 Medicare Part D program and are not subject to negotiation.
•All cost-sharing presumes eligible prescriptions filled at a network pharmacy or our mail-order vendor.
•The formulary is reviewed and approved annually by the Centers for Medicare 8 Medicaid Services(CMS),but is subject to change as maintenance updates are made
throughout the year.
•Prescnpbcn drug plans provided by HCSC Insurance Services Company(RISC),an Independent Licensee of the Blue Cross and Blue Shield Association.A Medicare-
approved Part 0 sponsor.Enrollment in HISC's plays depends on contract renewal.
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