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HomeMy WebLinkAboutPR 23922: CONTRACT WITH BLUE CROSS AND BLUE SHIELD OF TEXAS Energy 4 City of CU )41 ort rthtt Texas INTEROFFICE MEMORANDUM Human Resources Department Date: September 13, 2024 To: Ronald Burton, City Manager Trameka Williams, Director of Human Resources From: Elizabeth Diaz, Assistant Director of Human Resources RE: Blue Cross Medicare Advantage Renewal Effective 1/01/2025 P. R. No. 23922 - 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 1/1/2025 renewal has presented a 3% increase over last year's renewal. As per the attached, all aspects of the plan are renewed as current other than the mandated change by CMS. There are approximately 78 Medicare eligible retirees and/or Medicare dependents on the plan. P.R. No. 2392 2 09.13.2024--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 its plan participants. Benefits under a Medicare Advantage plan re governed by CMS, the Centers for Medicare Services, and minor prescription drug changes are included in the 2025 renewal as determined by CMS. The renewal plan offered includes RX benefits levels that exceed the CMS requirements. 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 • Silver Sneakers 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 retirees. 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 52 Medicare eligible retiree participants for whom the City has a shared premium cost. Recommendation: It is recommended that the Cit Council adopt P. R. No. 23922 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 1/01/2025-12/31/2025 plan year. Bucket Considerations: Approval of P.R.No.23352 will have a budgetary impact of$75,000 which is available in the FY 2024-2025 Health Insurance Fund(614-11-025-5127-00-00-00). "Remember we are here to serve the Citizens of Port Arthur." P.R. No. 23922 09/13/2024—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 01/01/2025; 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. 23922 09/13/2024 evd Page 2 of 3 or their Medicare eligible dependent(s) for the 01/01/2025 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 $225.20/month for all impacted Medicare eligible retirees (approximately 52 Medicare retiree participants). The City's monthly premium cost which equates to $112.60/per member/month, for all impacted Medicare eligible retirees for the 01/01/2025 — 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, 2024, 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 P.R.No. 23922 09/13/2024 evd Page 3 of 3 ATTEST: Sherri Bellard, City Secretary APP LOVED AS TO FORM: / UdZS Ceti Roxann Cotr. eo, City Attorney APPROVED FOR ADMINISTRATION: Trameka Williams, Director of Human Resources Ron Burton, City ager APPROVED AS TO AVAILABILITY OF FUNDS: Yt f Lynda` oswell, Director of Finance EXHIBIT "A" J.S. Edwards Sherlock INSURANCE AGENCY City of Port Arthur Medicare Advantage Renewal 1/1/25 The City moved Medicare eligible retirees and dependents from its ASO health plan to a Blue Cross Blue Shield administered, fully funded Medicare Advantage plan in order to remove the retiree and dependents from the significantly higher claim risk liability to the City under the ASO plan. Benefits under a Medicare Advantage plan are governed by CMS, The Centers for Medicare Services. Once again, minor prescription drug changes are included in the 2025 renewal as determined by CMS. The renewal plan offered includes RX benefit levels that exceed the CMS requirements. Minimal rate adjustments have been implemented each January 1st and have been as follow: 4155 Phelan Boulevard • Beaumont,TX 77707 • P.O. Box 22237, 77720-2237 Beaumont(409)832-7736 • Fax(409)833-1721 • Houston(713) 224-8723 1/1/20 1% 1/1/21 1.99% 1/1/22 1% 1/1/23 1% 1/1/24 3% 1/1/25 3% The original 1/1/25 renewal indicated a 5% adjustment which was subsequently negotiated to the 3% level. While no one likes any sort of rate adjustment, the 3% bump for the upcoming renewal reflects but a $6.60 change in monthly cost per member. The total monthly cost moves from $218.60 to $225.20. Blue Cross Blue Shield still offers the best combination of rates and benefits that both exceed requirements while affording a network that allows access to most medical providers and facilities. )1(-c,Geuv Mickey Moshier, MHP \ }j ! (\ | a« \/ �\ / \ Er II I 4 I . \ fa § ii in - � /8g I | ` i \ }k NIC CO _ ) N\ \ �� ( / \\ I Q 1:3E y \k� P To 5 •9 § To - - ) § k 2 ƒ / j ( \coi - | Q 2 I § o /(k \ ) }/ 7 m CC a ° - )k \ ! °4- 2 b / )\ _ § H I \� k 22 )/ • {/\ a. � / )k )7) ! Lu - L : } C 13 [ \ a }#$ s. 2)� ) ! ` _ 5 \ ! o O 113 (a c} \! lan a) kg O \ § L..) L., = CU }\ CO 7f cS 0\ , ƒ/ (...DI fl. Co\ )) { | { | ) ! i I a ® 2 2 k - Ate \ / cv cv ) //\ \ & | En � ` ®ƒ % 0 -0 ) /) @22 \ f � 32 oo o_To • [ § ) I ... 2 § ap & ! - , / © a m � 2 § @ $ ±� _ � @ T.±$ = 33 $ & 2S2 $ { \ ) I in § / c . c \ )\ : - . 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( � )! k / ` ) { ( \ t - { °« ; ! ! !! ! ° _ k \�} - \I - • ig I !Q! ; \ � ' 0 `§ ! | ; ( |; » 7 ` - ii I ! ! � | . || I ; }; { 2 ! } k I as OD. \ of : gl ] kp 1< 2 § - \ kk \ E I m } 1... 1 \ 82 ) : a 1 3 Gil Blue Cross Group Medicare Options Blue Cross Group Medicare Advantage — Account Information Account Name _ City of Port Arthur _ Account State TX Plan Type MAPD Traditional PPO — _ CMS Contract-PBP H1666 801 Benefit Effective Date 1/1/2025 Plan Name n/a Benefit Premium TBD it Design In-Network Out-of-Network Annual Medical Deductible' $0 $250 Annual Combined Medical Deductible' n/a — Annual Out-of-Pocket Maximum $1,500 $2,250 Annual Combined Out-of-Pocket Maximum $2,250 — Referral Requirement None _,—, Care Management-Continuity of Care(CoC) TBD Inpatient Hospital —— —Inpatient Hospital-Acute $100/day(days 1-6) 40%(days 7+) Inpatient Mental Health Care $100/day(days 1-6) Lim,!- ,';190 lifetime days $0/day(days 7+) 40% ISkilled Nursin• Facili i Benefit Period 1-20 days $0 copay/per day 40% Now �ospila:.. - __ _ Benefit Period 21-100 days2 ° Limited to 100 days per Medicare Benefit Period' $100 copay/per day 40/° Home Health/Hos•ice Home Health $0 copay 40% Hospice(Medicare-covered)3 Covered by Original Medicare at a Medicare certified hospice Emergent&Ur.ent Care I Emergency Care(Worldwide) Cost she.- lmitted within 3 days for the same condition. $50 copay $50 copay Urgently Needed Services(Worldwide) Cost share -.._ s 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% s Health Care Professional Services Primary Care Physician Services $30 copay 40% Physician Specialist Services ° Excluding Psyo -ology Services i $50 copay 40% — — --- —Other Health Care Professional Services j $30 copay/PCP $50 copay/SPC 40% Medicare-Covered Specialist Visits 1 Chiropractic Services(Medicare-covered) Coverage is limited to manual manipulation of the spine to correct for $10 copay 40% subtuxation Podiatry Services(Medicare-covered) I ,... ,.. ..:rant for diabetes-related nerve $5 copay 40% damage or medically necessary treatment for foot injuries or diseases. Acupuncture(Medicare-covered) i-,12 visits in 90 days No more than 20 $0 copay $0 copay •�d annually. Dental Services(Medicare-covered) Coverage for inpatient hospital care for emergency or complicated dental 20% 40% prom.:+.,_s -- --- Eye Exam(Medicare-covered) $0 copay 40% Co. to specific condition. _T _ _Eyewear(Medicare-covered) Coverage for corrective lenses if you have cataract swger y to implant an $Q copay 40% intraocular lens-one parr of eyeglasses with standard frames or one set of . contact lenses 1 1 Hearing Exam(Medicare-covered) t Coverage for diagnostic hearing and balance evaluations to determine if you 25% 40% need medical treatment. Outpatient Rehabilitation Services I )5 Cardiac Rehabilitation Services d Maximum of 2 one-hour sessions per day up to 36 sessions in 36 weeks.Limit copay 40% 8 to 36 per year.Medicare-covered Intensive Cardiac Rehab up to 72 sessions per year ------- ---- Pulmonary Rehabilitation Services 40% Limit to 36 sessions per year Supervised Exercise Therapy for PAD $20 copayr copay 40% Up to 36 sessions in 12 weeks Occupational Therapy Services $20 copay 40% Physical Therapy and Speech Language Pathology Services 40% Outpatient Mental Health Services I Mental Health Specialty Services- Individual Visa $20 copay 40% I Mental Health $20 copay 40% Virtual Mental Health Specialty . $20 co.a throu•h MDLive onl Not Applicable Psychiatric Services- '...-lividual Visit $20 copay 40% 40% Virtual Psychiatric Services-Visit through MDLive Partial Hospitalization $20 copay Not Applicable 1 40% Outpatient Substance Abuse Services I Outpatient Substance Abuse: Individual Visit $40 copay 40% Outpatient Substance Abuse:Group Visit $40 copay 40% Opioid Services $0 copay $0 copay 1 Outpatient Diagnostic/Therapeutic Radiation Services / Lab Services $20 copay 40% Diagnostic Procedures $10 copay 40% Therapeutic Radiology $60 copay 40% I % Diagnostic Radiology Services/X-Ray $30 copay 40 Advanced Imaging(MRI,MRA,CT Scan,PET) $50 copay 40% Other Ou •atient 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-. . .. ,:.,the i,'.5r,.iii or blood $0 copay $0 copay bEnd-Stage Renal Disease/Dialysis Services 10% 40% Kidney Disease Education Services $0 Copay $0 Copay DME,Prosthetics,Diabetic Su.•lies Durable Medical Equipment(DME) 10% 40% Prosthetics/Orthotics 10% 40% Wig(s)w/Cancer Diagnosis Not Covered t Medical Supplies 10% 40% Diabetes Supplies and Services-Preferred Testing Supplies' _ 0% 40% Diabetes Supplies and Services-Non Preferred Testing Supplies 20% 40% Diabetes Supplies and Services-All other supplies 20% 40% Therapeutic Shoes and Inserts i Linut to 1 pair of diabetic shoes per year.Limit to 2 pairs of inserts per year for 20% 40% custom fitted shoes Limit to 3 parrs of inserts per year for off the shelf shoes Medicare Preventive Services Medicare-covered Preventive Services $0 Copay $0 Copay Medicare Part B Rx Drugs Medicare Part B Rx Drugs:Chemotherapy/Radiation 20% 40% Medicare Part B Rx Drugs:Other 20% 40% Home Infusion Therapy Administration $0 copay $0 copay Su.•lemental Benefits Routine Dental (Vendor:DNoA) Preventive&Diagnostic 2x exams 2x cleaning 1 x-ray each year Not covered Not covered Basic Restorative Not covered Not covered Exam, ,surgical extractions dental pain relief Major Restorative Exam,, - i'^otth extractions.root canals includes crowns and Not covered Not covered dentw, Dental Deductible/Waiting Periods n/a i : n/a Dental Annual Calendar Maximum -; ,-of-network allowance on supplemental n/a .-rs each year Routine Vision (Vendor:EyeMed) Routine Eye Exam f Not Covered Not Covered t routine eye exam each year I Eyewear Allowance Not Covered Not Covered Eyewear Allowance Benefit Period n/a ;Routine Hearing (Vendor:TruHearing) i r Routine Hearing Exam o 'g exam each year $10 copay 40% Hearing Aids Allowance $1,000 Allowance Eenefit Per E=_r cr Bo'n Ears Both Ears Hearing Aid Allowance Benefit Period 36 months Other Supplemental Benefits Annual Physical Exam $0 copay $0 Copay Routine Podiatry Services Not Covered Not Covered Routine Chiropractic Services Not Covered Not Covered I Routine Acupuncture Not Covered Not Covered Private Duty Nursing Not Covered Not Covered Over-the-Counter Rx Allowance 1Pr6vrded by conve; = •=.Solaeons) Not Covered ! Not Applicablei Post-Discharge Meal Benefit Not Covered Not Applicable Non Emergency Transportation Services Not Covered Not Applicable iPr ided by;''• - a LLC) 1 Wellness/Clinical Pro5rams Fitness Program ake s ) Included Not Applicable Member Rewards Program Up to$100 per year Not Applicable NurseLine Included 1 Not Applicable Blue365® Discount Platform Included Not Applicable Intensive Case Management Included Not Applicable 1 Complex Care Management Programs6 Included Not Applicable Transplants Management Program Included Not Applicable Preferred Diabetic Supply Program Included Not Applicable Tru Hearing Aid Discount Program Included Not Applicable In-home assessments(Signify Health) Included Not Applicable Footnotes 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. I 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. 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 terminal condition are paid for by Original Medicare,not Blue Cross Group Medicare Advantage.Your plan will pay for a consultative visit before you select hospice. ° 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. " Complex Care Management Programs include:Alcohol and substance abuse disorders,Anxiety and panic disorders,Asthma/chronic obstructive ti 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 Y 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. c'3��� Blue Cross Group Medicare Options Blues s GT !.je.Me fe,M ie. • Account Name City of Port Arthur Deductible Stage Account State TX Plan Name Traditional PPO $0 Benefit Effective Date 2025-01-01 CMS Contract H1666 Initial Coverage Stage PBP 801 Formulary 5 Tier Standard Formulary The Following Cost Shares Will Apply Up To The Out-of-Pocket Cap Supplemental Drug n/a 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 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 S Tier 5:Specialty 33% 33% 33% 33% 33% 33% 33% 33% 33% 33% 33% 33% §§¢§ Maximum Out-of-Pocket Y When member reaches the maximum out-of-pocket limit, $1,500 cost shares will no longer apply. Catastrophic Stage iMember Cost Share SO Notes 'Rates are per member per month for persons who have Medicare as primary coverage. 1 •Areas in red indicate amounts required by the federal government to all 2025 Medicare Pad 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&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(RISC),an Independent Licensee of the Blue Cross and Blue Shield Association.A Medicare-approved Part D sponsor.Enrollment in HISC's plans depends on contract renewal. t •The coverage gap phase has been eliminated in CY 2025,meaning a beneficiary will leave the initial coverage phase and enter the catastrophic phase once they incur enough TrOOP-eligible costs to meet the annual OOP threshold,which is$2.000 in CY 2025.TrOOP is spending on covered iy Part D drugs by the beneficiary or on their behalf by certain third parties.As noted above,the categones of payments that count toward TrOOP will change in CY2025.Specifically,TrOOP will include previously excluded supplemental benefits and exclude Discount Program payments. •2025 CMS standard MOOP is$2,000. i i 1 • s€ F, i i I Blue Cross Group Medicare Options Blue Cross Group Medicare Advantage iAccount Information E Account Name City of Port Arthur _- 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 Deductible' n/a I Annual Out-of-Pocket Maximum $1,500 $2,250 Annual Combined Out-of-Pocket Maximum _ $2,250 Referral Requirement None Inpatient Hospital Inpatient Hospital-Acute $0/day(days 7+) $100/day(days 1-6) 40% g ------ - -, i9 Inpatient Mental Health Care $100/day(days 1-6) Limited to 190 lifetime days $0/day(days 7+) 40% I Skilled Nursing Facility ,Benefit Period 1-20 days o -or hospitalization required $0 copay 40/O I Benefit Period 21-100 days2 $100/per day 40% -_ -sd to 100 days per Medicare Benefit Period' 1 Home Health I Hos•ice Home Health $0 copay 40% Hospice(Medicare-covered)3 Covered by Original Medicare at a Medicare certified hospice 1 Emergent&Urgent Care Emergency Care(Worldwide) $50 copay $50 copay Vail if admitted within 3 days for the same condition. .Urgently Needed Services(Worldwide) Cosi share waived if admitted within 3 days for the same condition $40 copay $40 copay Virtual Urgent Care-Visit through MCtive $25 copay(through MDLive only) h(0 ? . . . . . .. Ambulance Services(Ground) 20% 20% B Ambulance Services(Air) 20% 20% i Health Care Professional Services 1 Primary Care Physician Services $30 copay 40% Physician Specialist Services Excluding- ; ?adiology Services $50 copay 40% t ,Other Health Care Professional Services r $30 copay/PCP I $50 copay/SPC 40% Medicare-Covered Specialist Visits Chiropractic Services(Medicare-covered) Coverage is limited to manual manipulation of the spine to correct for $10 copay 40% subluxalion. Podiatry Services(Medicare-covered) Coverage is limited to foot exams or treatment for diabetes-related nerve $5 copay 40% damage or medically necerAssary treatment for fool injuries or diseases. i Acupuncture(Medicare-covered) 12 visits in 90 days No more than 20 $0 copay $0 copay -d annually. 'Dental Services(Medicare-covered) 1 Coverage fore. - =-gency or complicated dental 20% 40% 8 procedures Eye Exam(Medicare-covered) Coverage lot eye exams limited to specific condition $0 Pay 40% Eyewear(Medicare-covered) Coverage for corrective lenses if you have cataract surgery to implant an $0 copay 40% intraocular tens-one pair of eyeglasses with standard frames or one set of contact lenses. Hearing Exam(Medicare-covered) 1 ) Coverage for diagnostic hearing and balance evaluations to determine if you 25% 40% need medical treatment Outpatient Rehabilitation Services Cardiac Rehabilitation Services i Maximum of 2 one-hour sessions per day up to 36 sessions in 36 weeks $20 copay 40% ILimit to 36 per year P Medic..,n i,,..ored Intensive Cardiac Rehab up to 72 sessions per years Pulmonary Rehabilitation Services o Lund $20 copay 40% Supervised Exercise Therapy for PAD $20 copay 40% i Occupational Therapy Services $20 copay _ 40% Physical Therapy and Speech Language Pathology Services $20 co.a 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 Applicable Psychiatric Services $20 copay 40% P Y —.- Psychiatric Services :,oup Visit $20 copay 1 40% . lVival 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% r Diagnostic Procedures $10 copay 40% --_ _ 1 Therapeutic Radiology $60 copay —_ 40% Diagnostic Radiology Services/X-Ray _ _ $30 copay 40% Advanced Imaging(MRI,MRA,CT Scan,PET) $50 co.a 40% Other Out•atient 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' 0% 40% — !Diabetes Supplies and Services-Non Preferred Testing Supplies 20% 40% Diabetes Supplies and Services-All other supplies' 20% 40% f Therapeutic Shoes and Inserts I 'L:urt to I parr of diabetic shoes per year.Limit to 2 pairs of inserts per year for 20% 40% 1 custom fitted shoes-Limit to 3 pairs of inserts per year for off the shelf shoes Medicare Preventive Services 1 Medicare-covered Preventive Services $0 Co•- $0 Co.- Medicare Part B Rx Drugs Medicare Part B Rx Drugs:Chemotherapy/Radiation 20% 40% Medicare Part B Rx Drugs:Other L 20% 40% Home Infusion Therapy Administration $0 co a I $0 co a Routine Dental I, Preventive&Diagnostic I I Not covered Not covered 1-v each year Basic Restorative Not covered Not covered non-surgical extractions.dental pain relief Major Restorative -_at tooth extractions.root canals.includes crowns and Not covered Not covered 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 i - - - - - - Routine Vision r 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% 1 routine hearing exam each year Hearing Aids Allowance $1,000 Allowance Benefit Per Ear or Both Ears Both Ears — — Other Su Hearing Aid Allowance Benefit Period 36 monthsPPlemental Benefits Annual Physical Exam $0 copay $0 copay Routine Podiatry Services Not Covered 'I 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 - ided by Convey Health Solutions) Not Covered Not Applicable i Post-Discharge Meal Benefit Not Covered Not Applicable Non-Emergency Transportation Services Not Covered Not Applicable (Provided by Modivcare Solutions LLC) Wellness/Clinical Pro•rams Fitness Program Included Not Applicable (Provided by S:: __ - ,,,.,� Member Rewards Program (Provided i, Up to$100 per year Not Applicable NurseLineBlue3 — Included • r Not Applicable x 1 Discount P Included ! Not Applicable f Discount Platform — Intensive Case Management _ Included Not Applicable Complex Care Management Programs6 Included Not Applicable Transplants Management Program — Included — Not Applicable Preferred Diabetic Supply Program Included Not Applicable Tru Hearing Aid Discount Program _ Included Not Applicable , In-home assessments Si•n' Health Included Not Applicable i Footnotes 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. 1 = Skilled Nursing Facility-The member cost sharing applies to covered benefits incurred during a member's inpatient stay.A benefit period begins 1 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. 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 ' terminal condition are paid for by Original Medicare,not Blue Cross Group Medicare Advantage.Your plan will pay for a consultative visit before 1 you select hospice. ' Diabetes: This footnote cell left blank due to non-applicability ° Continuous Glucose Monitoring(CGM)products obtained through the pharmacy will be subject to prior authorization. i6 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) ) f i 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. 1 1 1 1 I I I 1 ) 1`�1(7 Blue Cross Group Medicare Options ,.., TX � r' Account Name City Arthur .'- Phase 1:Deductible ...•, Account State .6 14,1,a. - 2w, S'^`.:., _ •-.,. .a._„._ 12.. Plan Name Traditional PPO $O Benefit Effective Date 11112024 CMS Contract H1666 Phase 2:Initial Coverage Limit(ICL) s PBP 801 Formulary Semi Custom The following cost shares will apply up to the ICL amount: $5,030 i. Supplemental Drug n!a r Premium' Retail Pharmacy - - Mail Order Pharm , 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 Tier 1:Preferred Generic $0 $5 $0 $10 $0 $15 SO $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 $117 $132 Tier 4:Non-Preferred Drug $85 $95 $170 $190 $255 $285 $85 $95 $170 $190 $255 $285 1 1 Tier 5:Specialty 33% 33%. 33% 33%. 33% 33%. 33% 33% 33% 33%. 33% 33%. M Phase 3:Coverage Gap s Coverage Gap Tiers 1 through 4 The following cost shares will apply for the Coverage Gap until member reaches n/a Defined Standard Tiers 5 the TrOOP amount of. (Reference Out-of-Pocket Maximum) Members will pay 25%of the cost ` - - Retail Pharmacy Mail Order Pharmacy 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 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 1 Tier 2:Generic $6 $11 $12 $22 $18 $33 $6 $11 $12 $22 $18 $33 iTier 3:Preferred Brand $39 $44 $78 $88 $117 $132 $39 $44 $78 $88 $117 $132 1 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%. Phase 4:Catastrophic The following cost shares will apply for the Catastrophic Phase after you meet this TrOOP threshold: n/a Member share of the cost for a covered drug will be either coinsurance or (Reference Out-of-Pocket Maximum) copaymenl the greater of the amounts listed below: n/a Percentage of the total cost.or n/a Copayment for generic(including brand drugs treated as generic),or n/a Copayment for all other drugs Maximum Out-of-Pocket When member reaches the maximum out-of-pocket limit, $1,500 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. •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 •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.Enrollment in HISC's plans depends on contract renewal. . I } ! 0 \ \ I \ $ / I \ \ 15 j \ \ 1 \ 2 \ } \ P 1 { \ | } / \ o ) \ | \ \ I /co CL Q \ f! | | < \ �` a) ,| / } ) / | t 2 . ; ; , ) !! 2 4 ! ; )| k \ a2 � � ) � ! 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