Group Name Plan Type 2020 CDHP · Out-of-pocket maximums exclude balances over allowable expense and non-covered services. Annual Out of Pocket Maximum - Family $10,000 $13,800 $36,000

Group Name Plan Type

2020 CDHPRochester Regional Health

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2020 CDHP

Rochester Regional Health

or visit us at excellusbcbs.com/rrh

Plan Features

Primary Care Physician (PCP) Not Required

Referrals Not Required

Out of network benefits Covered

Student / Dependent Coverage Covered to age 26

Domestic Partner Covered

Coverage Period 01/01/20-12/31/20

20031

Simply Blue HDHP$10/$40/$60 Subj. to Ded. Dom. $25/$70/$110 Subj. to Ded.

Preventive Rx not subject to DeductibleBenefit Time Period: 01/01/2020 - 12/31/2020

ROCHESTER REGIONAL HEALTH SYSTEM

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General InformationCost Sharing Expenses

Benefit Name RRH Network Excellus Network Out of Network Limits and Additional Information

Deductible - Single $2,500 $3,000 $6,000Deductible applies to annual OOP Maximum. Integrated Rx applies to deductible and OOP maximum.

Deductible - Family $5,000 $6,000 $12,000

The family deductible is met for all when one or more people on the contract meet the total family deductible. Family equals 2 or more people. Deductible applies to OOP Maximum. Integrated Rx applies to deductible and OOP maximum.

Coinsurance 10% 40% 50%

Annual Out of Pocket Maximum - Single $5,000 $6,900 $18,000

Out-of-pocket maximums accumulate coinsurance, copays and the deductible. Out-of-pocket maximums exclude balances over allowable expense and non-covered services.

Annual Out of Pocket Maximum - Family $10,000 $13,800 $36,000

The annual family OOP maximum is met for all when one or more people of the contract meet the annual family OOP maximum. Once a person under a Family contract meets the per person cap amount of $6,750 Domestic, the person will no longer pay for covered services and claims will be paid at 100% by the Health Plan for the remainder of the year. The Per Person Cap includes deductibles, coinsurance, and copays. The remaining annual family OOP Maximum still needs to be met by any combination of family members on the contract.

Annual Out of Pocket Maximum - Per Person Cap

$6,750 $6,900 $18,000

The Out-of-Pocket Maximum Per Person Cap includes deductible, coinsurance, copays and prescription drugs. If a member under a family contract meets the Out-Of-Pocket Maximum Per Person Cap amount, the individual will no longer pay for covered services and claims will be paid at 100% of the allowable amount by the Health Plan for the remainder of the plan year. The remaining annual out-of-pocket maximum still needs to be met by any combination of family members on the contract before claims are paid at 100% for the whole family.

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Cost Share - Primary Care10% CoinsuranceSubject to Deductible

20% CoinsuranceSubject to Deductible


INN Coins for all Services other than PCP and Spec are 40%. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Cost Share - Specialist10% CoinsuranceSubject to Deductible



INN Coins for all Sevices other than PCP and Spec are 40%. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Plan Limits


Plan/Calendar Year Calendar Year Benefits

Diabetic Preauthorization and Step Therapy

Yes

Who is Covered


Domestic Partner Coverage Covered

Inpatient ServicesInpatient Facility


Inpatient Hospital Services10% CoinsuranceSubject to Deductible



Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Mental Health Care10% CoinsuranceSubject to Deductible




Substance Use Detoxification10% CoinsuranceSubject to Deductible




Skilled Nursing Facility10% CoinsuranceSubject to Deductible



120 Days Per Plan YearPediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network. 360 Days Lifetime Max. Limits are combined Domestic, INN and OON.

Physical Rehabilitation10% CoinsuranceSubject to Deductible



60 Days per yearPediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network. Limits are combined Domestic, INN and OON.

Maternity Care10% CoinsuranceSubject to Deductible




Office Visit Cost Shares

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Inpatient Hospital SurgeryPCP/Specialist - 10% CoinsuranceSubject to Deductible

PCP/Specialist - 20% CoinsuranceSubject to Deductible



AnesthesiaPCP/Specialist - 10% CoinsuranceSubject to Deductible



Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Outpatient Facility ServicesOutpatient Facility Services


SurgiCenters and Freestanding Ambulatory Centers Surgical Care





Diagnostic X-ray10% CoinsuranceSubject to Deductible




Diagnostic Laboratory and Pathology10% CoinsuranceSubject to Deductible




Radiation Therapy10% CoinsuranceSubject to Deductible




Chemotherapy10% CoinsuranceSubject to Deductible




Infusion TherapyInclusive of Primary Service

Inclusive of Primary Service


Is inclusive in the Home Care benefit and not covered as a separate benefit.

Dialysis10% CoinsuranceSubject to Deductible




Mental Health Care10% CoinsuranceSubject to Deductible



Includes Partial Hospitalization. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Substance Use Care10% CoinsuranceSubject to Deductible



Includes Partial Hospitalization. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Home and Hospice CareHome Care


Home Care10% CoinsuranceSubject to Deductible




Home Infusion Therapy10% CoinsuranceSubject to Deductible




Inpatient Professional Services

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Hospice Care Inpatient10% CoinsuranceSubject to Deductible




Outpatient and Office Professional ServicesProfessional Services


Office SurgeryPCP/Specialist - 10% CoinsuranceSubject to Deductible




Diagnostic X-rayPCP/Specialist - 10% CoinsuranceSubject to Deductible




Diagnostic Laboratory and PathologyPCP/Specialist - 10% CoinsuranceSubject to Deductible




Radiation TherapyPCP/Specialist - 10% CoinsuranceSubject to Deductible




ChemotherapyPCP/Specialist - 10% CoinsuranceSubject to Deductible




Infusion TherapyPCP/Specialist - Inclusive of Primary Service

PCP/Specialist - Inclusive of Primary Service


Is inclusive in the Home Care benefit and not covered as a separate benefit.

DialysisPCP/Specialist - 10% CoinsuranceSubject to Deductible




Mental Health CarePCP/Specialist - 10% CoinsuranceSubject to Deductible




Maternity CarePCP/Specialist - Covered in FullSubject to Deductible

PCP/Specialist - Covered in FullSubject to Deductible


Pediatric (up to and including age 18): Covered in Full, subject to the deductible, for In-Network.

TeleMedicine ProgramPCP/Specialist - Not Covered

PCP/Specialist - Not Covered

Not Covered Not Covered

Chiropractic CarePCP/Specialist - Not Available



30 Visits per YearPediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Allergy TestingPCP/Specialist - 10% CoinsuranceSubject to Deductible



Allergy Testing includes injections and scratch and prick tests. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Allergy Treatment Including SerumPCP/Specialist - 10% CoinsuranceSubject to Deductible



Includes desensitization treatments (injections & serums). Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Hearing Evaluations RoutinePCP/Specialist - Not Available



1 Exam every 2 yearsPediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Hospice Care

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Physical Rehabilitation10% CoinsuranceSubject to Deductible



30 Visits Per Plan YearIncludes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Occupational Rehabilitation10% CoinsuranceSubject to Deductible



30 Visits per yearIncludes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Speech Rehabilitation10% CoinsuranceSubject to Deductible




Outpatient Professional Services


Physical RehabilitationPCP/Specialist - 10% CoinsuranceSubject to Deductible




Occupational RehabilitationPCP/Specialist - 10% CoinsuranceSubject to Deductible




Speech RehabilitationPCP/Specialist - 10% CoinsuranceSubject to Deductible




Preventive ServicesPreventive Professional Services Meeting Federal Guidelines*


Adult Physical ExaminationPCP/Specialist - Covered in Full

PCP/Specialist - Covered in Full


1 Exam Per Plan Year

Adult ImmunizationsPCP/Specialist - Covered in Full



Well Child Visits and ImmunizationsPCP/Specialist - Covered in Full



Routine GYN VisitPCP/Specialist - Covered in Full



Rehab and HabilitationOutpatient Facility

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Pre/Post-Natal CarePCP/Specialist - Covered in Full



Mammography Screening ProfessionalPCP/Specialist - Covered in Full



NYS Mammography Screening Mandates Applies - One Annual Mammogram for ages 35-39.

Colonoscopy Screening ProfessionalPCP/Specialist - Covered in Full



Bone Density Screening ProfessionalPCP/Specialist - Covered in Full



Preventive Facility Services Meeting Federal Guidelines*


Cervical Cytology Preventative Covered in Full Covered in Full50% CoinsuranceSubject to Deductible

Mammography Screening Facility Covered in Full Covered in Full50% CoinsuranceSubject to Deductible

NYS Mammography Screening Mandates Applies - One Annual Mammogram for ages 35-39.

Colonoscopy Screening Facility Covered in Full Covered in Full50% CoinsuranceSubject to Deductible

Bone Density Screening Facility Covered in Full Covered in Full50% CoinsuranceSubject to Deductible

Preventive services in addition to those required under Federal Guidelines - Professional


Prostate Cancer ScreeningPCP/Specialist - Covered in Full



Pediatric (up to and including age 18): Covered in Full for In-Network. NYS Prostate Cancer Testing Mandate applies.

Mammography Screening ProfessionalPCP/Specialist - Covered in Full



NYS Mammography Screening Mandates Applies - One Annual Mammogram for ages 35-39. Pediatric (up to and including age 18): Covered in Full for In-Network.

Colonoscopy Screening ProfessionalPCP/Specialist - Covered in Full



Pediatric (up to and including age 18): Covered in Full for In-Network.

Bone Density Screening ProfessionalPCP/Specialist - 10% CoinsuranceSubject to Deductible




Preventive services in addition to those required under Federal Guidelines - Facility


Mammography Screening Facility Covered in Full Covered in Full50% CoinsuranceSubject to Deductible

NYS Mammography Screening Mandates Applies - One Annual Mammogram for ages 35-39. Pediatric (up to and including age 18): Covered in Full for In-Network.

Colonoscopy Screening Facility Covered in Full Covered in Full50% CoinsuranceSubject to Deductible

Pediatric (up to and including age 18): Covered in Full for In-Network.

Bone Density Screening Facility10% CoinsuranceSubject to Deductible




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Treatment of Diabetes Insulin and Supplies




Limited to a 30 day supply for retail pharmacy or a 90 day supply for mail order pharmacy. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Diabetic EquipmentPCP/Specialist - 10% CoinsuranceSubject to Deductible




Durable Medical Equipment (DME)PCP/Specialist - Not Available




Medical SuppliesPCP/Specialist - Not Available




AcupuncturePCP/Specialist - Not Available



10 Visits per yearLimits are combined Domestic, INN and OON. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Private Duty NursingPCP/Specialist - Not Covered

PCP/Specialist - Not Covered

Not Covered Not Covered

Emergency ServicesER Facility


Facility Emergency Room Visit10% CoinsuranceSubject to Deductible



Prior Authorization may not apply to any emergency care services. Emergency services are covered worldwide if provided by a hospital facility. Pediatric (up to and including age 18): 10% Coinsurance, subject to the deductible, for In-Network.

Transportation


Prehospital Emergency and Transportation - Ground or Water

Not Available10% CoinsuranceSubject to Deductible


Urgent Care


Urgent Care Center Facility Visit10% CoinsuranceSubject to Deductible




Other BenefitsAdditional Benefits

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Adult Eye Exams - RoutineCovered in FullSubject to Deductible

Covered in FullSubject to Deductible


1 Exam per plan yearLimits are combined Domestic, INN and OON. One pair of corrective lenses after cataract surgery covered in full.

Adult Eyewear - Routine Covered Covered50% CoinsuranceSubject to Deductible

$60 Reimbursement per plan yearIncludes Frames/Lenses or Contact Lenses

Pediatric Eye Exams - RoutineCovered in FullSubject to Deductible

Covered in FullSubject to Deductible


1 Exam per plan yearLimits are combined Domestic, INN and OON. One pair of corrective lenses after cataract surgery covered in full.

Pediatric Eyewear - Routine Covered Covered50% CoinsuranceSubject to Deductible

$60 Reimbursement per plan yearIncludes Frames/Lenses or Contact Lenses.

Rx BenefitsRx Plan


Rx Plan$10/$40/$60 Subj. to Ded. Dom. $25/$70/$110 Subj. to Ded. Preventive Rx not subject to Deductible

Rx Benefits


Days Supply Per Retail Order 90 90

Days Supply Per Mail Order Not Available 90

Copays Per Mail Order Supply 3 3

This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined bythe terms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of thecontract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits arecombined limits for both in and out of network benefits.

* For non-grandfathered groups, Preventive Services coverage required by the Patient Protection and Affordable Care Act are notquoted herein. Please refer to the United States Preventive Services Task Force (USPSTF) list of items and services rated "A" or"B", the guidelines supported by the Health Resources and Services Administration (HRSA) and the list of immunizationsrecommended by the Advisory Committee on Immunization Practices (ACIP) for a complete list of services that are coveredpursuant to the Patient Protection and Affordable Care Act requirements.

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B-2850

Primary Care Physician (PCP)—A doctor who serves as your health care manager and coordinates virtually all of the health care services you routinely receive. Some plans do not require you to choose a PCP.

Referral—Instructions provided by a PCP for specialty care. Most plans do not require referrals.

In-network coverage—The coverage available when you receive services from a provider who participates in your health plan.

Out-of-network coverage—The coverage available when you receive services from a provider who does not participate in your health plan. Some plans may not include out-of-network coverage.

Out-of-area—Describes when you receive services while outside the geographic service area of your health plan. Your plan benefits may differ if you live or work beyond the geographic service area.

Copay—A dollar amount due at the time you receive certain services. A typical example would be an office visit copay due when visiting your physician’s office for treatment.

Allowed Amount—The maximum amount your health plan will pay for a specific service. In-network providers agree to accept the allowed amount as payment in full.

Coinsurance—A cost-sharing method that requires you pay a portion of the allowed amount for certain medical services.

Deductible—A set dollar amount you pay for covered services you receive before your insurer will make a payment.

Out-of-pocket maximum—The maximum amount of deductible and coinsurance payments that you will pay for health services each calendar year.

To help you better understand our plans and your coverage, here are a few definitions* for frequently used health care terms.

Some definitions may vary slightly by plan. In case of a conflict between your legal plan documents and this information, the plan documents will govern.

Health plan terms

*

Inside Back Cover

Documents

Group Name Plan Type 2020 CDHP · Out-of-pocket maximums exclude balances over allowable expense and non-covered services. Annual Out of Pocket Maximum - Family $10,000 $13,800 $36,000