Indiana Guide to benefit changes Blue 0.0 to 5.0

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1 Indiana Guide to benefit changes Blue 0.0 to 5.0 Blue 5.0 is a new version of our benefits. It is designed to provide additional cost savings and benefit refinements along with complying with the provisions in Health Care Reform and Federal Mental Health Parity. There are certain requirements all group health plans must adopt. This is regardless of whether you choose a grandfathered Blue 0.0 or non grandfathered Blue 5.0 health plan. If you don t grandfather your existing Blue 0.0 plan, your plan will include additional required changes. We ve based these grandfathered and non grandfathered plan changes on the interim final regulations published by the U.S. Department of Health and Human Services, as well as our analysis of these regulations. As we receive additional guidance and clarification from the U.S. Department of Health and Human Services, we may be required to make additional changes to your benefits INEENABS 11/10

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3 Benefit differences This applies generally to Blue Preferred Primary, Blue Preferred Primary Plus, Blue Access, Blue Traditional and Lumenos. (For Blue Traditional, Lumenos and Blue Access for HSA plans, all covered services are subject to the deductible and coinsurance except where noted in the benefits outlined below. Your specific Contract terms, which may be different, are not changed by this summary.) Benefit design Current features (Blue 0.0) New features (Blue 5.0) Allergy Testing and Injections Allergy testing and injections are covered in full (CIF) unless billed with an office visit charge, then the flat-dollar office visit copay applies. Allergy testing is subject to the Other Outpatient Services cost shares. It may be subject to the deductible and will accumulate to the out-of-pocket maximum (OPM). For plans with office visit copay: There is a $5 allergy injection copay in the Network office setting only without an office visit charge. The office visit copay still applies if the office visit is billed with an allergy injection. For plans with office visit coinsurance: The member is responsible for the appropriate percentage of the allowed charges (including the allergy injection). Alternative Care Facility No definition. Alternative care facility is a non-hospital health care facility or an attached facility designated as free standing by a hospital, which provides outpatient services primarily for, but not limited to: Diagnostic services (i.e., CT-SCANS, MRIs) Surgery Therapy services or rehabilitation Ambulance Services Behavioral Health Services (formerly known as Mental Health and Substance Abuse) Covered in full or subject to deductible and percentage copay, if applicable. Mental Health and Substance Abuse terminology. Outpatient Services subject to office visit cost share for Indiana Small Group. Subject to the deductible, if applicable, and Other Outpatient Services Network cost share. All services are subject to a place of service cost share. The certificate language has been updated along with the exclusion listing. Deductible may not apply to outpatient professional services depending on group s plan design. Copay Terminology Copay is a term used to represent all flat dollars and percentage amounts. Flat dollar amounts are called copays. Copays accumulate toward the out-of-pocket maximum. Coinsurance Terminology Percentage amounts are called coinsurance. Coinsurance accumulates toward the out-of-pocket maximum (except Non-network/Non-participating HOTT).

4 Benefit design Current features (Blue 0.0) New features (Blue 5.0) Cost Share Cost share is the term for variables used to describe what costs are required on covered services. Cost share includes copay and deductible. Cost share is the amount the member is required to pay for covered services. Cost share includes deductible, coinsurance and copay. The term no cost share means that on a particular service, the member has no deductible, coinsurance or copay up to the maximum allowable amount. The term no copay is used in place of no cost share on the Cost Share Option Sheets (CSOS), Group Quote Request Forms (GQRF), ART and equote. Deductible Deductibles apply to medical services listed with a percentage copay. Deductibles not previously offered on HMO products. Deductible 4th quarter carryover credit is credit allowed in the current benefit period when deductible has been satisfied during the 4th quarter of the prior benefit period. Deductibles ratio is 1:2 for single to family amounts for Network to Non-network amounts. The deductible always applies to covered medical services subject to coinsurance. However, the deductible does not apply to emergency room services at a hospital when subject to a copay plus coinsurance. Introduction of a deductible to HMO products. 4th quarter deductible carryover credit is no longer available as a standard option. Available as a case exception for 100+ groups only. The deductible accumulates to the OPM. Allergy testing that requires coinsurance is subject to the deductible, if applicable. Embedded deductible options are available for HDHP. Note: Deductible ratios on the high deductible health plans (HDHP) are not impacted by Blue 5.0. Dependent Child Ages Emergency Room Services at a Hospital Home Care Services Current dependent child age definition is to the end of the year in which the child attains age 19, to the end of the year in which the child attains age 24. Under Grandfathered Blue 0.0 plans, a dependent is eligible until the end of the month in which he or she turns age 26. ASO groups can define limiting age beyond 26. Flat dollar copay is all-inclusive. Copay accumulates to the OPM. Network benefits based upon medical necessity with CIF or percentage copay. Limited to 30 visits Non-network. Private duty nursing when medically necessary is allowed as part of case management under Home Care Services. A dependent is eligible until the end of the month in which he/she turns age 26. ASO groups can define limiting age beyond 26. Introduction of copay plus coinsurance cost sharing designs. A deductible does not apply when both a copay and coinsurance apply to the ER service. Emergency room copays and coinsurance apply to the out-of-pocket maximum. 90-visit limit per benefit period (combined Network and Non-network, where applicable). Home IV therapy continues to be excluded from the limit. Private duty nursing has a separate limit per benefit period and a lifetime limit. Physical therapy, occupational therapy and speech therapy in the home will accumulate toward the home care services limit. Manipulation therapy (including osteopathic and chiropractic therapy) is not covered in the home setting and will be denied.

5 Benefit design Current features (Blue 0.0) New features (Blue 5.0) Hospice Covered in full or subject to deductible and percentage copay, if applicable. Subject to the Network Other Outpatient Services cost share. Human Organ and Tissue Transplant (HOTT) Maternity Coverage Medical Supplies, Durable Medical Equipment (DME) and Appliances Morbid Obesity All HOTT-related charges are CIF during the transplant period, and have a separate lifetime maximum. Non-network/Non-participating is 50% and does not accumulate to OPM. Travel benefits are included per travel policy. Member has suspended code loaded for all claims to be reviewed, released or paid manually. Grandfathered Blue 0.0 plans have no lifetime maximum. Certificate list as diagnosis-based benefit and copay. One copay taken at office visit and one facility copay taken for maternity-related services for flat dollar copay designs. Additional maternity-related services are also covered under this benefit (i.e., ultrasounds). Durable medical supplies and equipment, prosthetics, mobile scanners, home defibrillators, etc. are covered services based on cost share amount and precertification/medical policy rules, but no benefit limits apply. DME provided at the office would be CIF if an office visit charge was billed; otherwise, it required the office visit copay on flat-dollar copays. DME provided by a vendor was subject to a specific DME percentage copay. Surgical treatment of morbid obesity and drugs are covered. No benefit limits. HOTT benefit covers transportation, meals, lodging and transplant procedure. Admission covered: No cost share for Network/Participating admission. Non-network/Non-participating (not participating in the transplant Network), where applicable, admission covered at 50% coinsurance. HOTT benefits do not apply to a covered service (related to a covered transplant procedure) received prior to or after the transplant benefit period. Transplant benefit period is defined as the period covered by the global fee arrangement for Network transplants, or 30 days following the transplant for Non-network transplants. Changed from a diagnosis-based benefit (cost sharing applied to the diagnosis) to a place of service based benefit (cost sharing applied by place of service). Global fee covers routine maternity visits (prenatal and postpartum care) and delivery. Additional maternity-related services are subject to cost sharing based on place of service (i.e., ultrasounds and false labor). Medical supplies in the office setting are covered under the office visit cost share amount. Other Outpatient Services cost share applies to all DME, DME vendor medical supplies, prosthetic devices and/or appliances obtained in the office visit, urgent care, other outpatient services setting, and/or home care services setting (in addition to the place of service cost share). There is no annual limit on medical supplies. All products exclude surgical treatment of morbid obesity and weight-loss drugs as standard benefits. However, a must offer benefit is available. Out-of-pocket Maximums (OPM) Includes deductibles, flat dollar and percentage copays (except drug and HOTT benefit). OPM for single vs. family and Network vs. Non-network is 1:2 ratio. OPM includes medical deductible, copay and coinsurance except prescription drugs and Non-network HOTT, where applicable. } } The Blue Access OPM for HSAs includes medical deductible and coinsurance, including drugs (excludes Non-network HOTT, where applicable).

6 Benefit design Current features (Blue 0.0) New features (Blue 5.0) Physician Office and Home Services Physical Medicine and Rehabilitation Services Copay applies to the out-of-pocket maximum for the physician services. All-inclusive copay. Same copay for all Network providers. E&M, office visit, surgeries and DME all roll up to one copay each day for same physician. Inpatient benefit with multi-discipline services. No Network limits on HMO and POS. PPO and TRAD limited to 60 days Network and Non-network (if applicable) combined. Addition of a primary care physician (PCP) and specialist (SCP) definition in the Blue Access PPO certificate. HMO, POS, and PPO plans: The specialist may have a higher copay than the primary care physician, except for Federal Mental Health Parity services. MRAs, MRIs, CT-SCANS, PETS, nuclear cardiology imaging studies (stress tests) and ultrasounds (excluding maternity) are subject to the Other Outpatient Services cost share, regardless of the setting where covered services are received. Other Outpatient Services cost share applies to all DME, DME vendor medical supplies, prosthetic devices and/or appliances obtained in the office visit, urgent care, other outpatient services setting, and/or home care services setting (in addition to the place of service cost share). Laboratory Services: No additional cost share for plans with office visit copay designs if performed during a Network office visit or at a Network laboratory. For plans with office visit coinsurance designs, the member is responsible for deductible and the appropriate percentage of the allowed charges for the lab services if performed during a Network office visit or at a Network laboratory. If lab services are provided by an outpatient hospital lab which is not a part of the Laboratory Network: But is a Network provider for other services, the lab services will be covered as Network outpatient services benefit (appropriate cost sharing applies). Or is a Non-network provider for other service, the lab services will be covered as a Non-network outpatient services benefit (appropriate cost sharing applies). 60-day inpatient limit per benefit period on HMO, POS, PPO and TRAD products. Network and Non-network limit combined, where applicable. Day Hospital Rehabilitation (DHR) applies toward the 60-day inpatient limit; however, is subject to the Other Outpatient Services cost share (1 day of DHR = 1 toward the 60-day inpatient limit). DHR programs are defined as structured therapeutic programs of an intensity that requires a multi-disciplinary coordinated team approach to upgrade the patient s ability to function as independently as possible; including skilled rehabilitative nursing care, physical therapy, occupational therapy, speech therapy and services of a social worker or psychologist.

7 Benefit design Current features (Blue 0.0) New features (Blue 5.0) Prescription Drugs Drugs categorized as generic or brand, formulary or non-formulary on two and threetier copay designs. Certain diabetic supplies, including test strips, are covered in full at Network/Participating pharmacies. Non-network/Non-participating retail copay is 50% and may have a minimum of the non-formulary retail copay. Mail Service copays were either double the retail or an additional $10. The prescription drug benefit is included in the overall medical lifetime maximum. Billed amount is used for Non-network/ Non-participating drug claims and no balance billing occurs; only cost sharing applies. Drugs categorized is as follows: Formulary drugs are now called Preferred Drugs. Non-formulary drugs are now called Non-preferred Drugs. Introduction of a four-tier prescription benefit design. Copay/coinsurance amount may vary based on whether the prescription drug has been classified as a first, second, third or fourth tier drug. Tier 1: Preferred Prescription Drugs (previously known as Formulary Generic) Tier 1 generally includes preferred generic prescription drugs. Tier 2: Preferred Prescription Drugs (previously known as Formulary Brand) Tier 2 generally includes brand-name or generic drugs. Tier 3: Non-preferred Prescription Drugs (previously known as Non-formulary Brand and Generic) Tier 3 generally includes brand-name or generic drugs. Tier 4: Preferred Prescription Drugs Tier 4 generally includes injectable drugs. The list of Tier 4 drugs can be found at anthem.com or by calling the number on the back of the ID card. Mandatory Generic substitution (DAW) applies except for Option K & M. When the member selects a brand drug when a generic equivalent is available the member is responsible for the generic copay plus (+) the cost difference between the generic and the brand drug. If the physician indicates no substitutions, the member is only responsible for the appropriate cost share. Mandatory Generic substitution does not apply to oral chemotherapeutic medications. Rx Option K Generic Premium uses a condensed preferred drug list. Non preferred drugs are not covered. Rx Option M Brand prescription drugs are 100% member cost share. Prescription Drug Card program includes chemotherapeutic agents and immunosuppressants at the appropriate generic copay. Oral Chemotherapy is covered with no deductible, copay or coinsurance. Certain diabetic and asthmatic supplies including test strips are covered subject to applicable Prescription Drug Copay/Coinsurance when obtained from a Network Pharmacy.

8 Benefit design Current features (Blue 0.0) New features (Blue 5.0) Prescription Drugs (continued) Preventive Care Services Skilled Nursing Facility Specialist Office Services Certificate language specifically identifies benefit with unique copay separately from setting copay and lists some services but not all. Include diabetes self-management training. Subject to the office visit copay. Unlimited days and is treated the same as inpatient hospital admissions except where there are day limits. Not currently defined in PPO certificate. One copay amount is payable for all Network providers, regardless of provider type: primary care, general practitioner, internist, OB-Gyn, pediatricians, chiropractor, physical therapist, oncologist, surgeon, etc. Additional information: Diabetic test strips are subject to the drug cost share. Non-network/Non-participating retail prescriptions are 50% coinsurance with a minimum dollar amount. There is a separate $2,500 out-of-pocket maximum for Tier 4 drugs per benefit period. Added maximum allowable amount certificate language, where applicable. Tiering cost share does not apply to HDHP designs. HDHPs will continue to have prescription drugs subject to coinsurance and the medical deductible. No cost shares apply for Network preventive care services. Enterprise HCR Preventive definition as the standard preventive coverage. Diagnostic mammograms performed by a Network provider are also covered with no cost share. Cost shares apply for Non-network preventive care services. 90-day limit per calendar year. Network/Non-network days combined, where applicable. A specialist care physician (SCP) is any Network provider not defined as a primary care physician (PCP). PCPs are General Physicians, Internists, Pediatricians, OB/Gyns, Geriatrics or any other Network provider as allowed by the plan. The SCP copay may be higher than the PCP copay, except for Federal Mental Health Parity services. Services received from a Non-network provider that are approved by Medical Management are subject to the Network specialist cost share. Services received from a BlueCard provider (outside the Anthem Midwest Service area) are subject to either the PCP or specialist cost share.

9 Therapy Services Benefit design Current features (Blue 0.0) New features (Blue 5.0) Physical and occupational visit limits are combined. Spinal manipulations 12 visits Speech 20 visits Subject to the office visit copay, regardless of the place of service. All therapies services physical therapy, occupational therapy, speech therapy and manipulation therapy received in office visits and/or outpatient facilities accumulate to each of their individual specific limits. Physical therapy has separate visit limits. Occupational therapy has separate visit limits. Subject to the place of service copay (i.e., office, outpatient services). Network and Non-network visit limits combined, where applicable. Travel Expenses Exclusions and Limitations Covered benefit for HOTT, Coronary Services Centers and services not available in the service area based on appropriate criteria. Allowed under HOTT benefit per Health Care Management (HCM) guidelines. Removed from Coronary Services Centers (CSC) and services not available in the service area (SOSA) certificate language. There are several new, revised and updated exclusions for medical services, behavioral health and prescription drugs. The following is a brief summary of changes. (See the Blue 5.0 certificate for complete details.): New medical exclusions: No benefits for health care service when a Non-network provider waives member copays and/or annual deductible. Complications of bariatric surgery that result in an inpatient stay or an extended inpatient stay. Vision orthoptic training. For hiring, or the services of, a surrogate mother. Fetal reduction surgery. Human growth hormone for children born small for gestational age. It is only a covered service in other situations when allowed by Anthem through prior authorization. Surgical treatment of benign gynecomastia (abnormal breast enlargement in males). For treatment of hyperhydrosis (excessive sweating/sweaty palms). For manipulation therapy services rendered in the home as part of home care services. Residential treatment services. For telephone consultations or consultations via electronic mail or internet/website. (This language was added to certificates on 7/1/04.)

10 Benefit design Current features (Blue 0.0) New features (Blue 5.0) Exclusions and Limitations (continued) Clarifications to medical exclusions and limitations: Dental. Accidental dental: $3,000 limit. See certificate for details. Travel benefits for CSC and SOSA will no longer be covered. Will continue to cover for HOTT only. Foot care definition broadened. Infertility/fertility diagnosis. Private duty nursing services. Sex transformation. Weight-loss programs. New prescription drug exclusions: Compound drugs unless there is at least one ingredient that requires a prescription. Drugs to eliminate or reduce dependency on, or addiction to tobacco and tobacco products. Treatment of Onchomycosis (nail fungus). Certain Prescription Legend Drugs are not Covered Services when any version or strength becomes available over the counter. Clarifications to prescription drug exclusions: Human Growth Hormone for children born small for gestational age. It is only a covered service in other situations when allowed by Anthem through prior authorization. Weight-loss drugs for morbid obesity. } } Drugs, devices and products, or Prescription Legend Drugs with over-the-counter equivalents and any drugs, devices or products that are therapeutically comparable to an over-the-counter drug, device or product. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. If there is a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

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12 Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.