Coverage Period: 01/01/2022 12/31/2022 Iowa State ...

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Iowa State University Employee Advantage HMO

Coverage Period: 01/01/2022 ? 12/31/2022 Coverage for: Single & Family | Plan Type: HMO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit or call 1-877-477-7485. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at sbc-glossary or call 1-877-477-7485 to request a copy.

Important Questions

What is the overall deductible?

Answers $0 person per calendar year.

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

Deductibles do not apply to this plan. No. There are no other deductibles.

Why this Matters: Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply.

You don't have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

What is not included in the out-of-pocket limit?

Not Applicable. Not Applicable.

This plan does not have an out-of-pocket limit on your expenses. This plan does not have an out-of-pocket limit on your expenses.

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Important Questions

Will you pay less if you use a network provider?

Answers

Yes. See or call 18 00-524-9242 for a list of health network providers.

Do you need a referral to see No. a specialist?

Why this Matters:

This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware, your network provider might use an out-ofnetwork provider for some services (such as lab work). Check with your provider before you get services.

You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay What You Will Pay

Common Medical Event

Services You May Need

In-Network (IN)

Provider (You will pay the

least)

Out-of-Network (OON) Provider (You will pay the

most)

Limitations, Exceptions, & Other Important Information

If you visit a health care provider's office or clinic

Primary care visit to treat an injury or illness

$15 copay for exams, 0% coinsurance other services per provider per date of service

Specialist visit

$15 copay for exams, 0% coinsurance other services per provider per date of service

Not covered Not covered

Primary Care Practitioners (PCP) are defined as General and Family Practice, Internal Medicine, OB/GYN, Pediatricians, Nurse Practitioners, and PAs. For this plan you must designate a personal doctor from the above provider types. $15 copay for exams, 0% coinsurance other services per provider per date of service applies to telehealth services delivered by in-network primary care providers. $15 copay per provider per date of service applies to telehealth services contracting through Doctor on Demand.

Applies to Non-PCP providers. $15 copay per provider per

date of service for in-network chiropractic services. This

copay is waived for mental health/ substance abuse. One

routine hearing exam per calendar year. $15 copay for

exams, 0% coinsurance other services per provider per

date of service applies to covered telehealth services

delivered by in-network specialists.

Preventive care/screening/ immunization

$15 copay for exams, 0%

Not covered

Must be provided by or coordinated through your designated personal doctor or OB/GYN. One preventive

For more information about limitations and exceptions, see your plan document or call Iowa State University at 1-515-294-4800.

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Common Medical Event

Services You May Need

If you have a test

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)

If you need drugs to treat your illness or condition

Tier 1 Tier 2

More information about prescription drug

Tier 3

coverage is available

at

Specialty drugs

.edu/benefits/insuranc

e/isu-plan#prescription

What You Will Pay

In-Network (IN) Provider

(You will pay the least)

coinsurance other services per provider per date of service

0% coinsurance

What You Will Pay Out-of-Network (OON) Provider (You will pay the most)

Not covered

Limitations, Exceptions, & Other Important Information

exam and one gynecological exam with Pap smear per calendar year. One mammogram per calendar year. Wellchild care is covered to age 7.

------None------

0% coinsurance

Not covered

------None------

Co-pay $15 / zero for

The HMO plan has limited drug coverage and the certificate

mail order

should be reviewed for the specifics.

Co-insurance 30% /

ISU has a stand-alone prescription plan. The drugs listed on

25% for mail order For OON pharmacies, the ISU/ Express Scripts plan drug formulary are covered per

Co-insurance 50% / you may be required to the Express Script contract ISU maintains.

33% for mail order pay 100% to pharmacy Drugs not on the plan formulary are not covered. The plan has

and file a claim;

clinical programs including step therapy and prior authorization

reimbursement will be requirements for some drugs or the drug may not be covered.

Specialty drugs may determined by the For Specialty drugs, participants should contact the customer

be in either Tier 3 or Express Scripts plan service on the prescription drug ID card.

Tier 2 category.

For brand name drugs the co-insurance has a maximum

cost limit dependent on drug tier.

If you have outpatient

Facility fee (e.g., ambulatory surgery center)

surgery

Physician/surgeon fees

0% coinsurance 0% coinsurance

Not covered Not covered

------None-----------None------

For more information about limitations and exceptions, see your plan document or call Iowa State University at 1-515-294-4800.

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Common Medical Event

Services You May Need Emergency room care

What You Will Pay

In-Network (IN) Provider

(You will pay the least)

$125 copay per visit for facility and physician(s) combined

What You Will Pay

Out-of-Network (OON) Provider (You will pay the

most)

$125 copay per visit for facility and physician(s) combined

Limitations, Exceptions, & Other Important Information

For emergency medical conditions treated out-of-network, you may be balance billed. Waive cost-share on emergency room services for mental health/substance abuse.

If you need immediate Emergency medical medical attention transportation

Urgent care

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

Facility fee (e.g., hospital room) Physician/surgeon fees

Outpatient services

Inpatient services

0% coinsurance

0% coinsurance

$15 copay for exams,

0% coinsurance other services per provider

Not covered

per date of service

0% coinsurance

Not covered

0% coinsurance

Not covered

0% coinsurance Not covered

0% coinsurance

Not covered

If you are pregnant

Office visits

0% coinsurance

Childbirth/delivery professional 0% coinsurance services

Childbirth/delivery facility services

0% coinsurance

Not covered Not covered Not covered

Benefits for non-participating ambulance providers are based on actual billed charges. For covered non-emergent situations, out-of-network ambulance services are NOT reimbursed at the in-network level.

Waive cost-share on urgent care services for mental health/substance abuse.

------None------

------None------

------None------

------None------

Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). For any in- network services that fall outside of routine obstetric care, the office visit benefits shown above may apply. Benefits shown reflect OB/GYN practitioner services which are typically globally billed at time of delivery for pre-natal, post-natal and delivery services.

------None------

For more information about limitations and exceptions, see your plan document or call Iowa State University at 1-515-294-4800.

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Common Medical Event

Services You May Need

If you need help recovering or have other special health needs

Home health care Rehabilitation services Habilitation services Skilled nursing care

Durable medical equipment

If your child needs dental or eye care

Hospice services Children's eye exam

Children's glasses Children's dental check-up

What You Will Pay

In-Network (IN) Provider

(You will pay the least)

What You Will Pay

Out-of-Network (OON) Provider (You will pay the

most)

0% coinsurance 0% coinsurance

Not covered Not covered

0% coinsurance 0% coinsurance

Not covered Not covered

0% coinsurance

Not covered

0% coinsurance

Not covered

$15 copay for exams,

0% coinsurance other Not covered services per provider

per date of service

Not covered

Not covered

Not covered

Not covered

Limitations, Exceptions, & Other Important Information

------None------

------None------

------None-----Limit of 120 days per calendar year. Orthotics are covered as follows: orthotic foot devices such as arch supports or in-shoe supports, elastic supports or examinations to prescribe or fit such devices and orthotics training. ------None------

One routine vision exam per calendar year. Must be performed by an in-network provider.

------None-----------None------

For more information about limitations and exceptions, see your plan document or call Iowa State University at 1-515-294-4800.

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