SUMMACARE SILVER 3000 SCConnect SCHEDULE OF BENEFITS
Enrollee Services
Per Member/Per Family Calendar Year Deductible (In-network and out-of-network deductibles are separate. Deductible applies to all covered services subject to coinsurance) Per Member/Per Family Calendar Year Out-of-Pocket Maximum (Includes deductible, coinsurance and copays. In- and out-ofnetwork out-of-pockets are separate. Once the member or family out-of-pocket is met, services will be paid at 100% of the maximum allowable charge.) Coinsurance (What the member pays after the deductible is met but before the out-of-pocket maximum is reached; after the out-of- pocket maximum is reached services are covered at 100%) Annual Dollar Limits on Essential Benefits per Calendar Year
In-Network (Preferred Provider)
Out-of-Network (Non-Preferred Provider)
What the Member Pays
What the Member Pays
$3,000/$6000
$20,000/$40,000
$6,850/$13,700
$40,000/$80,000
30% Maximum Allowable Charge
50% Maximum Allowable Charge
Unlimited
Lifetime Benefit Maximum
Unlimited
OFFICE SERVICES Primary Physician Visit (Other diagnostic tests and imaging studies, pharmaceutical injections (except services covered under “Preventive Care Services”) received in a physician’s office are subject to the outpatient services copay(s) or coinsurance level(s)) Preventive Care (Includes immunizations, well-child care and preventive services as defined by the United States Preventive Services Task Force under grades A and B preventive services. Also includes Women’s Health Preventive Services effective on or after 8/1/12.) Gynecological Visits (Paid at PCP level; preventive services are provided at No Cost Share; see Preventive Care above.) Specialist Visits and Allergist Visits (Preventive services are provided at No Cost Share; see Preventive Care above)
$0 copay for first three visits $10 copay per visit
50% (Subject to deductible)
No Cost Share, no copay, coinsurance or deductible for in-network services
50% (Subject to deductible)
$10 copay per visit
50% (Subject to deductible)
$50 copay per visit $0 copay injections only
50% (Subject to deductible) 50% (Subject to deductible)
INPATIENT HOSPITAL STAY AND SERVICES (Requires Prior Authorization) Inpatient Care (Includes charges for physician and facility) Refer to Skilled Nursing benefit for Inpatient Skilled Nursing services and limits. Surgical Services (Includes Temporomandibular (TMJ) or Craniomandibular Joint Disorder and Craniomandibular Jaw Disorder, as well as physician, facility and anesthesiologist services) Rehabilitative Services (At an inpatient hospital setting: limited to 60 inpatient days for rehabilitation combined limit for in-and out-of-network.)
30%(Subject to deductible)
50% (Subject to deductible)
30% (Subject to deductible)
50% (Subject to deductible)
30% (Subject to deductible)
50% (Subject to deductible)
SUMMACARE SILVER 3000 SCConnect SCHEDULE OF BENEFITS Enrollee Services
In-Network (Preferred Provider)
Out-of-Network (Non-Preferred Provider)
What the Member Pays
What the Member Pays
MATERNITY SERVICES Maternity Office Visits & Prenatal Care Hospital Services (48 hours for vaginal delivery; 96 hours for Cesarean delivery; if discharged early, home care is covered for up to 72 hours after discharge) Postnatal Care Preventive Care Services- Women’s Health
$10 copay for initial visit
50% (Subject to deductible)
30% (Subject to deductible)
50% (Subject to deductible)
30% (Subject to deductible) No Cost Share
50% (Subject to deductible) 50% (Subject to deductible)
OUTPATIENT SERVICES X-ray, Laboratory & Other Diagnostic Services (May require prior authorization) Outpatient Surgery & Services (Includes services at a hospital or other alternative care facility or ambulatory surgical care center)
30% (Subject to deductible)
50% (Subject to deductible)
30% (Subject to deductible)
50% (Subject to deductible)
EMERGENCY/URGENT CARE SERVICES Emergency Care (Any hospital emergency room visit inside or outside of the service area) Urgent Care (Urgently needed care that is not life- or limb-threatening)
$300 copay per visit (Subject to deductible); copay waived if admitted
$300 copay per visit (Subject to deductible); copay waived if admitted; May be subject to balance billing
$50 copay per visit
50% (Subject to deductible)
MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
Inpatient Outpatient
(Biologically and Non-Biologically Based Mental Health and Substance Abuse Disorders) 30% (Subject to deductible) 50% (Subject to deductible) $10 copay per visit 50% (Subject to deductible)
OTHER SERVICES Ambulance Services Chiropractic Services (Limited to 12 visits per calendar year) Durable Medical Equipment Home Health Care (Limited to 100 visits per calendar year combined in- and outof-network; Limits do not apply to IV Therapy and private duty nursing) Hospice Services
Rehabilitative Services (Limited to 20 visits Occupational Therapy; 20 visits Physical Therapy; 20 visits Speech Therapy; 36 visits Cardiac Rehabilitation; 20 visits Pulmonary. Visit limits per calendar year combined in- and out-of-network when rendered at an outpatient rehab facility.)
30% (Subject to deductible)
50% (Subject to deductible)
$50 copay per visit
50% (Subject to deductible)
30% (Subject to deductible)
50% (Subject to deductible)
30% (Subject to deductible)
50% (Subject to deductible)
30% (Subject to deductible)
50%(Subject to deductible)
$50 copay per visit
50% (Subject to deductible)
SUMMACARE SILVER 3000 SCConnect SCHEDULE OF BENEFITS Enrollee Services
Habilitative (Habilitative services will be determined by SummaCare and are included in the Mental Health and Rehabilitative Service Benefit). Habilitative services include: Outpatient Physical Rehab, including Speech and Language Therapy and Occupational Therapy, performed by a licensed therapist, limited to 20 visits per service; Clinical Therapeutic Intervention defined as therapies supported by empirical evidence, which includes but are not limited to, Applied Behavioral Analysis, provided by or under the supervision of a professional who is licensed, certified or registered by an appropriate agency of this state to perform the services in accordance with a treatment plan, 20 hours per week; and Mental/Behavioral Health Outpatient Services performed by a licensed psychologist, psychiatrist or physician to provide consultation, assessment, development and oversight of treatment plans. Skilled Nursing Facility (Limited to 90 days per calendar year combined in-and out-ofnetwork)
In-Network (Preferred Provider)
Out-of-Network (Non-Preferred Provider)
What the Member Pays
What the Member Pays
$50 copay per visit rehabilitation
50% (Subject to deductible)
$10 copay per visit per mental health visit
50% (Subject to deductible)
30% (Subject to deductible)
50% (Subject to deductible)
PEDIATRIC VISION FOR CHILDREN UP TO AGE 19 Well Vision Exam with Dilation as Necessary (One exam available per calendar year covered in full at a network pediatric vision provider) Frames (Designated available frame from Pediatric Vision Plan collection. Members can choose from select frame styles and colors. One frame per calendar year covered in full by a network pediatric vision provider.) Standard Prescription Lenses (Polycarbonate plastic or glass scratch-resistant and ultraviolet lenses are covered. One set of lenses per calendar year covered in full at a network pediatric vision provider.) Single Vision Lined Bifocal Lined Trifocal Lenticular lenses Contact Lens Fitting and Evaluation and Lenses (Contact lens fitting and evaluation is covered in full at a network pediatric vision provider) Standard contact lens fitting and evaluation Premium contact lens fitting and evaluation Elective contact lenses are covered in full at a network provider for the following: Standard (one pair per calendar year; one contact lens per eye for total of 2 lenses) Monthly (six month supply:6 lenses
$0 copay
50% UCR (Subject to deductible)
$0 copay
50% UCR (Subject to deductible)
$0 copay
50% UCR (Subject to deductible)
$0 copay $0 copay $0 copay
50% UCR (Subject to deductible) 50% UCR (Subject to deductible) 50% UCR (Subject to deductible)
SUMMACARE SILVER 3000 SCConnect SCHEDULE OF BENEFITS Enrollee Services
In-Network (Preferred Provider)
Out-of-Network (Non-Preferred Provider)
What the Member Pays
What the Member Pays
per eye for a total of 12 lenses) Bi-weekly (three-month supply: 6 lenses per eye for a total of 12 lenses) Dailies (one-month supply:30 lenses per eye for a total of 60 lenses) Contact lenses are in lieu of frame and lenses Members can choose from any available prescription contact lenses Necessary contact lenses are covered in full for members who have specific conditions for which contact lenses provide better visual connection. Plan limitations: Two pairs of glasses instead of bifocals Replacement of lenses, frames or contacts Medical or surgical treatment Orthoptics vision training or supplemental testing Items not covered under the contact lens coverage: Insurance policies or service agreements Artistically painted or non-prescription lenses Additional office visits for contact lens pathology Contact lens modification, polishing or cleaning
PRESCRIPTION DRUGS Prescription Drugs 30-day supply for Retail and Specialty Pharmacy 90-day supply for Mail Order Pharmacy (Day supply may be less than the amount shown due to prior authorization, quantity limits and utilization guidelines. SummaCare’s pharmacy network includes national pharmacy coverage; use contracted national pharmacies in- and out-ofnetwork whenever possible to save on out-of-pocket costs. Use of specialty pharmacy in-network for up to a 30-day supply.) Tier 1 Prescription Drugs-Preferred Generic
$5 copay per prescription for up to a 30-day supply retail at a participating pharmacy $10 copay per prescription for up to a 90-day supply through our mail order pharmacy
PRESCRIPTION DRUGS (Continued on next page)
50% of the cost of the drug (Subject to deductible) for up to a 30-day supply retail at a non-participating pharmacy
SUMMACARE SILVER 3000 SCConnect SCHEDULE OF BENEFITS Enrollee Services
In-Network (Preferred Provider)
Out-of-Network (Non-Preferred Provider)
What the Member Pays
What the Member Pays
PRESCRIPTION DRUGS (Continued)
Tier 2 Prescription Drugs-Non-Preferred Generic and Preferred Brand
$50 copay per prescription (Subject to deductible) for up to a 30-day supply retail at a participating pharmacy
50% of the cost of the drug (Subject to deductible) for up to a 30-day supply retail at a non-participating pharmacy
$125 copay per prescription (Subject to deductible) for up to a 90-day supply through our mail order pharmacy Tier 3 Prescription Drugs-Non-Preferred Brand
$100 copay per prescription (Subject to deductible) for up to a 30-day supply retail at a participating pharmacy
50% of the cost of the drug (Subject to deductible) for up to a 30-day supply retail at a non-participating pharmacy
$300 copay per prescription (Subject to deductible) for up to a 90-day supply through our mail order pharmacy Tier 4 Prescription Drugs-Specialty Drugs
50% of the cost of the specialty drug (Subject to deductible) for up to a 30day supply of a specialty drug at our participating specialty pharmacy
50% of the cost of the specialty drug (Subject to deductible) for up to a 30-day supply at a non-participating specialty pharmacy
No Mail Order for Specialty Tier 4 Drugs
For benefits or coverage questions call SummaCare Customer Service at 330-996-8700 or 800-996-8701 (TTY 800-750-0750) or visit www.summacare.com.
